1 1 THE BOARD OF MEDICAL EXAMINERS 2 FOR THE STATE OF NEVADA 3 4 --oOo-- 5 IN THE MATTER OF THE ) 6 WORKSHOP REGARDING ) PROPOSED REGULATIONS ) 7 ______________________________) 8 9 10 11 VOLUME I 12 TRANSCRIPT OF PROCEEDINGS 13 February 24th, 1999 14 Reno, Nevada 15 16 17 18 19 20 21 22 23 24 REPORTED BY: STEPHANIE KOETTING, CCR #207, RPR Computer-Aided Transcription 25 DISCOVERY REPORTING (775) 329-3500 2 1 APPEARANCES: 2 For the Medical Board: RICHARD LEGARZA, ESQ. 3 General Counsel 1105 Terminal Way 4 Reno, Nevada 5 LESLIE NIELSEN Deputy Attorney General 6 555 Washington Ave. Las Vegas, Nevada 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 DISCOVERY REPORTING (775) 329-3500 3 1 DATED: At Las Vegas, Nevada, February 24th, 1999, 10:00 a.m. 2 --oOo-- 3 4 MR. LEGARZA: This is Wednesday, February the 24th, 5 1999. My name is Dick Legarza. I'm General Counsel for the 6 Nevada State Board of Medical Examiners. Present in the room 7 is Leslie Nielsen, Senior Deputy Attorney General, counsel 8 for the Nevada State Board of Medical Examiners. And we have 9 two members of the public present who may or may not care to 10 identify themselves as soon as we get proceeding with this 11 matter. 12 This is the time and place set pursuant to notices 13 published and distributed to every county library in the 14 State of Nevada, several courthouses, Attorney General's 15 Office in Carson and in Las Vegas, indicating this is the 16 time and place for workshops to hear comments, solicit 17 comments from the public generally on proposed regulations of 18 the Nevada State Board of Medical Examiners. 19 We are in room 4412E of the Sawyer State Office 20 Building, 555 East Washington Avenue, Las Vegas, Nevada. 21 Once again, if I didn't say it, it's 10:15. This hearing has 22 been noticed for 10:00 o'clock in the morning. We've waited 23 15 minutes to begin this. 24 Miss Reporter, if you would, would you attach a 25 copy of the notice and the proposed new regulations, a DISCOVERY REPORTING (775) 329-3500 4 1 document consisting of 11 pages in total, signed on page 11 2 thereof by Arne D. Rosencrantz. If you could attach a copy 3 to the proceedings, I'd appreciate it. 4 For those of you who are present in the room, as I 5 indicated, this is the time and place where we are soliciting 6 comments on any or all of the proposed regulations. You may 7 make a statement or statements that you care to make with 8 respect to these regulations. 9 You do not have to identify yourself if you don't 10 care to do so. You do not have to -- you certainly won't be 11 testifying under oath. Or you may identify yourself if you 12 care to do so. So if there's anyone in the meeting room, a 13 member of the public, who cares to identify themselves or not 14 identify themselves and speak on these proposed regulations 15 at this time, either or both of you have the floor. 16 MR. VENSLOW: I'd like to comment on a few things. 17 My name is Robert Venslow and I'm acting today in the 18 capacity as a licensed physician assistant in the state. 19 I am also a third-year medical student at a foreign 20 medical school and as such have brought to the attention of 21 the board on section six, number five that the wording of 22 that is somewhat misleading in that foreign medical graduates 23 now take the U.S. Medical Licensing Examination through the 24 auspices of the Educational Commission for Foreign Medical 25 Graduates. And this, the way this is worded, tends to lead DISCOVERY REPORTING (775) 329-3500 5 1 you to believe that you need to pass all of the ECFMG 2 examinations prior to sitting for the USMLE and I've given 3 Mr. Legarza some documentation regarding that. 4 The other thing that I wanted to ask and maybe 5 address, bring to your attention, number three, it says the 6 board will authorize the Federation of State Medical Boards 7 to administer the special purpose examination. Is the intent 8 to say that the board may authorize or absolutely will 9 authorize? 10 MR. LEGARZA: The board has already, I believe, 11 authorized the Federation of State Medical Boards to 12 administered the USMLE. 13 MR. VENSLOW: That's automatic. 14 MR. LEGARZA: I think they're the agency that is 15 giving the USMLE. 16 MR. VENSLOW: This is about the specs. I guess 17 it's both, actually. 18 MR. LEGARZA: Yes. I think these things, Bob, are 19 some of the things that came out of our board book. You got 20 a board book? And you know the policy book, the board book, 21 these things came out of that. 22 It's my understanding that the federation is going 23 to get into the specs business and is already into the USMLE. 24 MR. VENSLOW: Even if an individual may not 25 otherwise qualify for the licensure, the board is willing to DISCOVERY REPORTING (775) 329-3500 6 1 stand for them and say under our auspices this person may sit 2 for the specs examine or the USMLE? 3 MR. LEGARZA: Correct. 4 MR. VENSLOW: So if I apply to you, then it's a 5 done deal? 6 MR. LEGARZA: I don't know. 7 MR. VENSLOW: That's how it looked. I don't know 8 if it makes anybody uncomfortable. 9 MR. LEGARZA: On number five on page four, I'll 10 represent to you that because of your good input, if you 11 will, and your helpful input and discussion, that you and I 12 the licensing specialist at the offices at the board, we 13 visited with Larry Leslie, the executive director, and we 14 took a look at the NRS, NRS 631.160, which refers to how you 15 get licensed. And what you must have passed and everyone and 16 we believe that the NRS specifically sets out, it talks about 17 the USMLE and it talks the about the ECFMG and what they may 18 or may not administer. 19 We believe that the NRS adequately covers the 20 testing requirements and we're going to propose based upon 21 your input that paragraph five be completely taken out. It's 22 pretty redundant, and who knows, they're not giving the 23 medical sciences thing and they do give, like you said, a 24 practical, if you will, and in the English language. We'll 25 take it out, and I think it's adequately covered in the NRSs. DISCOVERY REPORTING (775) 329-3500 7 1 We appreciate your input. 2 MR. VENSLOW: I think there's other sections of the 3 regulation of the state that you have to pass step three in 4 order to be licensed. 5 MR. LEGARZA: Correct. 6 MR. VENSLOW: And you can't pass step three without 7 taking the first two steps. 8 MR. LEGARZA: Absolutely. 9 MR. VENSLOW: It's pretty clear. I found that this 10 was kind of interesting to include. Is this rather than 11 rewrite all of these a physician assistant shall not and hold 12 them to the same standards that the physician has in section 13 eight by changing it from a physician to a licensee shall 14 not. In those instances where a section may refer to the 15 practice of medicine or the practice, are we implying that 16 physician assistants are practicing medicine, because under 17 the basic definitions, you know, that should not be the case. 18 MR. LEGARZA: Yeah, I think we're implying that, 19 Bob. 20 MR. VENSLOW: Because on general -- 21 MR. LEGARZA: They're not practicing medicine 22 independently. 23 MR. VENSLOW: I see what you're saying. Okay. All 24 right. Because under general provisions, you know, there is 25 a practice of medicine defined and I don't want to get us DISCOVERY REPORTING (775) 329-3500 8 1 caught up in that. Because part of that includes using the 2 words or letters MD or any other title or word. 3 MR. LEGARZA: I appreciate that. But the intent 4 and the understanding of these regulations, what my 5 understanding is, is that PAs do in fact practice medicine. 6 They're not independent, but in many instances, pretty close 7 to being. 8 MS. VENSLOW: Would the definition of physician 9 assistant supersede that? 10 MR. LEGARZA: Yes. Absolutely. Absolutely. And 11 the whole idea behind changing everything to licensee is, as 12 you know, we changed, no longer give a physician assistant a 13 certificate, we give a license. Because I think that was 14 part of the philosophy of making sure that physician 15 assistants would be able to be mobile rather than being a 16 service of one individual. I guess in the old days that 17 precede me, if your supervising physician decided he was 18 going to terminate your services, you had to go back to base 19 zero and start all over again. 20 MR. VENSLOW: That's correct. We were not 21 licensed. It was our relationship that was certified or 22 licensed. 23 MR. LEGARZA: And the idea behind the -- the main 24 idea behind the changes you see from physician to licensee is 25 to make all of this stuff with respect to discipline and DISCOVERY REPORTING (775) 329-3500 9 1 prescribing applicable to the PAs and the MDs alike. 2 Because, you see, we incorporate -- in the past, we have been 3 unable to proceed -- let me retract that. I'm not telling 4 you guys anything you don't know, but we're making a record 5 here. In the past, the Nevada State Board of Medical 6 Examiners has never proceeded against a PA. I'm the first 7 lawyer who came along that ever had to prosecute a PA and I 8 think I've done, yes, two, and one of them, the first thing I 9 looked at, was, ah-huh, engaging in sex with a patient. 10 MR. VENSLOW: Right. 11 MR. LEGARZA: No prohibition against that. 12 MR. VENSLOW: We thought we could get away with it. 13 MR. LEGARZA: So Larry and I, remember when we did 14 the regs last time, about a year and a half ago, we made some 15 changes to the regs. We completely -- it was before that 16 case, that particular PA, and we didn't even look at it, 17 didn't even think about it, because the law says you're going 18 to establish by regulations what you can discipline a PA for. 19 My God, we just assumed you could do this, and you can't. So 20 what we're attempting to do, it specifically says the NRS 21 such and such through NRS such and such are applicable to 22 PAs. The use of licensee and practitioner and practice are 23 applicable to both of them within the limitations as to what 24 we all understand they are. 25 MR. VENSLOW: I guess if you stretch the scope and DISCOVERY REPORTING (775) 329-3500 10 1 practice, the physician assistant not to be able to practice 2 without the scope of the supervising physician would have 3 limited him anyway. 4 MR. LEGARZA: I had a request the other day, it's 5 off the subject, but it's kind of on the subject as well. A 6 PA who was licensed by us in Northern Nevada who is an 7 orthopedic assistant and that makes sense. 8 MR. VENSLOW: Is he a PA or OPA? 9 MR. LEGARZA: PA. 10 MR. VENSLOW: Who works in the orthopedic clinic? 11 MR. LEGARZA: The one up at UNR on the campus. 12 He's an orthopedic PA. He is a PA. He's licensed by us. He 13 wrote us a letter and said I am being required, and this may 14 get into a subject you may want to get into, I am required in 15 order to have hospital privileges, or something to assist 16 people with whom I am not associated or be available for some 17 kind of -- anyway, he wanted to know: Is it possible that I 18 could assist people who are not my supervising physician? I 19 told him, no, you can't, but he had some kind of a special 20 spec. 21 MR. VENSLOW: Actually, you can. I have done it 22 before. Because I work for a cardiology group and a 23 cardiology group generally assists in whatever manner to -- 24 well, in this particular case, my area of expertise is pacing 25 and electro physiology. So another physician calls Dr. DISCOVERY REPORTING (775) 329-3500 11 1 Wesley and says, you know, I need some help down here in the 2 emergency room with a pacemaker. It doesn't look like it's 3 working right. He sends me down to help this guy figure out 4 what is up. Now, if you walked in on us, you would think I 5 was assisting this physician when in fact I'm representing 6 Dr. Wesley. 7 MR. LEGARZA: I appreciate that. 8 MR. VENSLOW: Dr. Wesley is still my supervising 9 physician. There's no question about that. It would appear 10 that I was assisting another physician when I don't think 11 that's the case. 12 MR. LEGARZA: He was asking like: Can I take call? 13 Can I be on call? And "can I do" kind of stuff. And his 14 supervising physician had nothing to do with it and was not 15 involved in the food chain whatsoever. 16 MR. VENSLOW: No. If he was on call representing 17 his group. 18 MR. LEGARZA: Oh, yeah. 19 MR. VENSLOW: And they were available to him 20 immediately. 21 MR. LEGARZA: That wasn't the question. Your floor 22 again. 23 MR. VENSLOW: I don't have any real problems with 24 the business about the HIV. I was wondering where it came 25 from. DISCOVERY REPORTING (775) 329-3500 12 1 MR. LEGARZA: It came out of the same policy book. 2 Which one is that, Bob? 3 MR. VENSLOW: Section five, page three. Because 4 I'm not sure how that's implemented. If a physician or a 5 physicians assistant is being investigated, is the board 6 going to actively try to find out whether they are in fact 7 HIV positive, or if in a matter of course they just happen to 8 find out or how does that work? 9 MR. LEGARZA: As I understand it, again, this is 10 one of those that came out of the policy board, if the board 11 finds out that a physician or a PA is HIV positive, then it 12 will immediately conduct an investigation to review the 13 nature of the practice and it will impanel a group of public 14 health and infectious disease specialists to do all these 15 things. 16 I guess if I'm answering your question, the board 17 has to become aware that a licensed physician or physician 18 assistant is HIV positive. I don't know what the burden is. 19 I had a discussion with Larry about this. And I don't know, 20 I had some problems with possible ABA violation and I also 21 have some problems with this isn't that big of a problem 22 anymore in society, for that matter, in the professions, and 23 he felt like he wanted it in the regulations anyway because 24 of the possible concern of if something like this happened, 25 but, you know, most of the concern nowadays is some DISCOVERY REPORTING (775) 329-3500 13 1 practitioner is going to contract HIV from a patient rather 2 than the practitioner transmitting it to the patient. 3 MR. VENSLOW: I don't understand what the board's 4 intent is in drafting this particular section, but to limit 5 to HIV, if in fact they really are concerned about the health 6 of the general public and recognizing that the physician or 7 PA may not come forth and say I shouldn't be taking care of 8 patients anymore, because I'm more of a risk to them than I 9 am a benefit to them, then it should not only include HIV but 10 other infectious diseases as well, hepatitis or tuberculosis. 11 There's any number of diseases that it could encompass. 12 MR. LEGARZA: When you say "other infectious 13 diseases," is HIV an infectious disease? 14 MS. VENSLOW: Absolutely. 15 MR. VENSLOW: And I think there are other parts of 16 the -- I cannot quote it for you, but it's under one of those 17 things that a physician shall not and that's to provide 18 medical services or practice medicine if they feel that they 19 are endangering them. 20 MR. LEGARZA: We've got a disciplinary thing that 21 says thou shalt not. I don't know if it talks about 22 endangering. 23 MR. VENSLOW: Lack of competence or something. 24 MR. LEGARZA: I know we got one. Thank you. 25 MS. VENSLOW: Active hepatitis C, for example, DISCOVERY REPORTING (775) 329-3500 14 1 would have as grave consequences. The treatment eventually 2 if someone became gravely ill for it is liver transplant. 3 MR. LEGARZA: Now, Dr. Baggett told me that they're 4 up to J, K or L in hepatitis now. 5 MS. VENSLOW: Correct. 6 MR. VENSLOW: It used to be A and B and they called 7 it nonA, nonB, and then they called it C. 8 MS. VENSLOW: There's D and there's so many things 9 we're discovering as the techniques get better. 10 MR. LEGARZA: Are they all infectious hepatitis? 11 MS. VENSLOW: Not to every person. 12 MR. VENSLOW: It's an immune thing. 13 MS. VENSLOW: There's so many variables, that, for 14 example, one patient with active, chronic active hepatitis C 15 could live with another person who continually tests negative 16 when they eat together, sleep together, are man and wife, et 17 cetera, and never contract the disease. 18 Someone else can, you know, have a small paper cut 19 and become exposed to an infected person's serum or other 20 body fluids and develop chronic, active hepatitis. 21 MR. LEGARZA: Individual immune system. 22 MS. VENSLOW: Too many variables. 23 MR. LEGARZA: You're looking at the possibility of 24 not just limiting it to HIV. 25 MR. VENSLOW: I think it would take the heat off of DISCOVERY REPORTING (775) 329-3500 15 1 HIV to say it's not the only bad disease out there, and, 2 secondly, if you're there to protect these patients, then 3 this group of public health and infectious disease 4 specialists could review the entire profile of a physician or 5 PA. Sue and I talked about this as well. We aren't headed 6 into big brotherism next on this. Like every two years we'll 7 have to have some kind of screen that shows we don't have an 8 infectious disease. 9 MR. LEGARZA: As I understand this, this is an old 10 thing out of the policy book that was a total, complete knee 11 jerk to the whole HIV problem and the whole HIV situation and 12 was something that the board at least or some highly 13 respected members of the board historically have been very 14 interested in and Larry feels like some comments or some 15 statement should be in there. What you're telling me and 16 what I like what I'm hearing and I can go back and fight with 17 Larry, let's not point our finger at HIV, which is in and of 18 itself not as controversial as chelation therapy. 19 MS. VENSLOW: It's discriminatory. 20 MR. VENSLOW: You talked about the ABA. 21 MR. LEGARZA: You have the ABA concerns. 22 MR. VENSLOW: If this concerns our concerns that we 23 have for patients of these potential individuals, then it 24 should include all those diseases. 25 MR. LEGARZA: I agree with that. DISCOVERY REPORTING (775) 329-3500 16 1 MS. VENSLOW: It opens a whole can of worms. If 2 you want to discuss licensees who are insulin-dependent 3 diabetics, unless they've eaten, they've taken their insulin, 4 they've monitored their sugar, they may be in the middle of a 5 surgical procedure and go into hypoglycemia shock. So -- 6 MR. LEGARZA: Maybe if we can -- 7 MR. VENSLOW: We don't want to get into that. 8 MS. VENSLOW: We don't. 9 MR. LEGARZA: You want to couch it in more generic 10 terms. If we start putting a long checklist leave something 11 in or put something in that shouldn't be, anyone who is a 12 licensed physician or physician assistant who has some 13 physical or mental health problem. 14 MR. VENSLOW: The public health and infectious 15 disease people would be able to give you a better list, or 16 something better if you are looking for what is significant 17 or what isn't. 18 MS. VENSLOW: The whole intent is to protect the 19 public. 20 MR. LEGARZA: Right. All right. Thank you, sir. 21 Thank you, ma'am. 22 MR. VENSLOW: That's all that I have. 23 MS. VENSLOW: If we could skip ahead to page five. 24 MR. LEGARZA: Uh-huh. 25 MS. VENSLOW: Item K. DISCOVERY REPORTING (775) 329-3500 17 1 MR. LEGARZA: Yes. 2 MS. VENSLOW: Can we discuss medical assistant for 3 a moment? This is really very general, and as you know, in 4 the State of Nevada, there is no board who oversees or 5 licenses medical assistants nor is there any particular 6 standard to which one must be held to be employed as a 7 medical assistant. 8 MR. LEGARZA: Are you talking old K, now new I? 9 MS. VENSLOW: Old K, now new I. Unless the medical 10 assistant has sufficient training to provide the assistance, 11 how is one to determine that necessarily when there is no 12 standard? 13 MR. LEGARZA: Well, I don't know that I have an 14 answer to that question. And, of course, you're asking that 15 question and you are a physician assistant and we're making 16 it applicable to you and so -- 17 MS. VENSLOW: I, who, by the way, would not 18 necessarily have the power to hire or fire a medical 19 assistant being employed, being totally dependent on my 20 employment through my supervising physician. 21 MR. VENSLOW: Physicians, too, would be in the 22 same -- are in the same boat right now. 23 MR. LEGARZA: What she's saying, we're making it 24 applicable to the PAs. 25 MR. VENSLOW: If a physician works for an HMO or is DISCOVERY REPORTING (775) 329-3500 18 1 an employee of the health center at UNLV. 2 MR. LEGARZA: Where are they in the chain of 3 command? 4 MR. VENSLOW: They're in the command chain but not 5 in administration. 6 MR. LEGARZA: They're not allowing. 7 MR. ALEXANDER: Maybe their employer requires them 8 to allow it. 9 MR. LEGARZA: They're not with the one who is 10 allowing it they have to work with the person as a term of 11 their employment. 12 MRS. VENSLOW: Right. 13 MR. LEGARZA: So it's -- what do you do, quit your 14 job or do you -- 15 MR. ALEXANDER: Then who gets disciplined? 16 MS. VENSLOW: The thing that's nice about a nurse, 17 a nurse has a license that he or she may be losing. 18 MR. LEGARZA: And MA does not. 19 MS. VENSLOW: An MA doesn't. 20 MR. VENSLOW: That's the definition. 21 MR. LEGARZA: Not licensed. 22 MR. VENSLOW: There's people who are quite 23 competent, x-ray technicians, radiologists technicians are 24 not licensed in this state. If you have them do an x-ray for 25 you in your office, ultimately you would be responsible for DISCOVERY REPORTING (775) 329-3500 19 1 whatever. 2 MS. VENSLOW: Many offices have medical assistants 3 shoot their x-rays. 4 MR. LEGARZA: You saw my legal opinion on lasers. 5 MS. VENSLOW: Yes. 6 MR. LEGARZA: Did you see it? 7 MR. VENSLOW: No, I did not. 8 MR. LEGARZA: We've been fighting with lasers for a 9 year and a half and we had a situation at the IC where the IC 10 told a physician that the physician's lab tech who for other 11 reasons was married to the physician and was probably 12 totally, completely highly qualified to run a particular 13 laser machine could not, and then turn around and told an RN 14 she could. 15 And we got ourselves in a position to where we 16 were, we thought, being inconsistent. So we wrote the legal 17 opinion that I did after a year of grieving about it to 18 everybody that says there are so many lasers and there are so 19 many different things out there and so many different uses of 20 it that if you've got a laser and you decide that Pete Smith 21 comes walking in off the street can operate that laser in 22 your business, that's your business. But if Pete Smith goofs 23 it up, you're in trouble. 24 I think that's the same thing here. If you've got 25 an MA that you're employing, that you're assigning tasks to, DISCOVERY REPORTING (775) 329-3500 20 1 you have a medical assistant that has no degree at all doing 2 frontal lobotomies, you're going to be in trouble. At least, 3 that's what I think. That's the way I would look at it as 4 somebody who was going to be enforcing this kind of thing. 5 We get a complaint that there's a, quote, unquote 6 medical assistant working in your office that you as the 7 physician or the PA supervised and assigned tasks to who is 8 goofing up, I'm going to look at you to see whether or not 9 you've made a legitimate determination of that person's 10 capabilities and the tasks you assign to that person are 11 confined within that person's abilities. And like you say, 12 there's a whole bunch of people out there who are really 13 qualified to do a whole bunch of things that you feel 14 confident in, and you use them, if they goof up, we're going 15 to look at their qualifications and/or your judgment in using 16 them in that arena. 17 MR. VENSLOW: I have a question: Is using a laser 18 for a medical purpose providing a medical service? 19 MR. LEGARZA: Well, I don't know that I know the 20 answer to that question, because the laser people tell me, 21 and I've looked at the federal law, and I think I agree with 22 what they tell me, that almost across the board they are 23 limited to selling lasers to physicians and those are the 24 only people they can sell them to. 25 MR. VENSLOW: Now, this nurse that you said was DISCOVERY REPORTING (775) 329-3500 21 1 able to operate this laser, did she have to be an employee of 2 the physician who owned the laser or did she own it herself? 3 MR. LEGARZA: She was an employee of the physician. 4 And the rationale behind that was, the rationale behind the 5 difference between the lab tech and the RN was that the 6 members of the IC felt that the RN had more medical knowledge 7 and training than the lab tech. 8 MR. VENSLOW: The lab tech is licensed by the Board 9 of Health and probably has a Bachelors Degree or Masters 10 Degree. 11 MS. VENSLOW: Depending upon the level of training 12 on that specific piece of equipment is probably or possibly 13 far better. 14 MR. LEGARZA: That's why I did the legal opinion. 15 I don't care who you let run it, doctor, an RN. 16 MR. VENSLOW: The emphasis on the RN, the RN wasn't 17 automatic. What I'm getting at is that the lab tech, even 18 though they have a license to work in this state or a 19 certificate that says they can do things in this state, 20 they're an employee of the physician, but now you're talking 21 about an independent licensee of another board who is 22 operating a piece of equipment just on the basis that she's 23 been licensed by this other board. 24 MR. LEGARZA: Once again, that's not where we are 25 and that's not what we say. We don't say an RN can do it, DISCOVERY REPORTING (775) 329-3500 22 1 because you are a licensed RN. We say, you, doctor, can use 2 your RN to do that. Where in the other case we said, you, 3 doctor, can't use your lab tech to do this. That was 4 inconsistent and we felt it was inconsistent. We don't care 5 what you call them. You can call them a PA, you can call 6 them an APM, you can be licensed, you can call them an MA, 7 unlicensed, they can be an RN, an LPN, if you have trained 8 them, they have been trained and they know how to do that, 9 provided you don't go in the morning, turn it on and set it 10 up and go drink whiskey downtown, either. 11 MR. VENSLOW: They're supervised. 12 MR. LEGARZA: If they burn somebody up, they look 13 to you. If you're in the supervisory chain of that person, 14 that person is doing tasks you delegated to that person to 15 do, we'll look to your license to make sure you made that 16 determination properly. 17 MS. VENSLOW: I'm concerned about what that person 18 does that I haven't delegated if someone comes in acutely and 19 there's no nurse or PA or doctor available, if an office 20 person calls for help, medical assistant comes rushing really 21 not knowing what they're doing. I had an episode in my 22 office two days ago with a lady came in said to the front 23 office: I think I'm going to have a seizure. Call for help. 24 Got a medical assistant who typically does more 25 administrative type duties, the patient subsequently DISCOVERY REPORTING (775) 329-3500 23 1 collapsed and, fortunately, they came and got me. She had no 2 clue what to do. None. 3 MR. LEGARZA: That wasn't in a situation that you 4 had authorized or -- 5 MS. VENSLOW: Would that be looked at? 6 MR. LEGARZA: I can tell you how we operate in 7 answer to your question, which you already know. If we 8 receive a complaint from any source, and we get complaints, 9 as you well know, from all kinds of sources, and we make a 10 determination that we have jurisdiction, which we do 11 initially on all complaints, currently Vicki does that, every 12 complaint that comes in goes to Vicki's desk. And, let's say 13 it's a fee dispute, we don't have jurisdiction over fee 14 disputes. There's nothing that we can do with doctors who 15 are in fee disputes with patients. We write them: Thank 16 you, patient, for the complaint, but there's nothing we can 17 do for that you. We don't open a case. 18 If we have jurisdiction, if somebody said they went 19 to your office and they had a medical assistant do something 20 to them and botched it and goofed them up or did whatever, we 21 would open a case and we would investigate it. The first 22 thing we would do is probably never investigate you, so you 23 don't know that this going on. We'd send a letter, dear so 24 and so, doctor so and so, PA so and so, we have received a 25 complaint. We don't identify the complainant, but, you know, DISCOVERY REPORTING (775) 329-3500 24 1 who it is. 2 Would you please respond to us with respect to your 3 thinking, your guidance, talk about this situation, your 4 involvement with, care provided on such and such a date at 5 such and such a time to so and so at your office. And you 6 respond. We get that response, we get any medical records 7 and Dr. Barnett looks at it. Dr. Barnett reviews the case 8 and makes a determination as to whether or not he thinks 9 there may be a problem there. 10 He will make a recommendation for further staff 11 investigation, he'll make a recommendation to have the 12 physician or PA brought in front of the IC, he'll make a 13 recommendation for staff discussion or we'll take the -- or 14 he'll make the recommendation to close the case. 15 We processed last year about 1100 complaints. We 16 opened about 750 and we prosecuted 25 and you guys know who 17 all those people are. 18 MS. VENSLOW: Right. 19 MR. LEGARZA: It's got to be pretty bad for us to 20 do anything. I mean, the borderline ones appear in the IC. 21 The situations where we may or may not go on something appear 22 in front of the IC. So if it gets to where it looks like 23 it's serious and, quite frankly, the ones that get the most 24 trouble are the ones that ignore us. 25 MS. NIELSEN: And the best example of this, DISCOVERY REPORTING (775) 329-3500 25 1 unsupervised medical assistant would be the Saint Ana Medical 2 Center scenario. 3 MS. VENSLOW: I think very positive things may come 4 out of this, because for me it certainly will increase my 5 awareness that when a new medical assistant to me, I will sit 6 down with that person and say: Tell me your training. Tell 7 me your comfort level. Tell me what you're accustomed to 8 doing, what you're not accustomed to doing. Ask questions. 9 MR. LEGARZA: We're throwing hooks out for you. 10 MS. VENSLOW: Because there's so many different 11 levels of training, ten years, twenty years of experience, if 12 it's imperfect does not matter. 13 MR. LEGARZA: An MA in a doctor's office could be 14 doing the filing, she's not a medical assistant, but she's a 15 medical assistant. 16 MS. VENSLOW: She went to medical assistant school, 17 but she ran the front office rather than back office. 18 MR. LEGARZA: She wouldn't know how to give 19 penicillin shot in the back end or the ear. 20 MR. VENSLOW: She knows how to call in a 21 prescription. 22 MS. VENSLOW: How to locate someone's DEA number. 23 MR. LEGARZA: Use it herself. We've got one now. 24 I'll tell you guys later. 25 MS. NIELSEN: Uh-ooh. DISCOVERY REPORTING (775) 329-3500 26 1 MR. LEGARZA: Anything else, Sue? 2 MS. VENSLOW: I'll say in general, I'm not just 3 representing myself, most PAs in the state, we welcome the 4 responsibility and appreciate being included as licensees 5 rather than being added on as others. 6 MR. LEGARZA: Okay. It's now five minutes to 7 11:00. We're still at the same place, room 4412E, 555 8 Washington Avenue, the Sawyer State Office Building. The 9 only people who have shown up to give us their input at this 10 workshop are Mr. And Mrs. Venslow, both licensed PAs in the 11 State of Nevada. 12 I know both of these people and appreciate their 13 thoughts and comments and they're well-taken and I thank both 14 of you. I'm going to close this hearing now. I know that 15 Mr. Venslow wants to talk about another subject that has 16 nothing to do with this while we are here, which we will do. 17 And if anyone does show up, we'll stay in this room for a 18 while and discuss this other matter and if anyone does show 19 up during that time, I'll reopen this hearing if anyone has 20 any input concerning these regulations. For now, I'll close 21 this hearing. 22 --oOo-- 23 24 25 DISCOVERY REPORTING (775) 329-3500 27 1 I, Stephanie Koetting, CCR #207, do hereby certify 2 that the foregoing transcript, consisting of pages 1 through 3 27, is true and correct to the best of my knowledge, skill 4 and ability. 5 DATED: This 8th day of March, 1999. 6 _________________________________ STEPHANIE KOETTING, CCR #207 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 DISCOVERY REPORTING (775) 329-3500 28 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 DISCOVERY REPORTING (775) 329-3500