library(tidyverse)
library(tidytext)
library(janitor)
library(lubridate)29 An intro to text analysis
Throughout this course, we’ve been focused on finding information in structured data. We’ve learned a lot of techniques to do that, and we’ve learned how the creative mixing and matching of those skills can find new insights.
What happens when the insights are in unstructured data? Like a block of text?
Turning unstructured text into data to analyze is a whole course in and of itself – and one worth taking if you’ve got the credit hours – but some simple stuff is in the grasp of basic data analysis.
To do this, we’ll need a new library – tidytext, which you can guess by the name plays very nicely with the tidyverse. So install it with install.packages("tidytext") and we’ll get rolling.
Here’s the question we’re going to go after: what words or phrases appear most in disciplinary alerts published by the Maryland Board of Physicians?
To answer this question, we’ll use the text of those alerts.
Let’s read in this data and examine it:
alerts <- read_rds("data/md_doc_alerts.rds")We can see what it looks like with head:
head(alerts) id file_id url
1 1 d1604912.124 https://www.mbp.state.md.us/BPQAPP/orders/d1604912.124.pdf
2 2 h4828611.244 https://www.mbp.state.md.us/BPQAPP/orders/h4828611.244.pdf
3 3 z0040911.174 https://www.mbp.state.md.us/BPQAPP/orders/z0040911.174.pdf
4 4 r0500911.174 https://www.mbp.state.md.us/BPQAPP/orders/r0500911.174.pdf
5 5 d2520911.134 https://www.mbp.state.md.us/BPQAPP/orders/d2520911.134.pdf
6 6 d7440711.124 https://www.mbp.state.md.us/BPQAPP/orders/d7440711.124.pdf
doctor_info_id first_name middle_name last_name suffix
1 1 Lawrence D Egbert NA
2 2 Joan Smith NA
3 3 Donald E Busick Jr.
4 4 David M Hush NA
5 5 John R McLean NA
6 6 Alexandra Gold NA
type year text_id
1 Medical License Revoked 2014 1
2 Medical License Cease and Desist Order 2014 2
3 Medical License Suspended for Delinquent Child Support 2014 3
4 Medical License Revoked 2014 4
5 Medical License Revoked 2014 5
6 Medical License Revoked 2014 6
date date_str filename
1 2014-12-12 December 12, 2014 d1604912.124.txt
2 2014-11-24 November 24, 2014 h4828611.244.txt
3 2014-11-17 November 17, 2014 z0040911.174.txt
4 2014-11-17 November 17, 2014 r0500911.174.txt
5 2014-11-13 November 13, 2014 d2520911.134.txt
6 2014-11-12 November 12, 2014 d7440711.124.txt
text
1 IN THE MATTER OF * BEFORE THE MARYLAND\n\nLAWRENCE D. EGBERT, M.D. i STATE BOARD OF PHYSICIANS\nRespondent. i Case Number: 2011-0870\n\nLicense No. D 16049 *\n\n* * * * * * * * * * * * *\n\nFINAL DECISION AND ORDER\nPROCEDURAL HISTORY\n\nLawrence D. Egbert, M.D. is a board-certified anesthesiologist, who has been licensed by\nthe Maryland State Board of Physicians (“Board”) since 1952. In November, 2012, the Board\ncharged Dr. Egbert with unprofessional conduct in the practice of medicine, see Health Occ. $\n14-404(a)(3)(ii), based on his actions as the Medical Director for Final Exit Network (“FEN”), a\nnational right-to-die organization, and his participation in the assisted suicides of six FEN\nmembers.\n\nDr. Egbert requested and received an evidentiary hearing on September 26, 2013, at the\nOffice of Administrative Hearings. At that hearing, the State presented expert witness testimony\nfrom Henry Silverman, M.D., who testified as an expert in internal medicine and medical ethics.\nDr. Egbert did not testify or present any witnesses. In a Proposed Decision issued on December\n23, 2013, Administrative Law Judge (“ALJ”) Jennifer M. Carter Jones found that Dr. Egbert\nengaged in unprofessional conduct in the practice of medicine based on Dr. Egbert’s review of\nFEN applicants’ medical records, his determinations on applicants’ suffering, and his\ndeterminations on whether applicants’ conditions could or could not benefit from additional\nmedical treatment. The ALJ further found that Dr. Egbert held himself out as a treating\n\nphysician to other physicians so they would provide patients’ medical documents to him as part\n\fof the FEN screening process. The ALJ did not deem Dr. Egbert’s presence or his assistance in\nthe suicides to be “in the practice of medicine.” The ALJ recommended that Dr. Egbert’s\nmedical license be revoked.\n\nOn January 8, 2014, Dr. Egbert filed exceptions (dated January 7, 2014) to the ALJ’s\nProposed Decision. The State also filed exceptions and a response to Dr. Egbert’s exceptions on\nJanuary 16, 2014. Both parties appeared before Disciplinary Panel B (the “Panel”) of the Board\nfor an oral exceptions hearing on March 26, 2014.\n\nFINDINGS OF FACT\n\nThe Panel adopts the findings of fact numbered 1-33 proposed by the ALJ (Attached as\nExhibit 1).! The facts, as described by the ALJ, and summarized below, are largely undisputed.\nDr. Egbert was the Medical Director for FEN, an organization dedicated to supporting and aiding\nnon-terminally ill persons to hasten their deaths. Individuals who wanted the organization’s help\nto commit suicide would submit to FEN an application with their medical records and a\nstatement explaining why they wished to end their lives.\n\nAs the Medical Director of FEN, Dr. Egbert received each applicant’s medical record and\ndetermined whether the applicant’s request for an assisted suicide would be accepted.” Dr.\nEgbert explained that he reviewed the medical records to determine: (1) whether the applicant\naccurately identified the source of his or her suffering, (2) whether the applicant’s suffering was\n“horrible,” and (3) whether the medical treatment that the applicant was receiving was adequate.\nIn at least one circumstance, Dr. Egbert rejected an application because the applicant’s pain was\n' The ALJ’s Findings of Fact incorporated twenty stipulated facts (numbered 1-20) agreed to by the\nparties and thirteen additional factual findings (numbered 21-33). ; ;\n\nThe applications were reviewed by the “medical evaluation committee.” That committee consisted of\nprofessionals in various disciplines, each needing to be licensed in their discipline, and at least one\n\nlayperson. As the medical director, Dr. Egbert made the final decision for each applicant.\n2\n\f4. Rehearsal and Procedure Aiding Suicide is In the Practice of Medicine.\n\nDr. Egbert’s review of the patients’ medical records cannot be separated from his conduct\nin rehearsing the process for suicide, including instructions on how to use the materials, walking\npatients through the steps of the suicide, and holding the patients’ hands during the suicide.\n\nThe ALJ explained that “participation in assisted suicide is antithetical to the long-\nstanding or prevailing purpose of medical practice to treat and heal patients and/or to make\npatients comfortable.” ALJ Proposed Decision at 19. The ALJ stated that assisting suicide was\nnot for the purpose of healing or relieving patients’ symptoms of ailments, and, therefore, should\nnot be considered in the practice of medicine.\n\nThe Panel disagrees with the ALJ’s rationale on this point because the ALJ disregarded\ncaselaw regarding the practice of medicine. Physicians are often found guilty of unprofessional\nconduct in the practice of medicine for acts that are not facially related to the practice of\nmedicine or are antithetical to the practice of medicine. Specifically, Maryland courts have\nfound the practice of medicine to include sexually harassing hospital co-workers (Banks, 354\nMd. at 76-77), sexual liaisons with patients (Finucan, 380 Md. 601), lying on peer reviews\n(Cornfeld, 174 Md. App. at 462), and lying on a renewal application. (Kim, 423 Md. at 527).\nThough none of these cases directly involved a physician acting to treat or heal patients they\neach were considered within the practice of medicine. Based on this caselaw, the Panel rejects\nthe ALJ’s reasoning.\n\nThe State’s expert, Dr. Silverman, testified that by holding the hands of the patients while\nthey committed suicide, Dr. Egbert provided emotional support to the patient and ensured that\nthe hood was not displaced because of an involuntary spasm of the patients’ arms. Dr. Silverman\n\nopined that both — providing emotional support and ensuring the hood stay on — were the role of\n\nll\n\fa physician and, therefore, constituted the practice of medicine. Dr. Egbert did not provide any\nexpert testimony contradicting this conclusion.\n\n5. Dr. Egbert had Notice that his Review of Medical Records would be\nConsidered In the Practice of Medicine.\n\nDr. Egbert argues in his exceptions that he was not given notice that his review of\nmedical records was unprofessional conduct in the practice of medicine. The charges allege,\nhowever, that “[iJn his capacity as Medical Director, [Dr. Egbert] evaluated the records\nsubmitted by applicants to determine whether the applicant’s request for assistance would be\naccepted.” This allegation in the charges is sufficient notice that Dr. Egbert could be held\nresponsible for unprofessional conduct in the practice of medicine for his review of medical\nrecords.\n\n6. The Principle of Edjusem Generis does not Lead to the Conclusion that\nAssisted Suicide was Outside the Practice of Medicine.\n\nThe ALJ concluded assisted suicide was outside the practice of medicine, in part, because\nthe definition of the practice of medicine in Health Occ. § 14-101(0) did not explicitly include\nassisted suicide, but did include “ending of a human pregnancy.” The ALJ used the doctrine of\nejusdem generis to infer that assisted suicide should not be considered “in the practice of\nmedicine.” The doctrine of ejusdem generis is defined as “when a general word or phrase\nfollows a list of specifics, the general word or phrase will be interpreted to include only items of\nthe same class as those listed.” Haile v. Siate,431 Md. 448, 468-69 (2013). Ejusdem\ngeneris may be applied under the following conditions: “(1) the statute contains an enumeration\nof specific words; (2) the members of the enumeration suggest a class; (3) the class is not\nexhausted by the enumeration; (4) a general reference supplementing the enumeration, usually\n\nfollowing it; and (5) there is not clearly manifested an intent that the general term be given a\n\n12\n\fbroader meaning than the doctrine requires.” Haile, at 469 (quoting Boyle v. Maryland-National\nCapital Park & Planning Comm’n, 385 Md. 142, 156 (2005)).\n\nThe Panel finds that the ALJ’s application of the doctrine of ejusdem generis was\nimproper. None of the conditions required to apply the doctrine of ejusdem generis are present\nhere. The statute does not have an enumeration of specific words and there is no applicable\nclass. The sole inclusion of “ending of a human pregnancy” by itself cannot be sufficient to\ndemonstrate that it is the first of a class of permitted actions. Even if there is an implicit class\nconsisting of controversial practices, there is no indication that this one item, ending pregnancy,\ncan, by itself, be considered an exhaustive list. Finally, there is no general reference\nsupplementing the enumeration. In sum, the doctrine of ejusdem generis is not applicable to\ninterpreting the definition of the practice of medicine.\n\nDr. Egbert’s actions throughout the suicide process were “in the practice of medicine,”\nunder § 14-404(a)(3)(ii).\n\nII. UNPROFESSIONAL CONDUCT\n\nA. ALJ’s Proposed Decision and Exceptions\n\nThe ALJ found that, because she had determined that participation during the actual\nassisted suicide did not constitute the practice of medicine, whether Dr. Egbert’s actions were\nunprofessional or not was of no consequence. The ALJ found that, in Dr. Egbert’s review of the\nmedical records, Dr. Egbert’s conduct was egregiously unprofessional.\n\nThe State took exception to the ALJ’s analysis. Dr. Egbert excepted to the conclusion\n\nthat his review of the medical records was inherently unprofessional.\n\n13\n\fB. Caselaw\n\n“Unprofessional Conduct” is not defined by the Medical Practice Act, Health Occ. § 14-101.\nMaryland courts have broadly interpreted what may be considered to be “unprofessional\nconduct” under Health Occ. § 14-404(a)(3)(ii). See Finucan, 380 Md. at 597 (sexual relationship\nwith three patients deemed unprofessional conduct); Salerian v. Maryland State Bd. of\nPhysicians, 176 Md. App. 231, 249 (2007) (disclosing confidential physician-patient information\nwas unprofessional conduct); Cornfeld, 174 Md. App. at 468 (dishonesty by lying to a hospital\npeer review deemed unprofessional conduct). Courts have stated that “unprofessional conduct” is\n“conduct which breaches the rules or ethical code of a profession, or conduct which is\nunbecoming” a physician in good standing. Salerian, 176 Md. App. at 248 (quoting Finucan,\n380 Md. at 593).\n\nC. Analysis\n1. Disposing of the Suicide Paraphernalia was Unprofessional.\n\nDr. Egbert removed and disposed of the helium tanks, hoods and suicide paraphernalia.\nAccording to the Final Exit book, the Exit Guide removes suicide paraphernalia to hinder any\npolice investigation, which would lead to longer inquiries. Dr. Egbert’s actions in removing the\nsuicide paraphernalia not only hindered police investigations, but also caused other physicians\nand medical examiners to list the cause of death incorrectly on the patients’ death certificates.\nDr. Silverman, the State’s expert, opined that removing the suicide paraphernalia was deceptive\nfor these reasons. Honesty with patients and colleagues is a fundamental principle of medical\nethics. See AMA’s Principles of Medical Ethics (http://www.ama-assn.org/ama/pub/physician-\nresources/medical-ethics/code-medical-ethics/principles-medical-ethics.page). See also\n\nCornfeld, 174 Md. App. at 479 (quoting Dr. K. v. State Bd. of Physician Quality Assurance, 98\n14\n\fMd. App. 103 (1993)). Lying to or misleading other physicians, medical examiners, and/or the\npolice is a dishonest act, see Cornfeld, 174 Md. App. at 479, and is unbecoming a medical\nprofessional in good standing. See Salerian, 176 Md. App. at 248.\n\n2. Dr. Egbert’s Conduct was Unprofessional because it was Contrary to the\nAmerican Medical Association’s Code of Medical Ethics.\n\nDr. Egbert’s actions are contrary to the American Medical Association’s Code of Medical\nEthics, Opinion 2.211. “[A]llowing physicians to participate in assisted suicide would cause\nmore harm than good. . . . Instead of participating in assisted suicide, physicians must\naggressively respond to the needs of patients at the end of life. . . . Patients near the end of life\nmust continue to receive emotional support... .” See State’s Exhibit 25. The Panel concludes\nthat performing actions that have been rejected by the AMA’s Code of Medical Ethics is\nevidence of unprofessional conduct. See Salerian, 176 Md. App. at 248.\n\n3. Dr. Egbert’s Conduct was Unprofessional because it is Illegal under\nMaryland Law.\n\nAssisting suicide is a criminal act under Section 3-102 of the Criminal Law Article. That\n\nSection provides as follows:\n\nWith the purpose of assisting another individual to commit or attempt to commit\nsuicide, an individual may not:\n\n(1) by coercion, duress, or deception, knowingly cause another individual to\ncommit suicide or attempt to commit suicide;\n\n(2) knowingly provide the physical means by which another individual commits\nor attempts to commit suicide with knowledge of that individual’s intent to use\nthe physical means to commit suicide; or\n\n(3) knowingly participate in a physical act by which another individual commits\nor attempts to commit suicide.\n\nDr. Egbert participated in the patients’ physical act of committing suicide, by holding down the\npatients’ hands. Committing this illegal act is further evidence that Dr. Egbert’s actions were\n\nunprofessional. See Salerian, 176 Md. App. at 248.\n15\n\f4. Dr. Egbert’s Conduct was Unprofessional because it does not Include\nProtective Safeguards Required by States that Permit Physician Assisted\nSuicide.\n\nDr. Egbert’s practices violate the strict protective standards to minimize the potential for\nabuse required in states that permit assisted suicide. In his expert report, Dr. Silverman noted\nthat states that allow physician assisted suicide require a psychiatric consultation to ensure\nexistence of a rational decision. Dr. Egbert and FEN do not have such a consultation to ensure\nrational decisions by the FEN applicant or member.\n\nDr. Egbert and FEN also ignore the strict requirement by states that permit assisted\nsuicide that limit such practice only to terminal patients. Oregon, Washington and Vermont, the\nthree states that have passed laws permitting physician assisted suicide, each limit physician\nassisted suicide to patients suffering from terminal disease. See 18 Vt. Stat. Ann. § 5281\n(terminal disease is defined as “an incurable and irreversible disease which would, within\nreasonable medical judgment, result in death within six months”); Or. Rev. Stat. 127.800 §1.01\n(defining terminal disease as “incurable and irreversible disease that has been medically\nconfirmed and will, within reasonable medical judgment, produce death within six months”);\nWash. Rev. Code § 70.245.010 (same). Vermont specifies that “a bona fide physician—patient\nrelationship with a patient with a terminal condition shall not be considered to have engaged in\nunprofessional conduct” under certain limited circumstances. 18 Vt. Stat. Ann. § 5289\n(emphasis added). Oregon and Washington requires the attending physician to “[mJake the\ninitial determination of whether a patient has a terminal disease .. .” Or. Rev. Stat. 127.815 §\n\n3.01; Wash. Rev. Code 70.245.040 (using identical language).°\n\n> This does not mean to suggest that had Dr. Egbert complied with the other states’ laws that his actions\n\nwould be legal or professional in Maryland.\n16\n\fDr. Egbert admitted by stipulation that none of the six patients whom he helped commit\nsuicide had terminal diseases. Dr. Egbert’s conduct towards non-terminal patients was not a\nmere administrative oversight. In FEN’s first responder and exit guide training, FEN explained\nits approach to non-terminal patients as a feature of the FEN organization, explaining that FEN\n“was created specifically to take nonterminal as well as terminal cases.” In a question and\nanswer pamphlet, FEN claims to be “the only organization in the United States that will support\nindividuals who are not ‘terminally ill’” and explains “[n]o other organization in the US has the\ncourage to make this commitment.” Dr. Egbert’s flagrant disregard for the common safeguards\nenacted by states that allow assisted suicides supports the conclusion that Dr. Egbert’s actions\nare “conduct .. . unbecoming a member in good standing of a profession.” Finucan, 380 Md. at\n593,\n\nII. DR. EGBERT’S ADDITIONAL EXCEPTIONS\nA. Fraudulently Obtaining Medical Records\n\nThe ALJ’s proposed decision concluded that Dr. Egbert improperly held himself out as a\npain management physician in order to obtain patient medical records even though he had no\nintention of treating the patients’ conditions. Dr. Egbert excepted to this conclusion. The Panel\naccepts Dr. Egbert’s exception because no evidence in the record demonstrates that Dr. Egbert\nrequested medical records from any physician, deceived any physician in order to obtain medical\nrecords, or that any medical records were directly transmitted to Dr. Egbert from another\nphysician. The Panel, therefore, does not include these acts, for which there was no evidence, in\n\nthe Board’s determination of unprofessional conduct in the practice of medicine.\n\n17\n\fB. Admissibility of Newspaper Articles, Exhibits 1 and 3\n\nDr. Egbert objects to the admission into evidence of newspaper articles from the\nBaltimore Sun and Washington Post, Exhibits 1 and 3 respectively, because the articles contain\nunreliable hearsay and prejudicial hyperbole. The Panel concludes that the articles were properly\nadmitted because they were relevant to the investigation and the issues raised in the charging\ndocuments. The panel, nevertheless, gives Exhibits 1 and 3 little weight based on their reliability\nlimitations, and instead bases the Panel’s opinion on the State’s other evidentiary exhibits and\ntestimony at the hearing and argument before the Board.\n\nC. Admissibility of Dr. Silverman’s Testimony\n\nDr. Egbert also excepts to the admission by the ALJ of Dr. Silverman’s curriculum vitae\nand report based on the report’s reliance on the AMA ethics opinion. Dr. Egbert claims that the\nAMA Code of Ethics was not adopted by the Panel and therefore cannot be applied to sanction a\nlicensee. The Panel agrees with Dr. Egbert that the Panel is not required to adopt or consider the\nAMA’s Ethics Opinion. Nor is the Panel required to accept the opinion of Dr. Silverman. The\nPanel may do so and chooses to do so here. The Board concludes that Dr. Silverman’s expert\nreport is relevant and its reliance on the AMA ethics opinion does not render it inadmissible.\nThe Panel agrees with the State that unprofessional conduct expressly includes conduct that\nbreaches rules or ethical codes of professional conduct. Finucan, 380 Md. at 593. See also\nSalerian, 176 Md. App. at 248.\n\nCONCLUSIONS OF LAW\nThe Panel concludes that Dr. Egbert’s actions, as described above, constitute\n\nunprofessional conduct in the practice of medicine, in violation of Health Occ. § 14-404(a)(3)(ii).\n\fORDER\nBased on the foregoing Findings of Fact and Conclusions of Law, it is, by a majority of\nthe quorum of Disciplinary Panel B hereby\nORDERED that the license of Lawrence D. Egbert, M.D., to practice medicine in\nMaryland is REVOKED; and it is further\nORDERED that this is a PUBLIC document pursuant to Md. Gen. Prov. Code Ann. §§\n\n4-101 to 4-601 (2014 Vol.)\n\ni2iz- [2014 )\nDate Astin, Farrelly, Exectitive Director\n\nMaryland State Board of Physicians\n\n \n\n \n\fNOTICE OF RIGHT TO PETITION FOR JUDICIAL REVIEW\nPursuant to Md. Code Ann., Health Occ. § 14-408(a), Dr. Egbert has the right to seek\njudicial review of this Final Decision and Order. Any petition for judicial review shall be filed\nwithin thirty (30) days from the date of mailing of this Final Decision and Order. The cover letter\naccompanying this final decision and order indicates the date the decision is mailed. Any petition\nfor judicial review shall be made as provided for in the Administrative Procedure Act, Md. Code\nAnn., State Gov’t § 10-222 and Title 7, Chapter 200 of the Maryland Rules of Procedure.\nIf Dr. Egbert files a petition for judicial review, the Board is a party and should be served\nwith the court’s process at the following address:\nMaryland State Board of Physicians\nChristine A. Farrelly, Executive Director\n4201 Patterson Avenue\nBaltimore, Maryland 21215\nNotice of any petition should also be sent to the Board’s counsel at the following address:\nDavid S. Finkler\nAssistant Attorney General\nDepartment of Health and Mental Hygiene\n\n300 West Preston Street, Suite 302\nBaltimore, Maryland 21201\n\n20\n\fnot being properly treated and he advised the applicant to seek further pain management from\nher physician. Dr. Egbert also noted that FEN accepted applicants with exclusively\npsychological/psychiatric issues. For psychological and psychiatric cases, Dr. Egbert could refer\nthe applicant to a mental health specialist, if he believed that his own determination would be\ninadequate.\n\nAfter FEN accepted the applicant as a member to FEN, that member would receive a\ncopy of the Final Exit book, which detailed how to commit suicide using helium gas to hasten\ndeath by releasing helium into an airtight bag/hood over the member’s head. FEN assigned each\nmember one or two “Exit Guides” to aid the member’s suicide. The Exit Guide talks with the\nmember, rehearses the suicide with the member, ensures all the paperwork is completed, attends\nthe member’s suicide, and holds the member’s hands to comfort the member and to prevent the\nmember from involuntarily displacing the bag during the suicide. After the member’s death, the\nExit Guide removes the helium tanks and bag, leaves, and disposes of the suicide paraphernalia.\nThe suicide paraphernalia is immediately removed from the suicide location to prevent the cause\nof death from being determined and listed on the death certificate and to hinder police\ninvestigations into the circumstances of the death. Each member plans in advance the person\nwho will “discover” the body and that person either calls 911 or the family physician. After the\nsuicide, the Exit Guide contacts the “discoverer” to find out what occurred after the death was\nreported.\n\nIt is undisputed that Dr. Egbert participated in six suicides in the State of Maryland as\neither a Senior Exit Guide or as the members’ only Exit Guide. Dr. Egbert reviewed their\napplications and medical records and recommended accepting them as members. Dr. Egbert\n\nattended their suicide rehearsals. He held each member’s hands and talked to him or her. Each\n\n3\n\f \n\nMARYLAND STATE BOARD * BEFORE JENNIFER M. CARTER JONES,\nOF PHYSICIANS * AN ADMINISTRATIVE LAW JUDGE\nV. * OF THE MARYLAND OFFICE OF\nLAWRENCE D. EGBERT, M.D., * ADMINISTRATIVE HEARINGS\nRESPONDENT i. OAH CASE NO.: DHMH-SBP-71-13-19027\nLICENSE NO.: D16409 *\n* * * * * * * * * * * * * *\nPROPOSED DECISION\nSTATEMENT OF THE CASE\nISSUES\nSUMMARY OF THE EVIDENCE\nFINDINGS OF FACT\nDISCUSSION\nCONCLUSION\nPROPOSED ORDER\nSTATEMENT OF THE CASE\n\n \n\nOn or about November 18, 2012, Maryland’s State Board of Physicians (the Board or SBP)\nissued charges (the Charges) against Lawrence D. Egbert, M.D. (the Respondent). The SBP\nspecifically alleged that the Respondent acted as the Medical Director for Final Exit Network (the\nOrganization or FEN), a right to die organization, and participated in assisted suicides in violation of\nsection 14-404(a)(3)(ii) of the Annotated Code of Maryland Health Occupations Article.\n\nOn July 15, 2013, the Respondent filed a Motion to Dismiss the Charges. On August 1,\n2013, the Board filed the State’s Opposition to Respondent’s Motion to Dismiss. On August 14,\n2013, the Respondent filed a Reply to the Opposition to Respondent’s Motion to Dismiss. On\nAugust 28, 2013, I conducted a hearing on the Motion at the Office of Administrative Hearings\n(OAH), 11101 Gilroy Road, Hunt Valley, Maryland. Lee Baylin, Esquire, represented the\n\nRespondent. Victoria H. Pepper, Assistant Attorney General, represented the State. On\n\fSeptember 18, 2013, I issued a decision denying the Respondent’s Motion to Dismiss the\nCharges.\n\nOn September 26, 2013, I conducted a hearing on the merits at the OAH. Once again, Lee\nBaylin, Esquire, represented the Respondent and Victoria H. Pepper, Assistant Attorney General,\nrepresented the State.\n\nThe contested case provisions of the Administrative Procedure Act, the Board’s Rules of\nProcedure and OAH’s Rules of Procedure govern procedure in this case. Md. Code Ann., State\nGov’t §§ 10-201 through 10-226 (2009 & Supp. 2013); Code of Maryland Regulations (COMAR)\n10.32.02; COMAR 28.02.01.\n\nISSUES\n\n \n\n1. Did the Respondent engage in unprofessional conduct in the practice of medicine, in violation of\nsection 14-404(a)(3(ii) of the Maryland Annotated Code’s Health Occupations Article?\n2. If so, what sanction is appropriate?\nSUMMARY OF THE EVIDENCE\nExhibits\nThe State submitted the following documents, which unless otherwise noted, I admitted\ninto evidence as the exhibits numbered below:\n1. February 29, 2012 letter from the Board to the Respondent, with attached May 21,\n2011 Baltimore Sun article entitled “Baltimore Doctor Helps the Il] Commit Suicide.”\n2. March 8, 2012 letter from the Respondent to the Board, with attached completed\nInformation Form, dated March 8, 2012\n3. January 19, 2012 Washington Post article, entitled “After the Death of Jack\nKevorkian, Lawrence Egbert is the new Public Face of American Assisted Suicide.”\n\n4. FEN records for Patient A, including correspondence and medical records\n\f10.\n\n1\n\n—\n\n12.\n\n14.\n\n15.\n\n16.\n\n17.\n\n18.\n\n9;\n\n20.\n\n2\n\n_\n\n22.\n\n2\n\nWw\n\n24.\n\n25.\n\n26.\n\nMay 27, 2008 Death Certificate for Patient A\nFEN records for Patient B, including correspondence and medical records\nNovember 20, 2008 Death Certificate for Patient B\n\nFEN records for Patient C, including correspondence and medical records\n\n. October 16, 2008 Death Certificate for Patient C\n\nFEN records for Patient D, including correspondence and medical records\n\n. July 18, 2008 Death Certificate for Patient D\n\nFEN records for Patient E, including correspondence and medical records\n\n. August 7, 2006 Death Certificate for Patient E\n\nFEN records for Patient F, including correspondence and medical records\nMay 28, 2004 Death Certificate for Patient F\n\nExcerpts from Final Exit — The Practicalities of Self-Deliverance and Assisted\nSuicide for the Dying (3" Ed. 2010)\n\n2007 First Responder and Exit Guide Training Manual\n\nNot offered\n\nNot offered\n\nNot admitted\n\n. Transcript of Respondent’s April 12, 2012 interview with the Board\n\nCurriculum Vitae — Henry Silverman, M.D., M.A.\n\n. October 5, 2012 report by Dr. Silverman\n\nJanuary 25, 2012 report by Dr. Silverman\nAmerican Medical Association — Medical Ethics — Opinion 2.211 — Physician\nAssisted Suicide\n\nOregon Statute ORS 127.800 et seq.\n\f27. November 28, 2012 Charges against the Respondent under the Maryland Medical\n\nPractices Act\nThe Respondent did not offer any exhibits for admission into evidence.\nTestimony\nThe State presented the testimony of Dr. Henry Silverman, who was accepted as an\nexpert in internal medicine with subspecialties in medical ethics as it relates to end-of-life issues.\nThe Respondent did not testify or offer the testimony of any witnesses.\n\nFINDINGS OF FACT\n\n \n\nThe Parties stipulate to the following facts:\n\n1. The charges in this case are limited to section 14-404(a)(3)(ii) of the Annotated Code of\nMaryland Health Occupations Article.\n\n2. Atall relevant times, the Respondent was and is licensed to practice medicine in the State of\nMaryland. The Respondent is Board-certified in anesthesiology, and was originally licensed\nto practice medicine in Maryland on July 15, 1952.\n\n3. The Respondent has retired from the practice of anesthesiology.\n\n4. The Respondent was one of the founders of the FEN.\n\n5. The FEN is a non-profit organization granted 501(c)(3) status as an educational organization\nby the United States Revenue Service.\n\n6. The Organization provides information and advice to its members! who choose to hasten\ntheir deaths by the inhalation of inert gas (helium). The Organization is a national\n\norganization with volunteers located throughout the country.\n\n \n\n' Throughout the Organization information’s and in the documentary evidence, those who sought FEN’s assistance\nwith terminating their lives are sometimes referred to as “patients” and other times referred to as “members.”\nThroughout this decision, I shall use both of those terms.\n\n4\n\f7. Organization literature states, “[t]he Organization is the only organization in the United\nStates that will support individuals who are not ‘terminally ill’ — six months or less to live —\nto hasten their death [;].” . . . No other organization in the US has the courage to make\nthis commitment.” [Emphasis in original.] These sentiments are echoed in the slogan:\n“[{The Organization] will serve many whom other organization may turn away.” (State Ex.\n27)\n\n8. In order to obtain advice from the Organization, an applicant must become an Organization\nmember by paying a small fee. The applicant then submits medical documentation of his or\nher condition and a letter written by the applicant which, according to the Organization\ntraining manual, subjectively detail[s] their condition, the length of time they’ ve had it, the\neffect it’s had on their quality of life and any other information that has led to their decision\nto exit.” The training manual states that an applicant is also required to read a book titled\n“Final Exit” by Derek Humphry. (State Ex. 17)\n\n9. In his capacity as Medical Director, the Respondent evaluated the records submitted by\napplicants to determine whether the applicant’s request for advice would be accepted.\n\n10. When interviewed by Board staff, the Respondent stated that if he was “uncomfortable with\nthe psychology of the members, I could consult with the [Organization] psychologist.”\n\n1\n\n_\n\n- In addition to being the Organization’s Medical Director, the Respondent was also a Senior\nExit Guide.\n\n12. The Exit Guide’s function is to provide the member and the member’s family with\n\ninformation about the Member’s suicide, or “death event,” the term used by the\n\nOrganization. The Exit Guide and the member discuss family members or friends who may\n\nwish to be present and who will maintain confidentiality regarding the circumstances of the\n\f13.\n\n15;\n\n17.\n\n18.\n\n19.\n\n20.\n\n2\n\n=\n\nmember’s death. The Exit Guide discusses the logistics and timing of “discovering” the\nmember’s body and reporting the death. The Exit Guide also rehearses the death event with\nthe member.\n\nThe Organization does not require that Exit Guides and Senior Exit Guides be physicians,\n\nand to the Respondent’s knowledge, he was the only physician who acted in such capacity.\n\n. The inhaled helium displaces the oxygen in the body and initiates brain death.\n\nAfter a few minutes, the Exit Guide announces that death has occurred. After the tanks have\nemptied, the Exit Guide removes the bag, detaches it from the tanks and places the tanks in\n\ntheir boxes, ready to be disposed of.\n\n. The Exit Guide reminds the person who has agreed to “discover” the body to wait at least\n\ntwo hours before making the discovery. The passage of time permits the body to cool and\ndiscourages attempts at resuscitation.\n\nDeath by inhalation of helium is not detectable when the body is autopsied.\n\nThe Respondent was present at six suicides in Maryland. Four occurred in 2008, one in\n2006 and one in 2004.\n\nNone of the six suicide members had a terminal condition, in that they were not facing\nimminent death within six months.\n\nWhen interviewed by Board staff, the Respondent stated that he was an Exit Guide at each\nof the suicides and that he “always” performed a rehearsal of the procedure prior to the\n“death event.”\n\nI find the following additional facts by a preponderance of the Evidence:\n\n. First Responders are Organization members who initially interview individuals who are\n\ninterested in becoming an Organization members and ending their lives.\n\f22. The Organization created a document entitled “First Responder and Exit Guide Training\nChicago IL, June 08 -10 2007” (Training Manual) which provides instructions for\nOrganization Exit Guides and First Responders. (State Ex. 17).\n\n23. The Training Manual includes the following language:\n\nPatients frequently express concern over obtaining their medical records. They’ re\nentitled to these records by law, but it isn’t unusual for them to say that their doctor\nwill question the need for the records and they’re reluctant to approach a doctor they\ndon’t feel confident about. Sometimes doctors will mail or fax records only to\nanother doctor. If that should be the case, as a last resort, tell the patient to ask the\ndoctor to send the records to:\n\nLawrence Egbert, MD, MPH\n\n814 Powers Street\n\nBaltimore, MD 21211\n\nThe record can also be faxed to him. . . . If a doctor questions why the patient is\nsending records to Baltimore, tell him/her to say that Dr. Egbert is a specialist in\npain management (maybe the patient found him on the Internet) and consults\nthroughout the country on difficult cases (he is and he does, and people do come\nacross his name on the Internet). As an alternative, the patient may say that other\ndoctors have asked for information the patient can’t recall so he/she has started\nkeeping copies of records.\n\n(State Ex. 17).\n\n24. The Organization has produced a document entitled “Procedure for Hastened Death Using\nInert Gas,” which details the procedure and materials the Organization must use to\neffectuate a member’s death by helium. That document states that was written “[b]y Richard\nMacDonald, M_D. edited by Lawrence D. Egbert, MD, MPH.” (State Ex. 17)\n\n25. As part of the Organization’s written material, the Respondent wrote a document entitled\n“Voluntary Stopping of Eating and Drinking (VSED).” The document details the\neffectiveness of VSED for individuals who wish to end their lives. The Respondent used his\nprofessional designation, M.D., as the named author of that document. (State Ex. 17)\n\n26. As Medical Director for the Organization, the Respondent received and evaluated the\n\nmedical records for each member who wished to end his or her life along with a copy of a\n\nZ\n\f2].\n\nletter from the member “stating why life had become only suffering and was no longer\nbearable.” It was the Respondent’s responsibility to “evaluate the care they were receiving.”\n(State Ex. 1; State Ex. 17).\n\nOn April 12, 2012, Heather McLaughlin, Board Lead Compliance Analyst, conducted an\ninterview of the Respondent. During the interview, the Respondent reported that he\nreviewed the medical records of all of the members who solicited the Organization for its\nassistance with suicide. When Ms. Laughlin asked the Respondent to further explain how he\nevaluated individual patients, the Respondent replied as follows:\n\nSo, for example, if they want - - I’ll give you a good example that we’ve had.\nA patient who had terrible pain and I realized that she was not being taken care of,\nJust from the paperwork. All patients had to send in their medical records so that I\ncould read their medical records.\n\nSo I called the patient up and said, you’re not getting pain care, you know.\nAnd she said, tell me about it. So she was quite upset about it, and I said, well, why\ndon’t you - - this is a long conversation that lam speeding up - - but why don’t you\ntell your doctors that this doctor from Hopkins will be glad to tell him how to do it\nright.\n\nSo - - and that was a bit of an overstatement of my credentials. But - - so I\ncalled her up about a month later. She didn’t call back or anything. And she said, no,\nI’m not going to die now, I’m okay, I’ve been taken care of, I’m okay. It’s tolerable,\nthe pain is tolerable. And I said well you jacked up the dose of the morphine then. I\nsaid, did you tell him that? And she said, yes. And I said, you’re getting the proper\ndose.\n\n(State Ex. 21).\n\n28.\n\n29.\n\n30.\n\nThe Organization requires patients to obtain the helium tanks and bag on his or her own.\nThe Organization’s training manual stresses that Exit Guides are prohibited from obtaining\nthis equipment for the patient.\n\nSenior Exit Guides and sometimes a second Guide are present at the death event and in most\ncases, dispose of the helium tanks and other equipment used for the patient’s suicide.\n\nThe Respondent was an Exit Guide in at least six Suicides, including the suicides of Member\n\nA., amale (DOD: May 25, 2008); Member B., a female. (DOD: November 20, 2008);\n\fMember C., a female (DOD: October 15, 2008); Member D, a female (DOD: July 16,\n2008); Member E, a female (DOD: August 5, 2006); and Member R, a female (DOD: May\n27, 2004).\n\n31. The cause of death as stated on each patient’s death certificate is a medical condition from\n\n=\n\nwhich the patient had suffered, such as Parkinson’s disease or coronary artery disease.\n\n32. The Respondent knew that each patient’s death was caused by the inhalation of helium and\nhe knew that none of the patients’ death certificates would state that helium inhalation was\nthe cause of the patients’ death. (State Ex. 17).\n\n33. The American Medical Association (AMA) issued Opinion 2.211 — Physician-Assisted\nSuicide, which provides as follows:\n\nPhysician-assisted suicide occurs when a physician facilitates a patients’s death by\nproviding the necessary means and/or information to enable patient to perform the\nlife-ending act (e.g. the physician provides sleeping pills and information about the\nlethal dose, while aware that the patient may commit suicide).\n\nIt is understandable, though tragic, that some patients in extreme duress — such as\nthose suffering from a terminal, painful, debilitating illness — may come to decide\nthat death is preferable to life. However, allowing physicians to participate in\nassisted suicide would cause more harm than good. Physician-assisted suicide is\nfundamentally incompatible with the physician’s role as a healer, would be difficult\nor impossible to control, and would pose serious societal risks.\n\n(State Ex. 25).\n\nDISCUSSION\n\n \n\nI. The Applicable Law and Board Charges.\nThe Board may reprimand any licensee, place any licensee on probation, or suspend or\n\nrevoke a license if the licensee:\n\n(2) Fraudulently or deceptively uses a license;\n(3) Is guilty of:\n(i) Immoral conduct in the practice of medicine; or\n(ii) Unprofessional conduct in the practice of medicine[.]\n\n9\n\fMd. Code Ann., Health Occ. § 14-404(a)(3)(ii) (Supp. 2012).\n\nThe State, as the moving party, has the burden of proof by a preponderance of the\nevidence to demonstrate that the Respondent violated the Statutory section at issue. Md. Code\nAnn., State Gov’t § 10-217 (2009); Md. Code Ann. Health Occ., § 14-405(b)(2) (2009); Comm’r\nof Labor and Indus. v. Bethlehem Steel Corp., 344 Md. 17, 34 (1996) citing Bernstein v. Real\nEstate Comm'n, 221 Md. 221, 231 (1959). See also Schaffer v. Weast, 546 U.S. 49, 56 - 57\n(2005).\n\nI. The Parties’ Positions.\n\nThe State argued that the Respondent is guilty of unprofessional conduct in the practice of\nmedicine by advocating for and participating in actual suicides of at least six of the Organization’s\nmembers. Particularly, the State argued that in his role as medical director, the Respondent\nundertook responsibilities that constitute the practice of medicine. That is, as Medical Director for\nthe Organization, the Respondent personally evaluated the medical records submitted by\nmembers to determine whether the request for assisted suicide would be accepted. Based upon\nhis medical expertise, the State asserts that the Respondent determined the appropriateness of\nassisting members with their desire to end their lives. In fact, argues the Board, the Respondent\nreferred to those he agreed to assist as “patients.”\n\nIn support of its position, the State offered the testimony of Dr. Silverman, who was\naccepted as an expert in internal medicine, with a subspecialty in pulmonology, critical care\nmedicine, and medical ethics as it relates to end-of-life issues. The State based its charges upon\nDr. Silverman’s written reports, his testimony, documentary evidence of the Respondent’s\nactions as the FEN Medical Director, and AMA Opinion - 2.211 — Physician-Assisted Suicide.\n\nThe Respondent argued that his actions did not occur within “the practice of medicine.”\n\nParticularly, the Respondent argues that his activities related to the Organization did not involve\n\n10\n\fof the members died from asphyxiation due to helium inhalation. After each member died, Dr.\nEgbert removed the hoods and helium tanks and disposed of the helium tanks. In each of these\nsuicides, the death certificates did not list asphyxiation, helium inhalation, or suicide as the cause\nof death. Dr. Egbert stipulated that in each of these suicides, the FEN member was not\nterminally ill, that is, would not have died within six months. The six FEN members for whom\nDr. Egbert acted as an Exit Guide are as follows:\n\n1. Patient A was a 68-year-old man with Parkinson’s disease who suffered from gait\ndisturbances and mental fogginess. He died on May 25, 2008. His death certificate states\nCoronary artery disease due to Parkinson’s disease as the cause of death.\n\n2. Patient B was a 71-year-old woman suffering from progressive Multiple Sclerosis\nfor 45 years complicated by axonal polyneuropathy. She died on November 20, 2008. Her death\ncertificate states acute myocardial infarction and multiple sclerosis as the cause of death.\n\n3. Patient C was an 85-year-old woman with a medical history of significant\nperipheral vascular disease, diabetes mellitus, hypertension, coronary artery disease, atrial\nfibrillation s/p pacemaker placement, anemia, and depression with significant functional\nimpairment. She stated that her reason for suicide was to leave enough money to establish a trust\nto care for her son with Asperger syndrome. She died on October 15, 2008. Her death\ncertificate states that she died from heart failure and aortic valvular disease.\n\n4. Patient D was an 82-year-old woman with chronic obstructive pulmonary disease\nwith increasing difficulty in breathing. She died on July 16, 2008. Her death certificate states\n\nthat she died from right heart failure, emphysema, and smoking.\n\fdiagnosis or treatment of medical conditions for the members, or any other attribute of the\npractice of medicine. Therefore, regardless of the ethical implications of his actions, the Board has\nno basis to revoke his medical license under section 14-404(a)(3)(i).\n\nThe Respondent also argued that his actions within the Organization constitute free\nassociation which is protected by the First Amendment of the United States Constitution\nThe Practice of Medicine\n\nAccording to section 14-101 of the Health Occupations Article “practice medicine” is\ndefined as follows:\n\n(0) Practice medicine. --\n(1) "Practice medicine" means to engage, with or without compensation, in medical:\n\n(i) Diagnosis;\n(ii) Healing;\n(iii) Treatment; or\n(iv) Surgery.\n\n(2) "Practice medicine" includes doing, undertaking, professing to do, and attempting\nany of the following:\n\n(i) Diagnosing, healing, treating, preventing, prescribing for, or removing any\nphysical, mental, or emotional ailment or supposed ailment of an individual:\n\n1. By physical, mental, emotional, or other process that is exercised or\ninvoked by the practitioner, the patient, or both; or\n\n2. By appliance, test, drug, operation, or treatment;\n(ii) Ending of a human pregnancy; and\n(iii) Performing acupuncture as provided under § 14-504 of this title.\n(3) "Practice medicine" does not include:\n(i) Selling any nonprescription drug or medicine;\n(ii) Practicing as an optician; or\n\n(iii) Performing a massage or other manipulation by hand, but by no other means.\n\n \n\nIn my September 18, 2013 Ruling on the Respondent’s Motion to Dismiss, I found that his actions within the\nOrganization do not constitute free association protected by the First Amendment. As the Respondent offered\nnothing new regarding this position, my tuling regarding that argument stands.\n\n11\n\fThe rules of statutory construction been often presented by the Maryland Court of\n\nAppeals as follows:\n\nThe cardinal rule of statutory interpretation is to ascertain and effectuate the real\nand actual intent of the Legislature. A court's primary goal in interpreting\nstatutory language is to discern the legislative purpose, the ends to be\naccomplished, or the evils to be remedied by the statutory provision under\nscrutiny.\n\nTo ascertain the intent of the General Assembly, we begin with the normal, plain\nmeaning of the statute. If the language of the statute is unambiguous and clearly\nConsistent with the statute's apparent purpose, our inquiry as to the legislative\nintent ends ordinarily and we apply the statute as written without resort to other\nrules of construction. We neither add nor delete language so as to reflect an intent\nnot evidenced in the plain and unambiguous language of the statute, and we do\nnot construe a statute with forced or subtle interpretations that limit or extend its\napplication.\n\nWe, however, do not read statutory language in a vacuum, nor do we confine\nstrictly our interpretation of a statute's plain language to the isolated section alone.\nRather, the plain language must be viewed within the context of the statutory\nscheme to which it belongs, considering the purpose, aim, or policy of the\nLegislature in enacting the statute. We presume that the Legislature intends its\nenactments to operate together as a consistent and harmonious body of law, and,\nthus, we seek to reconcile and harmonize the parts of a statute, to the extent\npossible consistent with the statute's object and scope. Where the words of a\nstatute are ambiguous and subject to more than one reasonable interpretation, or\nwhere the words are clear and unambiguous when viewed in isolation, but\nbecome ambiguous when read as part of a larger statutory scheme, a court must\nresolve the ambiguity by searching for legislative intent in other indicia, including\nthe history of the legislation or other relevant sources intrinsic and extrinsic to the\nlegislative process. In resolving ambiguities, a court considers the structure of the\nstatute, how it relates to other laws, its general purpose and relative rationality and\nlegal effect of various competing constructions.\n\nIn every case, the statute must be given a reasonable interpretation, not one that is\nabsurd, illogical or incompatible with common sense.\n\nGardner v. State, 420 Md. 1, 8-9 (Md. 2011) (internal quotation marks and citations\nomitted).\n\nA clear reading of section 14-101 reveals that the practice of medicine focuses on\nproviding care for patients with the goal of healing those patients, or relieving them from\n\nsymptoms of an ailment or condition. Arguably, assisting an individual with ending his or her\nymp guably, 8 &\n\n12\n\flife, particularly, if that individual has been diagnosed with a degenerative or painful medical\ncondition, could be interpreted as the removal of “any physical, mental, or emotional ailment or\nsupposed ailment of an individual.” That is, upon the patient’s death, he or she would be relieved\nof the medical condition; however, such an interpretation of section 14-101 is implausible and\nincompatible with the definition of “practic[ing] medicine.”\n\nThe statutory construction doctrine of ejusdem generis dictates that "when general words\nin a statute follow the designation of particular things or classes of subjects or persons, the\ngeneral words will usually be construed to include only those things or persons of the same class\nor general nature as those specifically mentioned." Haile v. State, 431 Md. 448, 458 (Md. 2013).\nSection 14-101 defines the of “practice medicine” to include the “ending of a human pregnancy.”\nCertainly, the inclusion of what has been and continues to be a controversial medical practice\nwas intended to make clear that the ending of human pregnancy is acknowledged as a legal form\nof authorized medical practice in the State of Maryland. Pursuant to the doctrine of ejusdem\ngeneris, therefore, the omission of assisted suicide, which is prohibited under Maryland law? and\ncertainly controversial, makes it clear that the legislature did not intend the definition of\n“practice of medicine” to include assisted suicide.\n\nHowever, the fact that participation in assisted suicide, generally, does not constitute the\npractice of medicine does not necessarily merit the conclusion that any act that a physician\nundertakes with the goal of assisting an individual or individuals achieve death also must be\ndeemed as outside of the practice of medicine. Indeed, Maryland courts have made it clear that\nthe actions of a physician constitute the practice of medicine when there is a nexus between the\nphysician’s actions and the provision of treatment to patients. McDonnell v. Comm’n on Medical\n\nDiscipline, 301 Md. 426 (1984); Finucan v. Md. Bd. of Physician Quality Assur., 380 Md. 577\n\n \n\n3 See Md. Code Annotated, Crim. Law § 3-102 (2012).\n\n13\n\f(2004); Board of Physician Quality Assurance v. Banks, 354 Md. 59 (1999); Cornfeld v. State\nBd. of Physicians, 174 Md. App. 456, cert. denied, 400 Md. 647 (2007); and Kim v. Md. State\nBad. of Physicians, 423 Md. 523 (2011).\n\nBy contrast, the Maryland Court of Appeals has made it clear that the practice of\nmedicine does not include acts that are only tangentially-related to the responsibilities and\npractice as a physician. McDonnell v. Comm'n on Medical Discipline, 301 Md. 426 (1984).\n\nParticularly, the McDonnell Court held that the actions of a physician, who attempted to\nintimidate experts scheduled to testify against him in a medical malpractice case, did not occur in\nthe practice of medicine. In so holding, the Court explained that although “Dr. McDonnell’s act\nwas ‘related to his professional practice . . . [it] was insufficient to bring his conduct within the\nStatute’s requirement that the conduct occur in his practice as a physician.” Jd. at 437. The Court\nfurther elucidated that the physician’s actions were aimed at prevailing at an adjudicative matter\nand had only a “general or associative relationship to the physician in his capacity as a member\nof the medical profession.” Essentially the Court opined that the adjudication of McDonnell’s\nmedical malpractice case was tangential to the work he performed as a physician.\n\nAfter the McDonnell Court made clear that the physician’s conduct in that case did not\nconstitute the practice of medicine, in Finucan v. Md. Bad. of Physicians Quality Assur. and\nBoard of Physician Quality Assurance v. Banks, 354 Md. 59 (1999), the Maryland Court of\nAppeals addressed when a physician’s actions may be considered to have occurred within the\npractice of medicine. Particularly, the Court held that a physician violates section 14-404 (a)(3)\nwhen he displays unprofessional conduct within the medical setting, or while he is generally\nperforming tasks that are integral to the practice of medicine, whether or not the conduct itself is\n\nmedical in nature.\n\n14\n\fIn Banks, a physician was charged with sexually harassing three female colleagues while\non extended duty at a hospital. The Board determined that each of the instances of sexual\nharassment occurred while the physician was engaged in the practice of medicine “because his\npresence in the hospital and on-call status clearly involved more than merely a general or\nassociative relationship with his practice as a physician.” Banks, 354 Md. at 66. The physician\nappealed and the Circuit Court for Carroll County, Maryland, affirmed the Board’s\ndetermination, reasoning that section 14-403(a)(3) did not require face-to-face dealing with\npatients to constitute the practice of medicine. Rather, because the physician was on his shift at\nthe hospital, in uniform, and present at the hospital for the sole purpose of practicing medicine,\nthe physician’s acts occurred in the practice of medicine. Id. at 66.\n\nThe Court of Special Appeals reversed the Circuit Court regarding two of the instances of\nsexual harassment because they did not occur “during the diagnosis, care, or treatment of\npatients.” Banks v. Bd. or Physicians Quality Assur., 116 Md. App. 249, 262 (1996).*\n\nThe Court of Appeals granted certiorari on the matter and reversed the Court of Special\nAppeals decision with regard to the two instances of sexual harassment,° reasoning that\n\n[t]he Board could reasonably hold that Dr. Banks’ conduct of sexually harassing\n\nhospital employees was within the practice of medicine because he was on duty\n\nand in the working areas of the hospital. When on duty, Dr. Banks was\n\nresponsible for admitting patients, caring for patients and assisting in the\n\noperating room and emergency department. He was not free to leave, and he was\n\nexpected to be available at all times. When Dr. Banks was on duty he was there\n\nfor the purpose of practicing medicine; i.e. for the ‘diagnosis, care, or treatment of\npatients.’\n\n \n\n‘The Court affirmed the Circuit Court’s finding regarding one instance of harassment because it occurred as the\nphysician was using an addressograph machine and requesting a patient record when the harassment occurred. As\nboth of those actions were “necessary procedures and . . . part of treatment of the patient,” the Court of Special\nAppeals determined that the harassment occurred in the course of the practice of medicine. Id. at 263.\n\n> The Court of Appeals affirmed the finding that the third instance of sexual harassment occurred in the practice of\nmedicine.\n\n15\n\fBanks, 354 Md. at 72 (quoting McDonnell, 301 Md. at 437). In so holding, the Court\ndistinguished the circumstances in Banks from those in McDonnell and offered the following\n\nreasoning:\n\nOn one previous occasion this Court examined what is embraced by the phrase “in\nthe practice of medicine." In McDonnell v. Comm'n on Medical Discipline, 301\nMd. 426, 429-430, 483 A.2d 76, 77-78 (1984), we considered the question of\nwhether a physician's attempt to intimidate adverse expert witnesses scheduled to\ntestify against him in a medical malpractice case was "immoral conduct of a\nphysician in his practice as a physician" in violation of § 14-404(a)(3)'s statutory\npredecessor, Code (1957, 1980 Repl. Vol.), Article 43, § 130(h)(8). We held that,\nalthough Dr. McDonnell's conduct was "improper and not to be condoned," it was\n“not censurable under § [14-404(a)(3)]." McDonnell, 301 Md. at 434, 483 A.2d at\n80. The Court agreed that Dr. McDonnell's act was "related to his professional\npractice" but was insufficient to bring his conduct within the statute's requirement\nthat the conduct occur in his “practice as a physician." 301 Md. at 437, 483 A.2d\nat 81. We held that immoral conduct merely committed during the term of\nlicensure or having only a "general or associative relationship to the physician in\nhis capacity as a member of the medical profession" is not within the language of\nthe statute. 301 Md. at 436, 483 A.2d at 81. Rather, the "application of [§ 14-\n404(a)(3)] is directly tied to the physician's conduct in the actual performance of\nthe practice of medicine, i.e., in the diagnosis, care, or treatment of patients." 301\nMd. at 437, 483 A.2d at 81.\n\nBanks, 354 Md. at 70-71.\n\nParticularly, the Court explained that “the primary factors that distinguish the Banks case\nfrom McDonnell were that Dr. Banks was on duty at the hospital, and was present in the working\nareas of the hospital.” Jd. at 74. The Court further explained that “[iJn other cases considering\nwhether a physician’s conduct was within the statutory definition of “in the practice of\nmedicine,” a critical factor has been whether the conduct occurred while the physician was\nperforming a task integral to his or her medical practice.” Jd. The Court refused to apply “a\nnarrow definition of the practice of medicine.” Id.\n\nIn Finucan, a case relatively similar to Banks, a physician engaged in sexual relationships\n\nwith patients and argued that his conduct did not occur in the practice of medicine because he\n\n16\n\fwas not treating the patients at the time of his sexual encounters with them. The Court of\nAppeals disagreed.\n\nRelying on its decision in Banks, the Court reiterated its refusal to apply a technical or\nnarrow definition of the “practice of medicine” and concluded that “Finucan used his\nprofessional skills and his knowledge of his three female patients’ personal and familial\nsituations to play upon their emotional vulnerabilities, even if they facially consented to sexual\nrelationships. Finucan, 380 Md. at 596. Ultimately, the Court explained that conduct “may\nindicate an unfitness to practice medicine if it raises reasonable concerns that an individual\nabused, or may abuse, the status of being a physician in such a way as to harm patients or\ndiminish standing of the medical profession in the eyes of a reasonable member of the general\npublic.” Jd. at 601.\n\nThe Court of Special Appeals echoed the Banks and Finucan Court’s reasoning of what\nconstitutes conduct in the practice of medicine in Cornfeld v. State Bd. of Physicians, 174 Md.\nApp. 456, cert. denied, 400 Md. 647 (2007). In that case, the Circuit Court for Baltimore City\naffirmed the Board’s determination that the Appellant physician had engaged in unprofessional\nconduct in violation of section 14-404(a)(3) of the Health Occupations Article when he made\nfalse statements to hospital peer reviewers and Board investigators related to the mechanical\nsettings for a surgical instrument he used on a patient. In making its determination, the Court did\nnot simply categorize Dr. Cornfeld’s behavior as improper because he was in the hospital setting.\nTo the contrary, the Court recognized that like McDonnell, the conduct at issue took the form of\nstatements made or actions taken during an adjudicatory review or proceeding. However, unlike\nthe case in McDonnell, in which the focus or the impetus of the physician’s acts were to prevail\n\nin an adjudicatory hearing generally unrelated to his practice of medicine, Dr. Cornfeld’s false or\n\n17\n\fmisleading statements directly related to a procedure he had recently performed on a patient and\nshifted blame from himself to other hospital staff.\n\nThe Court of Special Appeals affirmed the Circuit Court, explaining that “the touchstone\nfor determining whether misconduct occurred ‘in the practice of medicine’ must be whether it is\n‘sufficiently intertwined with patient care’ to pose a threat to patients or the medical profession.”\nId. at 474 (quoting Banks, 354 Md. at 76-77).\n\nIn this vein, the Cornfeld Court echoed the Court of Appeals’ reasoning in McDonnell\nthat the nature and effect of a particular act of professional misconduct determines whether it\noccurred in the practice of medicine, and that “[m]isconduct reasonably may be considered to be\nin the practice of medicine when it ‘relates to the effective delivery of patient care.’” Cornfeld,\n174 Md. App. at 477-78. Considering the Court of Appeals’ rejection of the “narrow view” of\nthe practice of medicine in Banks and Finucan, the Court of Special Appeals found Dr.\nCornfeld’s actions sufficiently tied to the practice of medicine to warrant the charges by the\nBoard.\n\nThe Court of Appeals amplified its interpretation of “in the practice of medicine” in Kim\nv. Md. State Bd. of Physicians, 423 Md. 523 (2011), in which the Court of Appeals affirmed the\nBoard’s determination that the physician’s actions occurred in the practice of medicine when he\nwillfully failed to report the pendency of a malpractice action on his application for renewal of\nhis license. Relying on Finucan, the Kim Court explained that ‘in the practice of medicine’\napplies not only to diagnosing and treating patients, but also to ‘misconduct relating to the\neffective delivery of patient care.” Jd. at 541 (quoting Finucan, 380 Md. at 597).\n\nIt is clear that the Respondent's actions in this case do not fit neatly into any of the\nscenarios at issue in McDonnell, Banks, Finucan, Cornfeld or Kim. As I have stated, the\n\nRespondent’s participation in assisted suicide, while illegal, does not, alone, constitute the\n\n18\n\fpractice of medicine. In fact, his participation in assisted suicide is antithetical to the long-\nstanding prevailing purpose of medical practice to treat and heal patients and/or to make patients\ncomfortable. However, aspects or actions the Respondent undertook as Medical Director of the\nFEN do fall within the definition of the practice of medicine.\n\nFirst, the Respondent does not dispute that he reviewed medical records to ensure that\npatients were suffering to the extent that they would be approved for assisted suicide by the FEN.\nAlthough the FEN had a three-member medical panel, the Respondent admitted in his April 12,\n2012 interview with Board Compliance Analyst, Heather McLaughlin, that as Medical Director,\nhe reviewed and evaluated all of the prospective patients’ medical documents and made the\ndetermination whether the individual was suffering sufficiently to qualify for FEN’s assistance\nwith suicide. Certainly, such a review of the medical documentation provided by members to\ndetermine whether the person meets medical criteria for additional treatment is an action\nphysicians undertake as part of their practice of medicine.\n\nIhave already determined that assisted suicide does not constitute the practice of\nmedicine. It logically follows that if the Respondent reviewed medical documentation as a\nformality — that is, if the outcome of his review of those documents always resulted in his\nacceptance of the member’s request for assisted suicide, regardless of other available medical\noptions or treatments of the members’ underlying ailments, then I might find that the review was\ninextricably linked to the Respondent’s participation in assisted suicide in furtherance of his\npersonal ethical involvement with FEN and I might find that his medical document review did\nnot constitute the practice of medicine.\n\nHowever, it is clear that the Respondent sometimes reviewed patients’ medical records\nand made diagnoses with an eye toward healing those patients or improving their lives rather\n\nthan approving them for FEN-assisted suicide. As the Respondent explained during his April 12,\n\n19\n\f2012 interview with Ms. McLaughlin, as the Medical Director for FEN, he was assigned to review\n“complicated cases.” When Ms. McLaughlin asked the Respondent to elaborate, he gave the\nfollowing example of a “complicated case”:\n\nA patient who had terrible pain and I realized that she was not being taken care of,\n\njust from the paperwork. All patients had to send in their medical records so that I\n\ncould read their medical records.\n\nSo I called the patient up and said, you’re not getting pain care, you know.\n\nAnd she said, tell me about it. So she was quite upset about it, and I said, well, why\n\ndon’t you - - this is a long conversation that I am speeding up - - but why don’t you\n\ntell your doctors that this doctor from Hopkins will be glad to tell him how to do it\n\nright.\n\nSo - - and that was a bit of an overstatement of my credentials. But - - so I\n\ncalled her up about a month later. She didn’t call back or anything. And she said, no,\n\nI’m not going to die now, I’m okay, I’ve been taken care of, I’m okay. It’s tolerable,\n\nthe pain is tolerable. And I said well you jacked up the dose of the morphine then. I\n\nsaid, did you tell him that? And she said, yes. And I said, you’re getting the proper\n\ndose.\n\nAs this passage demonstrates, the Respondent advised this patient to tell her practicing\nphysician that he, a doctor from Johns Hopkins Hospital,® had advised her to increase her pain\nmedication. In other words, the Respondent held himself out not only as the Medical Director of\nFEN, but as a physician. He recommended a course of treatment, advised the patient to convey\nhis prescribed treatment to her treating physician, and stood prepared to interact with her\nphysician in support of his prescription of increased pain medication. The Respondent’s actions\nin reviewing medical records to determine whether patients were sufficiently suffering, and\ndiagnosing the patient’s pain and prescribing increased pain medication fall squarely within the\ncontext of the practice of medicine. Unlike McDonnell, in which the Respondent’s actions of\nthreatening a witness in a malpractice case was ancillary to the diagnosis, treatment, or care of ,\n\npatients, the Respondent's actions, although performed as the Medical Director of an\n\norganization that is generally antithetical to the practice of medicine, still bears the hallmark of\n\n \n\n° The Respondent indicated in his statement to Ms. McLaughlin that his representation that he was a doctor at Johns\nHopkins Hospital was inaccurate. Indeed, the Respondent presented no evidence that he is a physician working at\nJohns Hopkins Hospital.\n\n20\n\f5. Patient F was an 87-year-old woman with worsening monopolar depression. She\ndied on August 5, 2006. Her death certificate lists atherosclerosis, cardiovascular disease as the\ncauses of death.\n\n6. Patient G was a 76-year-old woman with degenerative ataxia not amenable to\ntreatment, progressive symptoms and was diagnosed with depression. She died on May 27,\n2004. Her death certificate states that she died from degenerative cerebeller disorder.\n\nANALYSIS\n\nThe issue in this case is whether Dr. Egbert’s actions as Medical Director of FEN and his\nassistance to the suicide of six members of FEN constitutes unprofessional conduct in the\npractice of medicine under Health Occ. § 14-404(a)(3)(ii). In the Board’s analysis, the Board\nfirst discusses whether Dr. Egbert’s conduct was “in the practice of medicine,” second, whether\nhis conduct was “unprofessional,” and finally addresses miscellaneous exceptions filed by Dr.\nEgbert.\n\nI. PRACTICE OF MEDICINE\nA. ALJ’s Proposed Decision and Exceptions\n\nIn her proposed decision, the ALJ found that Dr. Egbert engaged in the practice of\nmedicine based on his review and evaluation of applicants’ medical records. The ALJ, however,\nfound that Dr. Egbert’s presence and assistance in the members’ suicides was not in the practice\nof medicine.\n\nDr. Egbert filed exceptions to the ALJ’s proposed decision’s conclusion that Dr. Egbert’s\nreview of the medical records was in the practice of medicine. He claims that the review of the\nmedical records was not within the practice of medicine. He also claimed that he had not\n\nreceived notice in the charges that his review of medical records was in the practice of medicine.\n\n5\n\fthe practice of medicine. The fact that the Respondent provided this “example” of the\ncomplicated cases he handled merits the conclusion that he recommended to other members that\nthey should seek further medical treatment rather than ending their lives.\n\nIt was only after the Respondent reviewed the patients’ medical documents that he was\nable to determine whether they would be accepted for FEN’s assistance with suicide. According\nto the Respondent, if he determined the patient had other alternatives for treatment, he\nrecommended against suicide and recommended the appropriate medical treatment.\n\nIn light of the admitted fact that the Respondent made medical diagnoses and\ndeterminations that some patients should seek additional or alternative medical treatment, I find\nthe Respondent’s argument that he did not practice medicine as the Medical Director, and that a\nlay person could have served as the Medical Director to be disingenuous. Although it may be\ntrue that a layperson could have served as Medical Director and could have made decisions\naccepting patients for assisted suicide based upon criteria established by the FEN, the fact is that\nthe Respondent is a physician and he clearly used his medical knowledge and expertise in\nmaking medical determinations and prescribed treatment that would help alleviate some of the\nsymptoms of some patients’ medical conditions. Indeed, in the example the Respondent gave, the\nRespondent even suggested that the patient could have her primary care physician consult with\nhim regarding his advisement that she should seek additional treatment for her pain. I find that\nthe Respondent’s act of reviewing medical documentation and making determinations regarding\ntreatment patients should receive constituted medical practice.\n\nSimilarly, I find that by virtue of the fact that the Respondent decided when patients\ncould potentially benefit from medical treatment in lieu of suicide, he also decided when patients\ncould not potentially benefit from additional medical treatment in lieu of suicide. According to\n\nthe unrebutted evidence, the FEN accepted applications and assisted in suicides of patients who\n\n21\n\fwere not diagnosed with terminal illnesses. Nevertheless, the Respondent reviewed these\npatients’ records and determined that they were eligible for assisted suicide. The fact that the\nRespondent occasionally determined that some individuals would benefit from additional\nmedical or psychological treatment, but determined that others could not benefit from such\ntreatment, merits the conclusion that he undertook a medical analysis for many, if not each of the\npatients he approved for assisted suicide. I find that the Respondent’s review of the medical\ndocuments resulting in assisted suicide cannot be extracted from his review of medical\ndocuments resulting in further medical treatment because at the time of review, either option was\navailable. The fact that the Respondent ultimately approved assisted suicide in many of the cases\ndoes not take his review of the medical documents outside of the practice of medicine.\nTherefore, I find that each time the Respondent reviewed medical records to determine whether\nthey would be accepted for assistance with suicide, he engaged in the practice of medicine.\n\nIt is also clear that the Respondent held himself out as a practicing physician to patients\nand other physicians for the purpose of obtaining medical records. According to the FEN training\nmanual, patients were advised that they could have their medical records sent to the Respondent,\na doctor, if they were uncomfortable obtaining the documents themselves. Particularly, the FEN\ntraining manual provided the following regarding obtaining medical records:\n\nPatients frequently express concern over obtaining their medical records. They’ re\n\nentitled to these records by law, but it isn’t unusual for them to say that their doctor\n\nwill question the need for the records and they’ re reluctant to approach a doctor they\n\ndon’t feel confident about. Sometimes doctors will mail or fax records only to\n\nanother doctor. If that should be the case, as a last resort, tell the patient to ask the .\n\ndoctor to send the records to:\n\nLawrence Egbert, MD, MPH\n\n814 Powers Street\n\nBaltimore, MD 21211\n\nThe record can also be faxed to him . . . . If a doctor questions why the patient is\n\nsending records to Baltimore, tell him/her to say that Dr. Egbert is a specialist in\npain management (maybe the patient found him on the Internet) and consults\n\n22\n\fthroughout the country on difficult cases (he is and he does, and people do come\n\nacross his name on the Internet). As an alternative, the patient may say that other\n\ndoctors have asked for information the patient can’t recall so he/she has started\n\nkeeping copies of records.\n\nAgain, unlike McDonnell, the Respondent is performing a traditional function of a\nphysician, requesting medical documents from another physician, ostensibly, to review those\ndocuments for the purpose of pain management. Although the Respondent’s actions may not have\noccurred within the context of a medical facility, as was the case in Banks and Finucan, his\nphysician-related actions were inextricably linked to the traditional duties and actions of a\nphysician. Indeed, it is reasonable to conclude that if a layperson held himself out as a physician,\nreviewed and evaluated medical documents, and prescribed additional medical treatment, one could\nreasonably interpret that individual’s action as practicing medicine without a license.\n\nUltimately, I find that the Respondent’s acts including reviewing patients’ medical records,\ndetermining whether they would benefit from additional medical treatment or determining whether\ntheir condition could not benefit from additional medical treatment constituted the practice of\nmedicine. I further find that holding himself out as a physician to whom other physicians could send\npatients’ medical documents, constituted the practice of medicine.\n\nUnprofessional Conduct\n\nThe term “unprofessional conduct” is not defined in the Maryland Medical Practice Act.\nThe Court of Appeals has, however, considered that term, in the context of the Maryland Medical\nPractice Act, and it determined that “unprofessional conduct” refers to conduct that breaches rules\nor ethical codes of professional conduct, or is conduct unbecoming a member in good standing in\nthe profession. Finucan, 380 Md. at 593.\n\nMuch of the State’s position in this case focused on the fact that the Respondent\nparticipated in assisted suicide, and that, generally, his actions were unprofessional. Dr.\n\nSilverman testified that physicians bear an extremely important role when it comes to end-of-life\n\n23\n\fissues. Often, patients who are struggling with end-of-life considerations turn to physicians for\nguidance and explanation of their options. According to Dr. Silverman, the physician fulfills a\nsignificant role in the psyche of their patients and, often, patients’ families who are making\ndecisions about the patient’s end-of-life choices. The physician, opined Dr. Silverman, is charged\nwith providing the patient and his or her family with options that will result in a dignified death,\nwith as little pain as possible. The Respondent, however, inappropriately used his authority as a\nphysician to guide, or at the very least, provide the means for patients to commit suicide. This,\nexplained Dr. Silverman, is in discord with the primary tenet of medicine — to do no harm.\n\nThe State also argued that the Respondent acted unprofessionally because he admittedly\nknew that helium was not detectable in the human body and he was aware that the death\ncertificate for the FEN’s assisted-suicide patients would reflect an erroneous cause of death by\nthe Medical Examiner and on the death certificate.\n\nAs Ihave stated, the actual participation in assisted suicide and the advocacy of assisted\nsuicide, does not constitute the practice of medicine as those actions are antithetical to the\npractice of medicine and are illegal in the State of Maryland. Therefore, generally, whether the\nRespondent’s actions were unprofessional within the context of his actual participation in the\nassisted suicide of the FEN’s patients is of no consequence because the unprofessional acts must\noccur in the practice of medicine.\n\nBecause I have found that the participation in assisted suicide, alone, does not constitute\nthe practice of medicine, I similarly find that the consequences of the Respondent's participation\nin assisted suicide can not constitute the practice of medicine. That is, although the Respondent\nknew that the patients’ death certificates would reflect an inaccurate cause of death, although\nthere may be legal implications to that knowledge, his knowledge alone can not create a nexus\n\nbetween the Respondent’s actions and the practice of medicine. Again, the entire goal of assisted\n\n24\n\fsuicide is wholly divorced from the treatment of patients and the practice of medicine.\nAccordingly, although the result of his actions would be considered unprofessional, and subject\nto sanction under section 14-404(a)(3)(ii) if his actions occurred within the context of his\n“practice of medicine,” because his actions in physically participating in the assisted suicide\ncannot be classified as the practice of medicine, its result cannot be so classified either.’\n\nIhave, however, determined that two aspects of the Respondent’s actions as the Medical\nDirector of FEN constituted the practice of medicine — that is, 1) the Respondent’s review and\nevaluation of medical records and the resulting prescribed action following that review; and, 2)\nthe Respondent’s act of holding himself out as a physician to whom other physicians could\ntransmit member’s medical records for review. I now turn to whether the Respondent’s actions\nrelated to those two aspects of medical practice were unprofessional.\n\nMedical document review and evaluation\n\nThe Respondent does not dispute that he reviewed and evaluated the medical records for\npatients who sought FEN’s assistance with terminating their lives. He also acknowledges that\nafter that review, he occasionally made “suggestions to improve their care.” (State Ex. 1). In\nthose instances when the Respondent made suggestions to improve care, I cannot determine that\nsuch suggestions were improper or unprofessional because the State has offered no evidence\nregarding those patients. However, it is also undisputed — and supported amply by the evidence —\nthat in many cases, after the Respondent reviewed the medical documentation of members, he\ndetermined that those members were suffering sufficiently to qualify for assisted suicide.\nEssentially, in his role as a physician, the Respondent rendered a medical determination and\n\nsanctioned a “remedy” to the patients’ condition that was wholly antithetical to the purpose and\n\n7 Furthermore, if the Board wished to pursue the Respondent for knowingly causing the filing of a false medical\nreport, it could have charged him with violating section 14-404(a)(12) of the Health Occupations Article, which it\ndid not do.\n\n25\n\fgoal of medicine — to do no harm. I find that the Respondent's action to approve assisted suicide\n“abused .. . the status of being a physician in such a way as to harm patients or diminish\nstanding of the medical profession in the eyes of a reasonable member of the general public.”\nFinucan, 380 Md. at 601.\n\nFor the foregoing reasons, I find that the only plausible interpretation of the Respondent’s\nreview and evaluation of medical records and sanctioning assisted suicide is that it was\negregiously unprofessional. He is therefore, subject to sanction under section 14-404(a)(3)(ii) of\nthe Health Occupations Article.\n\nHolding self out as a physician to whom other physicians could send patients’ medical\ndocuments\n\nAs I have stated, the Respondent held himself out as a practicing physician to patients\nand other physicians for the purpose of obtaining medical records. According to the FEN training\nmanual, when patients were reluctant to request medical documents from their physicians, or\nwhen their physicians would only fax medical documents to another physician, those patients\nwere advised that they could have their physicians send their medical documents to the\nRespondent in his capacity as a physician. The Exit Guide also advises that patients could tell\ntheir physicians that the Respondent is a specialist in pain management.\n\nEssentially, therefore, the Respondent mislead, or stood ready to mislead fellow physicians\nwho elected to send medical documents to the Respondent that he would receive medical\ndocuments ostensibly, to treat the patients for their underlying ailments. As has been proven, in\nmany cases, the Respondent did not treat patients in accord with the practice of medicine, but rather,\nsanctioned a course of action that ultimately resulted in the termination of the patients’ lives.\n\nI find that the Respondent’s actions divested - or stood prepared to divest - patients’ treating\nphysicians from the opportunity to offer their patients alternatives to the life-ending measures\n\nthey had chosen. Accordingly, I find that such action or willingness to act in this manner was\n\n26\n\fwholly unprofessional because it prevented - or potentially prevented - those patients’ treating\nphysicians from effectively delivering patient care. Cornfeld, 174 Md. App. at 477-78.\nProposed Sanction\n\nThe State recommends that the Respondent's license be revoked. In support of that\nrecommended sanction, the State argued that the purpose of the sanction in cases before the Board is\ntwo-fold. First, it serves as a prophylactic against further similar action by the Respondent. Second,\nit serves as a deterrent. That is, the sanction serves as notice to physicians that engaging in the\npractice of medicine in connection with assisted suicide is unconscionable and will result in the\n\nrevocation of one’s medical license.\n\nCOMAR 10.32.02.10 and .11 announce the specific sanctions the Board may levy against a\nphysician found in violation of section 14-404 of the Health Occupations Article. Among other\nthings, COMAR 10.32.02.10B(6) dictates that the Board may consider aggravating factors when\ndetermining the appropriate. sanction for unprofessional conduct in the practice of medicine.\nAmong those aggravating factors is whether “[t]he offense had the potential for or actually did\n\ncause patient harm.”\n\nThe evidence in this case certainly proves that the Respondent’s conduct not only resulted in\nharm to his patients, but it resulted in many of his patients’ deaths. I agree with the State that it has a\nvested interest in making it clear that it will not abide physicians who use their medical practice and\nexpertise for the purpose of ending human life.\n\nIn so finding, I acknowledge the Respondent’s position that any lay person could have *\nundertaken the actions that the Respondent undertook as Medical Director for the FEN; the fact\nremains, however, that the Respondent took these actions as a physician — performing traditionally\n\nphysician-related tasks. The Board has a strong interest in preventing behavior such as the\n\n27\n\fRespondent’s to preserve the integrity of the medical profession as one that uses medical expertise\nto heal and treat its patients.\nAccordingly, based on the evidence presented in this case, I propose that revocation of the\n\nRespondent's license is an appropriate sanction.\n\nCONCLUSIONS OF LAW\n\n \n\nI conclude that the Respondent violated section 14-404(a)(3)(ii) of the Health Occupations\nArticle. I further conclude that because of this violation the Board may discipline the Respondent.\nMd. Code Ann., Health Occ. § 14-404(a).\n\nPROPOSED ORDER\n\nI PROPOSE that the charge filed by the Board on November 18, 2012, against the\n\nRespondent for violation of section 14-404(a)(3)(ii) be UPHELD.\n\nI PROPOSE that the Respondent’s license be REVOKED.\n\nDecember 23, 2013 / CA We\nDate Decision Mailed i L\n\nAdministrative Law Judge\n\n \n\nNOTICE OF RIGHT TO FILE EXCEPTIONS\nSSE OO BILE EXCEPTIONS\n\nAny party may file written exceptions to this Proposed Decision with the Board of\nPhysicians within fifteen days of issuance of the decision. Md. Code Ann., State Gov’t § 10-216\n(2009) and COMAR 10.32.02.03F. The Office of Administrative Hearings is not a party to any\nreview process.\n\nJCJ/emh\n#146840\n\n28\n\fMARYLAND STATE BOARD * BEFORE JENNIFER M. CARTER JONES,\n\nOF PHYSICIANS * AN ADMINISTRATIVE LAW JUDGE\nv. # OF THE MARYLAND OFFICE OF\nLAWRENCE D. EGBERT, M.D., * ADMINISTRATIVE HEARINGS\nRESPONDENT * OAH CASE NO.: DHMH-SBP-71-13-19027\nLICENSE NO.: D16409 “\n%* * * * * * * * * * * * * *\nFILE EXHIBIT LIST\n\n \n\nThe State submitted the following documents, which unless otherwise noted I admitted\ninto evidence as the exhibits numbered below:\n\n1. February 29, 2012 letter from the Board to the Respondent, with attached May 21,\n2011 Baltimore Sun article entitled “Baltimore doctor helps the ill commit suicide.”\n\n2. March 8, 2012 letter from the Respondent to the Board, with attached completed\nInformation Form, dated March 8, 2012\n\n3. January 19, 2012 Washington Post article, entitled “After the Death of Jack\nKevorkian, Lawrence Egbert is the new Public Face of American Assisted Suicide.”\n\n4. FEN records for Patient A, including correspondence and medical records\n\n5. May 27, 2008 Death Certificate for Patient A\n\n6. FEN records for Patient B, including correspondence and medical records\n\n7. November 20, 2008 Death Certificate for Patient B\n\n8. FEN records for Patient C, including correspondence and medical records\n\n9. October 16, 2008 Death Certificate for Patient C\n\n10. FEN records for Patient D, including correspondence and medical records\n\n11. July 18, 2008 Death Certificate for Patient D\n\f12.\n13.\n14.\n15.\n\n16.\n\nbye\n\n18.\n\n20.\n\n2\n\n-\n\n22.\n\n23:\n\n24.\n\n25.\n\n26.\n\n27.\n\nFEN records for Patient E, including correspondence and medical records\nAugust 7, 2006 Death Certificate for Patient E\n\nFEN records for Patient F, including correspondence and medical records\nMay 28, 2004 Death Certificate for Patient F\n\nExcerpts from Final Exit — The Practicalities of Self-Deliverance and Assisted\nSuicide for the Dying (3" Ed. 2010)\n\n2007 First Responder and Exit Guide Training Manual\n\nNot offered\n\n. Not offered\n\nNot admitted\n\n. Transcript of Respondent’s April 12, 2012 interview with the Board\n\nCurriculum Vitae ~ Henry Silverman, M.D., M.A.\n\nOctober 5, 2012 report by Dr. Silverman\n\nJanuary 25, 2012 report by Dr. Silverman\n\nAmerican Medical Association — Medical Ethics — Opinion 2.211 — Physician\nAssisted Suicide\n\nOregon Statute ORS 127.800 et seq.\n\nNovember 28, 2012 Charges against the Respondent under the Maryland Medical\n\nPractices Act\n\nThe Respondent did not offer any exhibits for admission into evidence.\n\fThe State filed exceptions to the ALJ’s proposed decision’s conclusions that aiding\npatients in committing suicide was not the practice of medicine, arguing that the continuum of\nDr. Egbert’s conduct including reviewing the medical records, his participation in the suicide\nrehearsal, his conduct during the suicides, and his conduct after the suicides, such as removing\nthe helium tanks and suicide paraphernalia, should be considered the practice of medicine.\n\nB. Practice of Medicine in Statute and Caselaw\n\nThe Medical Practice Act, Health Occ. § 14-101(0) defines practicing medicine as\nfollows:\n\n(1) “Practice medicine” means to engage, with or without compensation, in\n\nmedical:\n\n(i) Diagnosis;\n(ii) Healing;\n\n(iii) Treatment; or\n(iv) Surgery.\n\n(2) “Practice medicine” includes doing, undertaking, professing to do, and\nattempting any of the following:\n(i) Diagnosing, healing, treating, preventing, prescribing for, or\n\nremoving any physical, mental, or emotional ailment or supposed ailment\n\nof an individual:\n1. By physical, mental, emotional, or other process that is\n\nexercised or invoked by the practitioner, the patient, or both; or\n2. By appliance, test, drug, operation, or treatment;\n(ii) Ending of a human pregnancy; and\n(iii) | Performing acupuncture as provided under § 14-504 of this title.\nMaryland courts have not strictly interpreted the statutory definition of practicing\nmedicine, but rather have applied a broad interpretation of what is “in the practice of medicine”\nunder Health Occ. § 14-404(a)(3)(ii). See Kim v. Maryland State Board of Physicians, 423 Md.\n523, 527 (2011) (lying on a renewal application deemed in the practice of medicine); Finucan v.\n\nMaryland Bd. of Physician Quality Assurance, 380 Md. 577, 597 (2004) (sexual relationship\n\nwith three patients deemed in the practice of medicine); Board of Physician Quality Assurance v.\n\fBanks, 354 Md. 59, 66 (1999) (sexual harassment of administrative employees of a hospital\ndeemed in the practice of medicine); Cornfeld v. State Board of Physicians, 174 Md. App. 456,\n468 (2007) (lying to a hospital peer review deemed in the practice of medicine). In deciding\nwhether Dr. Egbert’s action is in the practice of medicine, the Board must consider whether his\nactions were “intertwined with patient care to pose a threat to the patients or the medical\nprofession.” Cornfeld, 174 Md. App. at 474.\nC. Analysis\n1. Physician-Patient Relationship\n\nBefore the Panel considers whether Dr. Egbert’s actions can be considered intertwined\nwith patient care, the Panel must determine whether these FEN applicants and members were\npatients. The Panel concludes that the FEN applicants and members were Dr. Egbert’s patients.\n\nFirst, Dr. Egbert considered the FEN members to be his patients. In his letter to Board\nstaff and throughout his interview with Board staff, Dr. Egbert described the FEN members who\ncommitted suicide as “patients.” In his letter to the Board, Dr. Egbert further stated that he\nbelieved that “if a person has the right to hasten death, a physician has the right to guide him or\nher in doing this in a painless and dignified manner.”\n\nSecond, Dr. Egbert held himself out to the members as a physician and medical\nprofessional. Dr. Egbert was identified as the Medical Director of FEN and performed the\nduties, including deciding which individuals could be approved for membership based on the\nseverity of their illnesses. In two publications for FEN members, Dr. Egbert was referred to by\nhis title as an “M.D.” In a document titled “Procedure for Hastened Death Using Inert Gas,” Dr.\nEgbert was identified as an editor with his “M.D.” and “M.P.H.” degrees listed after his name.\n\nAdditionally, the training manual suggested that if a physician refuses to provide a patient’s\n\n7\n\fmedical record, the patient could send the records to “Lawrence Egbert, MD MPH,” and\nsuggested the patient tell his doctor that “Dr. Egbert” is a pain management specialist. This\ntraining manual refers to the FEN members as patients as well. These documents indicate that\nDr. Egbert and FEN identify their members as patients, and Dr. Egbert is identified to them as a\nphysician. As discussed further below, the actions taken by Dr. Egbert were also the type of\nactions that a physician undertakes, such as reviewing and evaluating patient medical records and\naiding the patients with their end of life decisions.\n2. Review of Medical Records to Determine Diagnosis of Conditions,\nSeverity of Suffering and Possible Treatment Options is “In the Practice\nof Medicine.”\n\nNext, the Panel finds that the continuum of Dr. Egbert’s conduct was intertwined with\npatient care, that is, involved patient welfare, health, and the potential for patient harm. Dr.\nEgbert acted in his role as a physician both when he reviewed the medical records as part of his\nduty as medical director of FEN as well as the actions he took as an Exit Guide.\n\nDr. Egbert argues in his exceptions that lawyers, nurses, insurance adjusters, nutritionists\nand pharmacists all review patient records without engaging in the practice of medicine. While\nthat is true, each professional reviews records for different purposes. The Panel concludes that\nDr. Egbert cannot divest himself of his licensure or his medical training and expertise or his\npurpose in reviewing the medical records, in considering whether he has acted as a physician.\n\nThe State’s expert, Dr. Silverman, opined that determinations based on medical records\nabout what disease or illness the person was suffering from, whether the individual had\nintolerable suffering, and whether the care the individual was receiving was sufficient are\n\nmedical determinations because he made medical assessments about patients conditions. See\n\fHealth Occ. § 14-101(0). Dr. Egbert presented no expert testimony to contradict this opinion.\nThe Panel finds Dr. Silverman’s testimony persuasive.\n\nFurther, Dr. Egbert stated in his letter to the Board Senior Compliance Analyst:\n\nMy work for the Final Exit Network was to evaluate each person’s request to\n\nhasten death. I received their medical records and a copy of their letters stating\n\nwhy life had become only suffering and was no longer bearable. /t was my job to\n\nevaluate the care they were receiving and occasionally there were suggestions\n\nmade to improve their care. \\ had several psychologists for consultation. No one\n\nhas suggested that our patients were not suffering severely.\nEvaluation of medical care for improved care is one example that demonstrates that his role in\nreviewing medical records was in the medical realm, Another example given by Dr. Egbert at\nhis interview concerned an applicant who wanted to commit suicide because of her pain. After\nhis review of the file, he determined that her pain was not being properly treated. He advised\nthe patient that she tell her doctor that she needed more pain medicine, and “this doctor from\nHopkins [Dr. Egbert], will be glad to tell him how to do it right.” As a result of his medical\nadvice, the applicant withdrew her application for FEN. Such evaluation and advice are\nillustrative of the way in which Dr. Egbert’s review of patient files in this context was medical in\nnature and within the practice of medicine. Even if the review were not squarely under the\ndefinition of “practicing medicine,” it was certainly “in the practice of medicine” under the broad\ninterpretation the Court of Appeal applied in Banks. 354 Md. at 66.\n\nDr. Egbert noted that he sought additional information if he believed that the medical\nrecords were incomplete. Additionally, Dr. Egbert made referrals to psychologists when he was\nuncomfortable evaluating the psychology of the patients. Dr. Egbert explained that with regards\n\nto the psychology of patients “[t]he difficulty was that I am not a psychiatrist.” In so doing, Dr.\n\nEgbert used his medical expertise, and when he did not have requisite medical expertise, he\n\fwould refer the patient to a specialist, rather than use his lay, non-medical opinion. Referring\npatients to specialists is also an element of what physicians do. This also indicates that in non-\npsychiatric cases he was using his expertise as a physician to diagnose the patient. Dr. Egbert’s\nevaluations were, thus, in the practice of medicine, even in cases that Dr. Egbert approved\nwithout comment.\n\nIn sum, Dr. Egbert used his medical expertise to evaluate the medical records, diagnose\nthe patients, and measure the severity of their conditions, and he gave medical advice about\ntreatment, when appropriate. When he did not feel comfortable with his diagnosis or felt his\nmedical knowledge was insufficient, such as the psychological matters, he would refer the\npatients to a specialist. The Board, thus, rejects Dr. Egbert’s claim that he did not practice\nmedicine.\n\n3. Aiding Suicide Concerned Patient Well-being and is In the Practice of\nMedicine.\n\nDr. Egbert was also acting in the practice of medicine in his role as an Exit Guide\nbecause his conduct led to extreme threats to the patient’s well-being by aiding their suicide.\nThe Maryland Court of Appeals held that suicide is a type of harm to patients that may be\nevidence that the physician’s conduct should be considered within the practice of medicine. See\nFinucan, 380 Md. at 599 (quoting Finucan, 151 Md. App. at 417) (considering the possibility\nthat Dr. Finucan’s sexual relationship with a patient caused her apparent suicide attempt as\n\nevidence that Dr. Finucan’s conduct was in the practice of medicine).\n\n10\n\f
2 IN THE MATTER OF * BEFORE THE\nJOAN SMITH, D.O. * MARYLAND STATE\nRespondent * BOARD OF PHYSICIANS\n\nLicense Number: H48286 * Case Numbers: 2014-0741 & 7714-0061\n\n* * * * * * * * * * * *\n\nCEASE AND DESIST ORDER\n\nPursuant to the authority granted to the Maryland State Board of Physicians (the\n“Board”) under Md. Code Ann., Health Occ. (“Health Occ.”) § 14-206(e)(2) (2014 Repl.\nVol.), the Board hereby orders Joan Smith, D.O. (the “Respondent”), License Number\nH48286, to immediately CEASE AND DESIST from providing medical care to her family\nmembers, including but not limited to the prescribing of any medications.\n\nINVESTIGATIVE FINDINGS"\n\nBased on investigatory information received by, made known to, and available to\nthe Board, it has reason to believe that the following facts are true:\nBACKGROUND\n1. At all times relevant, the Respondent was licensed to practice medicine in the\nState of Maryland. The Respondent was originally licensed to practice medicine in\n\nMaryland on July 3, 1995, and her current license is scheduled to expire September 30,\n\n2015.\n2. The Respondent is board-certified in family medicine.\n3. At all times relevant, the Respondent was a solo practitioner in family medicine in\n\nSalisbury, Maryland.\n\n‘ The statements regarding the Respondent's conduct are intended to provide the Respondent with notice\nof the basis of the Cease and Desist Order. They are not intended as, and do not necessarily represent a\ncomplete description of the evidence, either documentary or testimonial, to be offered against the\nRespondent in connection with this matter.\n\f4. On October 23, 2013, the Board charged the Respondent with violating the\nstandard of quality care pursuant to Health Occ. § 14-404(a)(22) and inadequate\nrecordkeeping pursuant to Health Occ. § 14-404(a)(40).\n5. On March 14, 2014, the Respondent entered into a Consent Order with the\nBoard in order to resolve the charges noted in J. 4. The Consent Order imposed a\nreprimand, and ordered the Respondent within 30 days of the Consent Order to\npermanently cease prescribing controlled dangerous substances (“CDS”) for pain\nmanagement purposes and buprenorphine, and placed her on probation for a minimum\nperiod of two years under terms and conditions.\n6. At all times relevant, the Respondent was under the probationary terms and\nconditions imposed by the Board’s Consent Order.\nCURRENT COMPLAINTS\n7. On or about April 1, 2014, a pharmacist employed by Pharmacy A? in Salisbury,\nMaryland, filed a complaint with the Board alleging she had concerns the Respondent\nhad been inappropriately prescribing medications to two family members (Patients A\nand B). Several of the medications that had been prescribed were alleged to have been\n“atypical” based on their respective ages.\n8. The American Medical Association (“AMA”) Code of Medical Ethics provides in\npertinent part:\nOpinion 8.19 — Self-treatment or Treatment of Immediate Family Members\nPhysicians generally should not treat themselves or members of their immediate\nfamilies. Professional objectivity may be compromised when an immediate\n\nfamily member or the physician is the patient; the physician’s personal feelings\nmay unduly influence his or her professional medical judgment, thereby\n\n2 In order to maintain confidentiality, facility, employee and patient names will not be used in this\ndocument, but will be provided to the Respondent on request.\n\n2\n\finterfering with the care being delivered. Physicians may fail to probe sensitive\nareas when taking the medical history or may fail to perform intimate parts of the\nphysical examination...When treating themselves or immediate family members,\nphysicians may be inclined to treat problems that are beyond their expertise or\ntraining.\n...Concerns regarding patient autonomy and informed consent are also relevant\nwhen physicians attempt to treat members of their immediate family. Family\nmembers may be reluctant to state their preferences for another physician or\ndecline a recommendation for fear of offending the physician...\n...Except in emergencies, it is not appropriate for physicians to write\nprescriptions for controlled substances for themselves or immediate family\nmembers.\n9. Shortly after receiving the April 1, 2014 complaint, the Board initiated an\ninvestigation.\n10. By letter dated May 5, 2014, the Board notified the Respondent of its\ninvestigation and issued to the Respondent a subpoena for the medical records of\nPatients A and B. The Respondent stated she was unable to produce all the records in\nher possession for Patients A and B as her computer “server” was not functioning.\n11. On or about May 8, 2014, a second complaint was filed by a physician (Dr. C)\nwho had seen Patient A for medical care the day before. Dr. C alleged in her complaint\nthat the Respondent had treated Patient A after inadequately evaluating him, and that\nher use of medications for Patient A was inappropriate.\n12. Onor about May 15, 2014, the Board’s staff interviewed Dr. C, who stated that\nthe Respondent acknowledged to her that she (the Respondent) had prescribed several\nmedications for Patient A. According to Patient A’s medical record and Dr. C's\ninterview, the Respondent had been prescribing several medications to Patient A\n\nincluding a Schedule |V barbiturate, a Schedule IV benzodiazepine, blood pressure\n\nmedications including a diuretic, Vitamin D supplementation, allergy medications and a\n\fnonsteroidal anti-inflammatory medication. Additionally, according to Dr. C, the\nRespondent stated that she did not have experience stopping the benzodiazepines that\nshe was prescribing to Patient A.°\n\n13. By letter dated May 15, 2014, the Board sent a letter by facsimile and regular\nmail requesting the medical records for Patients A and B be provided on or before May\n22, 2014, and notifying her that the Board may consider her failure to produce the\nrecords to constitute a failure to cooperate with a lawful investigation.\n\n14. By letter dated May 19, 2014, the Board’s staff reiterated that it was requesting\nthe complete medical records of Patients A and B, as the Respondent had reported that\nshe had not provided all of the records as requested, making clear that her submission\nto the Board had not been complete.\n\n15. On May 20, 2014, the Board reissued a subpoena for complete copies of any\nand all medical and billing records for Patients A and B generated by the Respondent or\nany other health care entity in her possession or constructive possession.\n\n16. On May 22, 2014, the Respondent sent by electronic mail additional patient\nrecords for Patients A and B in response to the Board’s subpoena.\n\n17. On May 22, 2014, the Respondent submitted a letter to the Board stating:\n\nIt is my intention to cease and-desist from the [p]rovision of [mJedication\n[p]rescriptions for the following [i]ndividuals:\n\n[Patient A and Patient B]...\n18. On May 23, 2014, the Respondent sent by electronic mail additional patient\n\nrecords, stating, “please let me know if | have missed anything.”\n\n° When stopping benzodiazepines, a patient must be appropriately weaned in order to prevent withdrawal\nsymptoms from occurring.\n\n4\n\f19. Onor about June 12, 2014, the Board's staff interviewed the Respondent under\noath. During the interview, the Respondent acknowledged that she had treated both\nPatients A and B since they were toddlers.\n20. In furtherance of its investigation, Disciplinary Panel A transmitted medical\nrecords and other relevant documents to two physicians board-certified in family\nmedicine for a peer review (the “reviewers’”).\n21. Based on their review of medical records and other relevant documents, the\nreviewers concurred that the Respondent failed to meet the appropriate standard of\nquality care for Patient A. Additionally, one of the reviewers opined based on his review\nof Patient A’s records:\n\n...this is a highly concerning case in which a physician is not only breaching the\n\nstandard of medical care and documentation, but one in which she is treating [a\n\nfamily member] inappropriately and dangerously...\n\nCONCLUSION OF LAW\n\nBased on the foregoing Investigative Findings, the Board concludes as a matter\nof law that there is a preponderance of evidence that the Respondent's actions pose a\nserious risk to the health, safety and welfare of her family members.\n\nORDER\n\nBased on the investigative findings and the Board’s conclusion of law that the\n\nRespondent actions pose a serious risk to the health, safety and welfare of her family\n\nmembers, and pursuant to the Board’s authority under Health Occ. § 14-206(e)(2), it is\n\nhereby:\n\fORDERED that, pursuant to the authority vested by the Maryland Medical\nPractice Act, Health Occ. § 14-206(e)(2), the Respondent shall IMMEDIATELY CEASE\nAND DESIST from treating her family members; and it is further\n\nORDERED that this order is EFFECTIVE IMMEDIATELY pursuant to Md. Code\nRegs. 10.32.02.13A (2), and it is further\n\nORDERED that this is a PUBLIC DOCUMENT pursuant to Md. Code Ann., Gen.\n\nProv. §§ 4-101-4-601 (2014).\n\n(1/24/2014\n\nDate Chast A. Farrelly\nExecutive Director\nMaryland State Board of Physicians\n\n \n\nNOTICE OF OPPORTUNITY FOR A HEARING\n\nThe Respondent may challenge the factual or legai basis of this Order by filing a\nwritten opposition within 30 days of its issuance. The written opposition should be\nmade to: Christine A. Farrelly, Executive Director, Maryland State Board of Physicians,\n4201 Patterson Avenue, Baltimore, Maryland 21215, with a copy mailed to Dawn L.\nRubin, Assistant Attorney General, Health Occupations Prosecution and Litigation\nDivision, Office of the Attorney General, 300 West Preston Street, Suite 201, Baltimore,\nMaryland 21201. If the Respondent files a written opposition, a disciplinary panel of the\nBoard shall consider that opposition and shall provide a hearing, if requested. If the\nRespondent does not file a written opposition, the Respondent will lose the right to\n\nchallenge this Initial Order to Cease and Desist.\n\f
3 IN THE MATTER OF * BEFORE THE MARYLAND\n\nDONALD BUSICK JR. " STATE BOARD OF\nRespondent a PHYSICIANS\n\nLICENSE NO.: Z00409 - CASE NO.: 2015-0239\n\n* * * & * * & * x * * *\n\nORDER OF SUSPENSION OF POLYSOMNOGRAPHY LICENSE\nFOR DELINQUENT CHILD SUPPORT\n\nBACKGROUND\nOn or about October 9, 2014, the Maryland State Board of Physicians (the “Board”)\nreceived a written request from the Baltimore County Office of the Child Support Enforcement\nAdministration of the Maryland Department of Human Resources (the “Administration”) to\nsuspend the polysomnography license held by Donald Busick Jr., (the “Respondent”), License\nNo. Z00409, for delinquent child support. This action was to be taken by authority of Md. Code\nAnn., Fam. Law § 10-119.3 (2012 Repl. Vol.), which provides, in pertinent part:\n\n(e)(2) Except as provided in paragraph (3) of this subsection, upon\nnotification by the Administration under this section, a licensing\nauthority! shall:\n\n(i) suspend an individual’s license; or\n\n(ii) deny the license of an individual who is an applicant for a license\nfrom the licensing authority.\n\n* * *\n\n(h) Right to contest identity. — (1) Except as provided in paragraph\n(2) of this subsection, prior to the suspension or denial of a license\nunder subsection (e) of this section, a licensing authority shall send\nwritten notice of the proposed action to the individual whose license\nis subject to suspension or denial, including notice of an\n\n' The Maryland State Board of Physicians is a unit within the Maryland Department of Health and Mental Hygiene,\nMd. Code Ann., Health-Gen. §§ 2-101 & 2-106(a)(20), and is therefore a “licensing authority” within the meaning\nof Md. Code Ann., Fam. Law § 10-119.3(a)(3)(i) and (ii)(2).\n\findividual’s right to contest the identity of the individual whose\nlicense or application is to be suspended or denied.\n\n* * *\n(i) Appeal; hearing. ~1)() Except as provided in paragraph (2) of\nthis subsection, an individual may appeal a decision of a licensing\n\nauthority to suspend or deny the individual’s license in accordance\nwith Title 10, Subtitle 2 of the State Government Article.\n\n(ii) At a hearing under this paragraph, the issue shall be limited to\nwhether the Administration has mistaken the identity of the\nindividual whose license has been suspended or denied.\n\n* * *\n(k) Reinstatement of license—Duty of licensing authority. — A\nlicensing authority shall immediately reinstate any license\n\nsuspended, or process an application for any license denied, under\nthis section if:\n\n(1) notified by the Administration that the license should be\nreinstated; and\n(2) the individual otherwise qualifies for the license.\n\nOn October 17, 2014, the Board sent an unexecuted copy of this Order of Suspension to\nthe Respondent’s last known address of record with the Board and also to the address on the\nrequest form that the Board received from the Administration. Accompanying the unexecuted\nOrder of Suspension was a cover letter notifying the Respondent of his right to contest his\nidentity in writing within thirty days of the date of the letter and notifying the Respondent that if\nhe did not submit a signed, written appeal to the Board on or before November 16, 2014, the\nBoard would execute this Order of Suspension as written. The Respondent did not submit a\nwritten contest of identity to the Board by November 16, 2014.\n\nFINDINGS OF FACT\n\n1. The Board issued a license to practice polysomnography to the Respondent on\n\nOctober 18, 2013. His license is currently active and is scheduled to expire on May 30, 2015.\n\f2: On or about October 9, 2014, the Board received a written request from the\nAdministration, entitled “Request to Suspend or Deny License for Delinquent Child Support”\n(the “Request”), which requested that the Board suspend the polysomnography license held by\nthe Respondent for delinquent child support under the authority of Md. Code Ann., Fam. Law §\n10-119.3. The Request stated that, as of October 1, 2014, the arrearage amount of child support\nthat the Respondent owed was $9,820.52, in the Administration’s case numbered 700136591.\n\n3: As noted above, Md. Code Ann., Fam. Law § 10-119.3(e)(2) & (h)(1) requires\nthat the Board suspend the license of the Respondent upon notification by the Administration and\nafter sending written notice to the Respondent of the proposed suspension of his license and of\nhis right “to contest the identity of the individual whose license . . . is to be suspended.”\n\n4. On October 17, 2014, the Board sent an unexecuted copy of this Order of\nSuspension to the Respondent’s last known address registered with the Board and also to the\naddress on the Request. Included with the unexecuted Order of Suspension was a letter notifying\nthe Respondent of his right to contest his identity, in writing to the Board, within thirty days of\nthe date of the letter; that is, to contest that he was not the Donald Busick Jr., License No.\nZ00409, named by the Administration as the individual whose license should be suspended for\ndelinquent child support. In addition, the letter also gave Respondent written notice that if he did\nnot submit to the Board a signed, written appeal on or before November 16, 2014, the Board\nwould execute this Order of Suspension as written.”\n\n5. The Respondent did not submit a written contest of identity to the Board by\nNovember 16, 2014; nor was the Board notified that the Respondent arranged to pay the arrears\nin full.\n\n? The letter also notified the Respondent that he could prevent the suspension of his registration by contacting the\nAdministration and arranging to pay the arrears in full within 15 days of the date of the letter.\n\f6. Having given the Respondent the statutorily required written notice of the Board’s\nintent to suspend his license and of his right to contest identity pursuant to Md. Code Ann., Fam.\nLaw § 10-119.3(h)(1), and having not received a written response or appeal from the\nRespondent, the Board is statutorily required to suspend the Respondent’s license, pursuant to\nMd. Code Ann., Fam. Law § 10-119.3(e)(2).\n\nCONCLUSIONS OF LAW\n\nBased on the foregoing Findings of Fact, the Board concludes that, pursuant to Md. Code\nAnn., Fam. Law § 10-119.3(e)(2)(i), it is statutorily required to suspend the Respondent’s\nlicense to practice polysomnography until the Board receives notification from the\nAdministration that the Respondent’s license should be reinstated pursuant to Md. Code Ann.,\nFam. Law § 10-119.3(k)(1)-(2), provided that the Respondent is otherwise qualified for a license.\n\nORDER\n\nBased upon the foregoing Findings of Fact and Conclusions of Law, it is hereby:\n\nORDERED that the polysomnography license held by the Respondent, Donald Busick\nJr., License No. Z00409, is SUSPENDED; and it is further,\n\nORDERED that the Respondent’s license shall remain suspended until the Board\nreceives notification from the Child Support Enforcement Administration of the Department of\nHuman Resources that the Respondent’s license should be reinstated pursuant to Md. Code Ann.,\nFam. Law § 10-119.3(k)(1)-(2), provided that the Respondent is otherwise qualified for a license;\nand it is further,\n\nORDERED that this is a Final Order of the Maryland State Board of Physicians and, as\n\nsuch, is a public document and is reportable to any entity to which the Board is obligated by law\n\fto report, and is disclosable under the Maryland Public Information Act, Md. Code Ann., State\n\nGov’t §§10-611 et seg. (2009 Repl. Vol.)\n\niz[zol4 Ch pti\nDate Christine A. Farrelly, Execfitiye Director\n\nNOTICE OF APPEAL RIGHTS\n\n \n\n \n\nThe Respondent has a right to appeal this Final Order of the Board pursuant to Fam. Law\n\n§ 10-119.3(i), which provides as follows:\n\n(i) Appeal; hearing —(1)(i) Except as provided in paragraph (2) of\nthis subsection, an individual may appeal a decision of a licensing\nauthority to suspend or deny the individual’s license in accordance\nwith Title 10, Subtitle 2 of the State Government Article.\n\n(ii) At a hearing under this paragraph, the issue shall be limited to\nwhether the Administration has mistaken the identity of the\nindividual whose license has been suspended or denied.\n\f
4 IN THE MATTER OF * BEFORE THE\n\nDAVID M. HUSH * MARYLAND STATE\nRespondent * BOARD OF PHYSICIANS\n\nLicense Number: R05009 * Case Number: 2014-0177\n\n* * * * * * * * * * * * *\n\nORDER FOR REVOCATION OF LICENSE TO PRACTICE RADIOGRAPHY\n\n \n\nOn July 25, 2014, Disciplinary Panel B of the Maryland State Board of Physicians\n(the “Board”) notified DAVID M. HUSH (the “Respondent”), License Number R05009, of\nits intent to revoke his license to practice radiography in the State of Maryland under the\nMaryland Radiation Therapy, Radiography, Nuclear Medicine Technology, and\nRadiology Act (the “Act”), codified at Md. Code Ann., Health Occ. (“Health Occ.”) §§ 14-\n5B-101 et seq. (2009 Repl. Vol. and 2013 Supp.).\nSpecifically, Disciplinary Panel B based its action on the Respondent's violation\nof the following provisions of the Act under Health Occ. § 14-5B-14:\n(a) In general. -- Subject to the hearing provisions of § 14-405 of this\nsubtitle, the Board, on the affirmative vote of a majority of the\nquorum of the Board, may deny a license to any applicant, or a\ndisciplinary panel, on the affirmative vote of a majority of the\nquorum of the disciplinary panel, may reprimand any licensee,\nplace any licensee on probation, or suspend or revoke a license if\nthe licensee:\n(1) Fraudulently or deceptively obtains or attempts to obtain a\nlicense or temporary license for the applicant, licensed\n\nindividual, holder of a temporary license, or for another;\n\n(3) Is guilty of unprofessional or immoral conduct in the practice\nof radiography;\n\n(10) Willfully makes for files a false report or record in the\npractice of radiography;\n\f(14) knowingly makes a misrepresentation while practicing\nradiography; and\n\n(26) Fails to cooperate with a lawful investigation conducted by\nthe Board or a disciplinary panel.\n\nThe Respondent was notified that an Order for Revocation of License to Practice\nRadiography would be executed THIRTY (30) DAYS from the date of service of\nDisciplinary Panel B's Notice of Intent to Revoke License to Practice Radiography,\nunless the Respondent requested a hearing.\n\nThe Respondent was further notified that notice under Md. Code Regs.\n10.32.02.03 is sufficient when the charges are served by regular mail or hand delivery\nat the address the Respondent maintains for purposes of licensure notice. Md. Code\nAnn., State Gov't, § 10-209(c) provides that a person holding a license shall be deemed\nto have had reasonable opportunity to know of the fact of service if: (1) the person is\nrequired by law to notify the agency of a change of address within a specified period of\ntime; (2) the person failed to notify the agency in accordance with the law; (3) the\nagency or the Office mailed the notice to the address of record; and (4) the agency did\nnot have actual notice of the change of address prior to service. Disciplinary Panel B\nhas received no notice that the Respondent has changed his address.\n\nIn order for Disciplinary Panel B not to execute this Final Order, a written request\nfor hearing had to be received from the Respondent on or before August 27, 2014. The\nRespondent failed to request a hearing on or before this date.\n\nFINDINGS OF FACT\n\nDisciplinary Panel B makes the following Findings of Fact:\n\fdate of mailing of this Final Order and shall be made as provided for judicial review of a\nfinal decision in the Maryland Administrative Procedure Act, State Gov't Article, § 10-\n222 and Title 7, Chapter 200 of the Maryland Rules of Procedure. The cover letter\nshows the date on which the Final Order was mailed.\n\nIf the Respondent files an appeal, Disciplinary Panel B is a party and should be\nserved with the court's process. In addition, the Respondent should send a copy to\nDisciplinary Panel A's counsel, Noreen Rubin, Assistant Attorney General, at the Office\nof the Attorney General, 300 West Preston Street, Suite 302, Baltimore, Maryland\n21201. The Administrative Prosecutor is not involved in the circuit court process and\n\nneed not be served or copied on pleadings filed in that court.\n\n11\n\fBACKGROUND\n\n1. At all times relevant hereto, the Respondent was and is licensed to\npractice radiography in the State of Maryland. The Respondent was originally licensed\nto practice radiography in Maryland on November 19, 1997, under License Number\nRO5009. The Respondent's license is current until April 30, 2015.\n\n2. The Board initiated an investigation of the Respondent after receiving an\nanonymous complaint, dated August 16, 2013, informing the Board that the Respondent\nwas charged with a number of criminal offenses in 2013, including: obtaining controlled\ndangerous substances ("CDS") by fraud; obtaining CDS by forged prescription; making\nfalse statements to an officer or state official; obstructing and hindering; misdemeanor\ntheft; telephone misuse; and harassment. The complainant attached documents from\nthe Maryland Judiciary Case Search confirming the existence of various criminal\ncharges against the Respondent.\n\n3. In a second complaint, dated September 10, 2013, the anonymous\ncomplainant further informed the Board that the Respondent was charged with drunk\ndriving and other criminal offenses in Maryland on July 9, 2013. Similarly, the\ncomplainant attached documents from the Maryland Judiciary Case Search confirming\nthe existence of drunk driving and other criminal charges against the Respondent.\nBOARD INVESTIGATION\nCriminal History\n\n4. In the course of its investigation, the Board made the following discovery\n\nwith respect to the Respondent's criminal history:\n\f2013 Charges for Prescription Fraud - On or about August 16,\n2013, the Respondent was charged in the Circuit Court for\nBaltimore County, Maryland, Case Number 03K13004813, with:\nObtaining CDS by Fraud; and Obtaining CDS by Forged\nPrescription. These charges were nolle prosed on October 9, 2013,\nthe same day that the Respondent pleaded guilty to charges of\nHarassment and Telephone Misuse in Case Numbers\n03K13001610 and 03K13001611.\n\n2013 Charges for False Statement and Obstruction and\nHindering - On or about July 28, 2013, the Respondent was\ncharged in the District Court of Maryland for Baltimore City, Case\nNumber 1B02223593, with: two counts of False Statement to\nOfficer; False Statement to State Official; and Obstructing and\nHindering. These charges are pending.\n\n2013 Conviction for Theft (Less than $1000) - On or about May\n29, 2013, the Respondent was charged in the District Court of\nMaryland for Montgomery County, Case Number 2D00301996, with\ntwo counts of Theft (Less than $1,000). On or about August 19,\n2013, the Respondent pleaded guilty to and was convicted of one\ncount of Theft (Less than $1,000). The Court sentenced the\nRespondent to one year incarceration, all suspended, followed by\n\nprobation for two years.\n\f2013 Conviction for Harassment - On or about March 15, 2013,\nthe Respondent was charged in the Circuit Court for Baltimore\nCounty, Maryland, Case Number 03K13001610, with: Harassment\n(Course of Conduct); and Telephone Misuse (Repeat Calls) for an\nincident that occurred on or about December 8, 2012. On or about\nDecember 11, 2013, the Respondent pleaded guilty to and was\nconvicted of Harassment (Course of Conduct) and was placed on\nsupervised probation through the Division of Parole and Probation.\n2013 Conviction for Telephone Misuse - On or about March 15,\n2013, the Respondent was charged in the Circuit Court for\nBaltimore County, Maryland, Case Number 03K13001611, with\nTelephone Misuse (Repeat Calls). On or about December 11,\n2013, the Respondent pleaded guilty to and was convicted of the\ncharge and was given a time-served disposition.\n\n2010 Conviction for Theft (Less than $500) - On or about April 26,\n2010, the Respondent was charged in the Circuit Court for\nBaltimore County, Maryland, Case Number 03K10002245, with:\nTheft (Less than $500); and Trespass (Private Property). On or\nabout July 30, 2010, the Respondent was convicted of Theft (Less\nthan $500) and placed on supervised probation for a period of 18\nmonths.\n\n2000 PBJ for Theft (Less than $300) - On or about January 11,\n\n2000, the Respondent was charged in the District Court of\n\fMaryland for Baltimore County, Case Number 6C00121911, with\none count of Theft (Less than $300). On or about March 13, 2000,\nthe Respondent was found guilty of the charge and was granted\nprobation before judgment.\n\nh. 1995 Conviction for Theft (Less than $300) - On or about\nSeptember 24, 1994, the Respondent was charged in the District\nCourt of Maryland for Baltimore County, Case Number\n1C00004068, with one count of Theft (Less than $300). On or\nabout February 13, 1995, the Respondent was found guilty of the\ncharge and was granted probation before judgment.\n\nFraudulent Applications\n\nDB: By application ("Initial Application") dated September 29, 1997, the\nRespondent applied to the Board for certification as a Medical Radiation Technologist.\nUnder Section 12 in a question, which asked "Have you ever been charged with or\nconvicted of any criminal act for which you pled nolo contendere, could receive, or did\nreceive, probation before judgment, or were sentenced to probation or confinement?",\nthe Respondent answered "No."\n\n6. The Respondent failed to disclose in the Initial Application that on or about\nFebruary 13, 1995, he was found guilty of and received probation before judgment for\nTheft (Less than $300).\n\n7. In a license renewal application for the 2011 renewal period ("2011\nRenewal") the Respondent filed with the Board, dated March 25, 2011, he answered\n\n"No" to a Character and Fitness question, which asked "Have you been charged with or\n\fconvicted of any criminal act for which you pled nolo contendere, could receive, or did\nreceive, probation before judgment or were sentenced to probation or confinement?"\n\n8. The Respondent failed to disclose in the 2011 Renewal that on or about\nJuly 30, 2010, he was convicted of Theft (Less than $500) and placed on supervised\nprobation for 18 months in the Circuit Court for Baltimore County, Maryland.\n\n9. In a license renewal application for the 2013 renewal period ("2013\nRenewal") the Respondent filed with the Board, dated March 21, 2013, he answered\n"No" to a Character and Fitness question, which asked "Have you been charged with or\nconvicted of any criminal act for which you pled nolo contendere, could receive, or did\nreceive, probation before judgment or were sentenced to probation or confinement?"\n\n10. The Respondent failed to disclose that as of the date he filed the 2013\nRenewal, he had pending criminal charges for one count of Harassment (Course of\nConduct) and two counts of Telephone Misuse (Repeated Calls) in the Circuit Court for\nBaltimore County, Maryland, under Case Numbers 03K13001610 and 03K13001611.\n\n11. — In the Initial Application, the 2011 Renewal and the 2013 Renewal, the\nRespondent either affirmed or certified that the information he provided was true and\ncorrect to the best of his knowledge.\n\nPrescription Fraud\n\n12. The Board obtained court records and a police report concerning criminal\ncharges that were filed on or about August 16, 2013, which alleged that the Respondent\nobtained CDS by fraud and/or forged prescription in Baltimore County. The documents\nthe Board obtained revealed that on or about May 15, 2013, at approximately 3:00 a.m.,\n\nthe Respondent called in a prescription for Lortab 10/500 mg. (#90), a Schedule III CDS,\n\ffor himself at an area pharmacy (Pharmacy A"). When the pharmacist contacted the\nphysician ("Physician A"), who purportedly issued the prescription, for verification,\nPhysician A advised that she had not issued such prescription for the Respondent. The\nPharmacist immediately reported the event to the Baltimore County Police Department.\n\n13. At around 9:00 a.m. that same day, detectives from the Baltimore County\nPolice Department waited at Pharmacy A parking lot anticipating that the Respondent\nwould appear in person to pick up the prescription. The detectives observed the\nRespondent pull into Pharmacy A in a black Hummer and proceeded to the drive-thru\nwindow. The Respondent asked a pharmacy technician whether his prescription was\nready, at which time the pharmacy technician stated that it was. When the pharmacy\ntechnician told the Respondent that she needed to inform the pharmacist, he quickly\ndrove away. The detectives did not pursue the Respondent's vehicle, but instead\nobtained video footage of the Respondent from the pharmacy's security camera. The\nRespondent later called the pharmacy and stated that he would pick up his prescription\nnext week.\n\n14. Later that same day, the detectives made contact with the Respondent for\nan interview. During the interview, the Respondent admitted orally and in writing that he\nhad called in the prescription for Lortab without Physician A's authorization and that he\nknew it was a crime to do so.\n\nFailure to Cooperate\n\n15. In furtherance of its lawful investigation of the Respondent, the Board\n\nissued a Subpoena Ad Testificandum to him on or about November 5, 2013, ordering\n\nhim to appear at the Board's offices on November 21, 2013, to give testimony in the\n\fform of an interview. The Respondent failed to appear or otherwise respond to the\nBoard's subpoena, dated November 5, 2013.\n\n16. The Board reissued the subpoena to the Respondent on or about\nNovember 21, 2013, for an interview scheduled to take place on December 12, 2013,\nand on or about December 12, 2013, for an interview scheduled to take place on\nDecember 26, 2013. The Respondent failed to appear or otherwise respond to the\nBoard's subpoenas, dated November 5, November 21 and December 12, 2013.\n\nCONCLUSIONS OF LAW\n\nBased on the foregoing Findings of Fact, Disciplinary Panel B concludes as a\nmatter of law that the Respondent's failure to disclose: in his Initial Application that he\nwas granted probation before judgment for Theft (Less than $300) on or about February\n13,1995; in his 2011 Renewal that he was convicted of Theft (Less than $500) on or\nabout March 25, 2011; and in his 2013 Renewal that he had pending charges for\nHarassment and Telephone Misuse, constitutes: fraudulently or deceptively obtaining or\nattempting to obtain a license or temporary license for the applicant, licensed individual,\nholder of a temporary license, or for another, in violation of Health Occ. § 14-5B-\n14(a)(1); being guilty of unprofessional or immoral conduct in the practice of\nradiography, in violation of Health Occ. § 14-5B-14(a)(3); willfully making or filing a false\nreport or record in the practice of radiography, in violation of Health Occ. § 14-5B-\n14(a)(10); and knowingly making a misrepresentation while practicing radiography, in\nviolation of Health Occ. § 14-5B-14(a)(14).\n\nDisciplinary Panel B further concludes that the Respondent's admitted attempt to\n\nobtain a Schedule III CDS by fraud on or about May 15, 2013, constitutes being guilty of\n\funprofessional or immoral conduct in the practice of radiography, in violation of Health\nOcc. § 14-5B-14(a)(3).\n\nFinally, Disciplinary Panel B concludes that the Respondent's failure to comply\nwith the Board's subpoenas, dated November 5, November 21, and December 12, 2013,\nconstitutes: being guilty of unprofessional or immoral conduct in the practice of\nradiography, in violation of Health Occ. § 14-5B-14(a)(3); and failing to cooperate with a\nlawful investigation conducted by the Board or disciplinary panel, in violation of Health\nOcc. § 14-5B-14(a)(26).\n\nORDER\n\n \n\nBased on the foregoing Findings of Fact and Conclusions of Law, it is, by\na majority of the quorum of Disciplinary Panel B considering this case:\nORDERED that the Respondent's license to practice radiography in the State of\nMaryland is hereby REVOKED; and it is further;\nORDERED that this Final Order is a public document pursuant to Md. Code Ann.,\n\nState Gov't, § 10-611 et seq. (2009 Repl. Vol. and 2013 Supp.).\n\n \n\nChristine A. Farfell\nExecutive Director\nMaryland State Board of Physicians\n\nDat\n\n \n\nNOTICE OF RIGHT TO APPEAL\nPursuant to Md. Code Ann., Health Occ. § 14-408(b), the Respondent has the\n\nright to take a direct judicial appeal. Any appeal shall be filed within 30 days from the\n\n10\n\f
5 IN THE MATTER OF x BEFORE THE\n\nJOHN R. McLEAN, M.D. * MARYLAND STATE BOARD\nRespondent i OF PHYSICIANS\n\nLicense Number D25209 * Case Number: 2013-0874\n\n* * * * * * * * * * n *\n\nFINAL DECISION AND ORDER\nPROCEDURAL HISTORY\n\nJohn R. McLean, M.D. is a physician licensed by the Maryland State Board of Physicians\n(“Board”). Dr. McLean was charged in the United States (“U.S.”) District Court for the District\nof Maryland in August, 2010, with seven felony counts of health care fraud and making false\nstatements in connection with the delivery of or payment for health care services, in violation of\nfederal law. (Criminal Docket No. 10-cr-WDQ-10-0531)\n\nFollowing a trial, a federal jury convicted Dr. McLean of six of those counts. In\nNovember, 2011, the federal criminal court (Quarles, Jr.) sentenced Dr. McLean to a total of 97\nmonths imprisonment followed by three years of supervised release. In addition, Dr. McLean\nwas ordered to pay $579,070 in restitution. Dr. McLean filed an appeal.\n\nOn April 22, 2013, the Board suspended Dr. McLean’s medical license, as required by\nSection 14-404(b)(1) of the Maryland Medical Practice Act. On April 23, 2013, the United States\nCourt of Appeals for the Fourth Circuit issued an Opinion affirming Dr. McLean’s convictions\nand sentence.\n\nOn February 11, 2014, the Office of the Attorney General filed with the Board a Petition\nto Revoke [Dr. McLean’s] Medical License and Show Cause Order pursuant to Section 14-\n404(b) of the Medical Practice Act. The statute provides:\n\n(1) On the filing of certified docket entries with the Board by the Office of the\nAttorney General, a disciplinary panel shall order the suspension of a license if the\n\flicensee is convicted of or pleads nolo contendere with respect to a crime\ninvolving moral turpitude, whether or not any appeal or other proceeding is\npending to have the conviction or plea set aside.\n\n(2) After completion of the appellate process if the conviction has not been reversed\n\nor the plea has not been set aside with respect to a crime involving moral\nturpitude, a disciplinary panel shall order the revocation of a license on the\ncertification by the Office of the Attorney General.\n\nMd. Health Occ. (“H.O.”) Code Ann, §14-404(b)(2) (2009 & Supp. 2013). Attached to the\n\npetition was the Final Decision and Order dated April 22, 2013, and the Opinion of the U.S.\n\nCourt of Appeals for the Fourth Circuit dated April 23, 2013.'\n\nThe Show Cause Order mandated that Dr. McLean show cause in writing, by March 19,\n\n2014, why his medical license should not be revoked pursuant to H.O. §14-404(b)(2). The Board\n\ndid not receive any response from Dr. McLean or from anyone representing Dr. McLean.\n\nA disciplinary panel of the Board -- Disciplinary Panel B -- convened for a final decision\n\non April 23, 2014. Having reviewed and considered the entire record in this case, Disciplinary\n\nPanel B issues this Final Decision and Order.\n\n1\n\nFINDINGS OF FACT\n\nDisciplinary Panel B finds the following facts by a preponderance of the evidence:\n\n. Dr. McLean is a physician licensed by the Board since July 23, 1980.\n\nAt all times relevant to the Board’s investigation, Dr. McLean has held a license to\npractice medicine in the State of Maryland.\n\nDr. McLean was charged in the U.S. District Court for the District of Maryland on\nAugust 31, 2010, with seven counts of felony Health Care Fraud and False Statements\nRelating to Health Care Matters, in violation of 18 U.S.C. §§1347 and 1035(a)(2).\n\nDr. McLean pled not guilty to the charges in the indictment.\n\nDr. McLean requested a jury trial which took place over approximately two weeks in\n\nJuly, 2011.\n\nPrior to the Board’s suspension of Dr. McLean’s license in April, 2013, the Board had already reviewed the\n\ncertified copies of the Indictment, Verdict Form, sentencing transcript, Judgment and Notice of Appeal in this case.\n\f6. Dr. McLean was represented by counsel throughout the criminal proceedings in his case.\n\n7. On July 29, 2011, following the trial, a federal jury found Dr. McLean guilty of all counts\nwith exception to Count 6, which the prosecutor dismissed with prejudice prior to the\ntrial. The six counts of which Dr. McLean was found guilty, in violation of 18 U.S.C.\n§1347,? and 18 U.S.C. §1035(a)(2),° were as follows:\n\nCounts 1-5, 7: Health Care Fraud (18 U.S.C. §1347) and False Statements Relating to\nHealth Care Matters (18 U.S.C. §1035(a)(2))\n\n(a) Count One: Beginning at least in 2003 and continuing through May 2007, Dr.\nMcLean knowingly and willfully submitted insurance claims to Medicare, Medicaid\nand private insurers for medically unnecessary stent procedures that he performed and\nfor unnecessary cardiac testing and procedures that he ordered on patients. Dr.\nMcLean falsely documented on patient records the need for said testing and\nprocedures for the purpose of increasing his profit and revenue and personally\nprofited from this scheme to defraud.\n\n(b) Count Two: On or about September 8, 2005, Dr. McLean knowingly and willfully\ncaused an entry in a patient’s medical record to state that the lesion in the patient’s\nleft anterior artery (“LAD”) was 80 percent, well knowing that the medical record\ncontained a materially false, fictitious and fraudulent statement and entry, in that the\nlesion was substantially less than 80 percent.\n\n(c) Count Three: On or about November 2, 2005, Dr. McLean knowingly and willfully\ncaused an entry in a patient’s medical record to state that the lesion in the patient’s\nLAD was 80 to 90 percent, well knowing that this entry contained a materially false,\n\n* Section 347 of the United States Code provides:\nHealth care fraud\n(a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice —\n(1) to defraud any health care program; or\n(2) to obtain, by means of false or fraudulent pretenses, representation, or promises, any of the money\nor property owned by, or under the custody or control of, any health care program, in connection\nwith the delivery of or payment for health care benefits, items, or services, shall be fined under\nthis title or imprisoned not more than 10 years or both.\n(b) With respect to violations of this section, a person need not have actual knowledge of this section or\nspecific intent to commit a violation of this section.\n18 U.S.C. §1347.\n\n* Section 1035 of the United States Code provides:\nFalse statements relating to health care matters\n(a) Whoever, in any matter involving a health care benefit program, knowingly and willfully—\n(1) Falsifies, conceals, or covers up by any trick, scheme, or device a material fact; or\n(2) Makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses\nany materially false writing or document knowing the same to contain any materially false,\nfictitious, or fraudulent statement or entry, in connection with the delivery of or payment for\nhealth care benefits, items, or services, shall be fined under this title or imprisoned not more than 5\nyears or both.\n18 U.S.C. §1035.\n\f—\na\n\nfictitious and fraudulent statement, in that the lesion was substantially less than 80 to\n90 percent.\n\n(d) Count Four: On or about December 12, 2005, Dr. McLean knowingly and willfully\ncaused an entry in a patient’s medical record to state that the lesion in the patient’s\nright coronary artery (“RCA”) was 80 to 90 percent, well knowing that the medical\nrecord contained a materially false, fictitious and fraudulent statement and entry, in\nthat the lesion was substantially less than 80 to 90 percent.\n\n(e) Count Five: On or about March 29, 2006, Dr. McLean knowingly and willfully\ncaused an entry in a patient’s medical record to state that the lesion in the patient’s\nLAD was 80 percent, well knowing that the medical record contained a materially\nfalse, fictitious and fraudulent statement and entry, in that the lesion was considerably\nless than 80 percent.\n\n(f) Count Seven: On or about July 24, 2006, Dr. McLean knowingly and willfully\ncaused an entry in a patient’s medical record to state that the lesion in the patient’s\nLAD was 80 to 90 percent, well knowing that the medical record contained a\nmaterially false, fictitious and fraudulent statement and entry, in that the lesion was\nsubstantially less than 80 to 90 percent.\n\nIn convicting Dr. McLean of health care fraud and making false statements relating to\nhealth care matters, the jury found that he had implanted medically-unnecessary cardiac\nstents in more than 100 patients. He also prescribed unnecessary follow up diagnostic\ntests — for example, nuclear stress tests — and he falsified patient medical records to\nestablish the necessity of the procedures. After receiving a subpoena from the U.S.\nAttorney’s Office, Dr. McLean began to shred medical files. In fact, when the agents\nexecuted a search warrant, he was discovered going through subpoenaed patient files and\napparently putting the contents into a shred box.\n\nThe federal court also stated that Dr. McLean’s criminal acts were not due to physical\nhandicaps, incompetence, or lack of training, but were “largely for the money.” In the\ncourt’s view, it was clear that Dr. McLean implanted unnecessary stents and prescribed\nunnecessary diagnostic procedures for the basest of reasons — greed.\n\n. On November 10, 2011, the federal court sentenced Dr. McLean to 97 months\n\nimprisonment, followed by three (3) years of supervised release as to Counts 1, 2, 3, 4, 5\nand 7, all to run concurrently and to include a special condition of mental health\ncounseling. The court imposed a special assessment of $600 and restitution in the amount\nof $579,070.\n\n. On November 15, 2011, Dr. McLean filed an appeal of his criminal conviction.\n\n. On April 23, 2013, the U.S. Court of Appeals for the Fourth Circuit issued an Opinion\n\naffirming Dr. McLean’s convictions and sentence. The appellate court concluded, inter\nalia, that direct evidence supported the jury’s verdict of Dr. McLean’s fraudulent scheme\nto defraud insurers, that he submitted claims for medically unnecessary stent procedures,\nthat he willfully misrepresented the level of stenosis in patients’ arteries, and recorded\nstenosis of 10% to 95% for lesions of no more than 10% to 30% in numerous cases.\n\f13. Pursuant to COMAR 10.32.02.08 C, Disciplinary Panel B reviewed all of the documents\nin this case, including the Final Decision and Order dated April 22, 2013, the Opinion\nissued by the U.S. Court of Appeals for the Fourth Circuit and the filing submitted by the\nState, as well as the criminal docket entries and relevant criminal documents received\nfrom the U.S. District Court.\n\nCONCLUSIONS OF LAW\n\nDr. McLean committed crimes of moral turpitude. He was convicted of knowingly and\nwillfully submitting false and fraudulent bills to Medicare, Medicaid and private insurers. He did\nso in order to obtain payment for these services, in violation of 18 U.S.C. §1347, a statute whose\nessential elements include a scheme to defraud and an intent to defraud. His actions included, but\nare not limited to, implanting unnecessary cardiac stents in more than 100 patients; falsely\nrecording in patients’ medical records the existence or extent of coronary artery blockages;\nsubmitting fraudulent claims to health benefit programs; and ordering his patients to undergo a\nbattery of unnecessary follow up tests such as Cardiolite Stress Tests; echocardiograms and\nEKGs.\n\nIf fraud or an intent to defraud is an essential element of a statute under which a\ndefendant is convicted, the crime is one involving moral turpitude as a matter of law. Attorney\nGrievance Commission v. Klauber, 289 Md. 446, 457-59, cert. denied, 451 U.S. 1018 (1981)\n(the term “moral turpitude” connotes a fraudulent or dishonest intent); Attorney Grievance\nComm'n v. Walman, 280 Md. 453, 459-60 (1977)(a crime of moral turpitude is characterized by\ndishonesty, fraud, or deceit); Oltman v. Maryland State Board of Physicians, 162 Md. App. 453,\n485-87, cert. denied, 389 Md. 125 (2005) (crime was one of moral turpitude [because] it was\ndishonest, and characterized by fraud); see also Board of Physician Quality Assurance vy.\n\nFelsenberg, 351 Md. 288, 295 (1998)(crimes involving fraud are crimes involving moral\n\nturpitude).\n\fIt is also settled that “the related group of offenses involving intentional dishonesty for\npurposes of personal gain are crimes involving moral turpitude.” Oltman, 162 Md. App. at 486,\nciting Klauber, 289 Md. at 457-58 and Walman, 280 Md. at 459-60. [citations and quotation\nmarks omitted]. By making materially false, fictitious, fraudulent and dishonest statements, Dr.\nMcLean intended to defraud and deceive Medicare, Medicaid and private health care insurers to\nobtain monetary reimbursement to which he was not entitled. Dr. McLean’s willful submissions\nof fraudulent bills were characterized by repeated fraud, deceit and intentional dishonesty for\npurposes of his own personal gain. His crimes therefore established moral turpitude. Oltman, 162\nMd. App. at 486.\n\nMoreover, in prior decisions, the Board has concluded that health care fraud, in violation\nof 18 U.S.C. §1347, is a crime of moral turpitude. See e.g., In the Matter of Douglas F. Greer,\nM.D., Case Nos, 2008-0640, 2008-0653, July 23, 2009; In the Matter of Ehigiator Akhigbhe,\nM.D., Case No. 2010-0770. In prior decisions, the Board also concluded that knowingly and\nwillfully making a materially false, fictitious and fraudulent statement and representation in\nconnection with the delivery of health care benefits, items and services, in violation of 18 U.S.C.\n§1035, is a crime of oral turpitude. See e.g. In the Matter of Martin R. McLaren, M.D., Case No.\n2008-0811, July 23, 2009; see also Akhigbe, M.D., supra.\n\nIn addition, the Board has concluded in multiple prior decisions that defrauding health\nplans constitutes a crime of moral turpitude. See e.g., In the Matter of Oparaugo I. Udebiuwa,\nCase No. 2006-0851, October 24, 2007; In the Matter of Roman Ostrovsky, Case No, 2006-0522,\nJune 12, 2007; In the Matter of James An Nguyen, M.D., Case No. 2004-0638, February 1, 2006;\n\nsee also Akhigbe, M.D., supra.\n\fDr. McLean’s criminal violations also undermine the public’s confidence in the medical\nprofession. See Stidwell v. Maryland State Board of Chiropractic Examiners, 144 Md. App. 613,\n619 (2002)(a criminal offense that undermines the public’s confidence in a profession may be a\ncrime of moral turpitude if so determined by the appropriate licensing board). In addition, Dr.\nMcLean’s repeated fraudulent billing was “an act of baseness, vileness, or depravity in the\nprivate and social duties which man owes to his fellow man, or to society in general, contrary to\nthe accepted and customary rule of right and duty between man and man.” Board of Dental\nExaminers v. Lazell, 172 Md. 314, 320 (1937). In the panel’s view, Dr. McLean’s exploitation of\na health care plan to this extent, as well as the long-standing and repetitive nature of his criminal\nconduct, disparaged professional principles, and were a disgrace to the medical profession.\nUnder any definition of the term of Maryland law, Dr. McLean’s crime constituted a crime of\nmoral turpitude, in violation of H.O. §14-404(b)(2).\n\nORDER\n\nIt is hereby:\n\nORDERED that the license of John R. McLean, M.D., license number D25209, to\npractice medicine in the State of Maryland, is hereby REVOKED as mandated by Md. Code\nAnn., Health Occ. §14-404(b)(2); and it is further\n\nORDERED that this is a Final Order of a disciplinary panel of the Maryland State Board\nof Physicians and as such is a PUBLIC DOCUMENT pursuant to Md. Code Ann., Gen. Prov. §\n\n4-101 et seg. (2014)\n\n \n\nii fia/zorg\nDat Christine A. Farrell\nExecutive Director\n\nMaryland State Board of Physicians\n\fNOTICE OF RIGHT TO PETITION FOR JUDICIAL REVIEW\n\nPursuant to Md. Code Ann., Health Occ. § 14-408(a), Dr. McLean has the right to seek\njudicial review of this Final Decision and Order. Any petition for judicial review shall be filed\nwithin thirty (30) days from the date of mailing of this Final Decision and Order. The cover letter\naccompanying this Final Decision and Order indicates the date the decision is mailed. Any\npetition for judicial review shall be made as provided for in the Administrative Procedure Act,\nMd. Code Ann., State Gov’t § 10-222 and Title 7, Chapter 200 of the Maryland Rules of\nProcedure.\n\nIf Dr. McLean files a petition for judicial review, the Board is a party and should be\nserved with the court’s process at the following address:\n\nMaryland State Board of Physicians\nChristine A. Farrelly, Executive Director\n4201 Patterson Avenue\nBaltimore, Maryland 21215\nNotice of any petition should also be sent to the Board’s counsel at the following address:\nNoreen M. Rubin\nAssistant Attorney General\nDepartment of Health and Mental Hygiene\n\n300 West Preston Street, Suite 302\nBaltimore, Maryland 21201\n\f
6 IN THE MATTER OF * BEFORE THE MARYLAND\n\nALEXANDRA GOLD, M.D. * STATE BOARD OF\nRespondent * PHYSICIANS\nLicense Number: D74407 x Case Number: 2014-0486\n\n* * * * * * * * * * * * * * * * * * * * *\n\nCONSENT ORDER\nBACKGROUND\n\nThe Maryland Board of Physicians (the “Maryland Board”) received information\nthat Alexandra Gold, M.D.., (the “Respondent”), License Number D74407, was\ndisciplined by the Delaware Board of Medical Licensure and Discipline (the “Delaware\nBoard”) based upon a guilty plea to one count of maintaining a drug-involved premises.\nIn an Order dated October 7, 2014, the Delaware disciplined the Respondent by\npermanent revocation of her medical license.\n\nBased on the above referenced Delaware sanction, the Maryland Board has\ngrounds to charge the Respondent with violating the following provisions of the\nMaryland Medical Practice Act (the “Act”), under H. O. § 14-404(a):\n\n(a) Subject to the hearing provisions of § 14-405 of this subtitle, a\n\ndisciplinary panel, on the affirmative vote of a majority of the quorum\nof the disciplinary panel, may reprimand any licensee, place any\nlicensee on probation, or suspend or revoke a license if the licensee:\n(21) _ Is disciplined by a licensing or disciplinary\nauthority or convicted or disciplined by a court of\nany state or country or disciplined by any branch of\nthe United States uniformed services or the\n\nVeteran’s Administration for an act that would be\ngrounds for disciplinary action under this section,\n\fThe Maryland Board has determined that the acts for which the Respondent was\ndisciplined in Delaware would be grounds for disciplinary action under H.O. § 14-404(a).\nThe grounds for disciplinary action under H.O. § 14-404(a) are as follows:\n\n(3) Is guilty of:\n\n(i) Immoral conduct in the practice of medicine;\n(ii) | Unprofessional conduct in the practice of medicine;\n\n(27) Sells, prescribes, gives away, or administers drugs for illegal or\nillegitimate medical purposes.\n\nBased on the action taken by the Delaware Board, the Respondent agrees to enter\ninto this Consent Order with the Maryland Board of Physicians, consisting of Procedural\nBackground, Findings of Fact, Conclusions of Law, and Order of reciprocal action.\n\nI. FINDINGS OF FACT\nThe Board finds the following:\n\n1. At all times relevant hereto, the Respondent was a physician licensed to\npractice Obstetrics and Gynecology in the State of Maryland. The Respondent was\ninitially licensed in Maryland in June, 2012.\n\n25 In November, 2013, the Drug Enforcement Administration (“DEA”) filed\na criminal complaint alleging that the Respondent violated: (i) 21 U.S.C. § 841 (a)(1)\n(knowingly and intentionally possessing with the intent to distribute a controlled\nsubstance) by participating in the sale of controlled substances over the internet via the\nwebsite “Silk Road,” by shipping controlled substances through the mail in boxes of\ncandy, and by utilizing an on-line alias identity and a shipping address registered to a\nfictitious company; and (ii) 21 U.S.C. § 846 (conspiracy to distribute a controlled\n\nsubstance).\n\f3 The Respondent was also arrested and charged in Delaware with at least\none count of violation of 21 U.S.C. § 856(a)(1), a federal criminal law that renders it a\nfelony to knowingly and intentionally maintain and use a dwelling for the purpose of\nunlawfully manufacturing and distributing controlled substances.\n\n4. At the time of her arrest, the Respondent admitted that she engaged in\npacking controlled substances in candy boxes for distribution via mail, including Xanax,\nOxycodone and Adderall.\n\n3; As a result of the Respondent’s actions, the Maryland Board summarily\nsuspended the Respondent’s medical license in this State on February 25, 2014, and\ncontinued the summary suspension on March 14, 2014.)\n\n6. On June 18, 2014, the Respondent pleaded guilty to the federal charge of\nviolating 21 U.S.C. § 856. By Order dated October 7, 2014, the Delaware Board\npermanently revoked the Respondent’s medical license. A copy of the Delaware Order is\nattached hereto.\n\nII. CONCLUSIONS OF LAW\n\nBased on the foregoing Findings of Fact, the Maryland Board concludes as a\nmatter of law that the disciplinary action taken by the Delaware Board against the\nRespondent constitutes a violation of Health Occ. § 14-404(a)(21) (is disciplined by a\nlicensing or disciplinary authority of any state for an act or acts that would be grounds for\ndisciplinary action under this section). The Respondent’s acts would violate Health Occ.\n§ 14-404(a)(3)G) Gmmoral conduct in the practice of medicine) and (ii) (unprofessional\n' The Respondent’s medical license in Maryland expired on September 30, 2014. With respect to the\n\nmedical license of an individual the Board regulates, however, “the license [may not] lapse by operation of\nlaw while the individual is under investigation or while charges are pending.” H.O. § 14-403(a).\n\fconduct in the practice of medicine) and (27) (sells, prescribes, gives away, or\nadministers drugs for illegal or illegitimate purposes) if committed in this state.\nIll. ORDER:\nBased on the foregoing Findings of Fact and Conclusions of Law, it is hereby:\nORDERED that the Respondent’s license to practice medicine in the State of\nMaryland be and is hereby PERMANENTLY REVOKED; and be it further\nORDERED that this CONSENT ORDER is a PUBLIC DOCUMENT pursuant\n\nto Md. State Gov’t Code Ann. § 10-611 et seq. (2009 Repl. vol.).\n\n \n\nExecutive Director\nMaryland Board of Physicians\n\nHHZ a014 Parties f telly\nDatd Christine A. Farrelly /)\n\nCONSENT\nI, Alexandra Gold, M.D., acknowledge that I have had the opportunity to consult\nwith counsel before signing this document. By this Consent, I admit to the Findings of\nFact and Conclusions of Law, and I agree and accept to be bound by this Consent Order\nand its conditions and restrictions. I waive any rights I may have had to contest the\nFindings of Fact and Conclusions of Law.\nI acknowledge the validity of this Consent Order as if entered into after the\n\nconclusion of a formal evidentiary hearing in which I would have had the right to\n\fcounsel, to confront witnesses, to give testimony, to call witnesses on my behalf, and to\nall other substantive and procedural protections as provided by law. I acknowledge the\nlegal authority and the jurisdiction of the Board to initiate these proceedings and to issue\nand enforce this Consent Order. I also affirm that I am waiving my right to appeal any\nadverse ruling of the Board that might have followed any such hearing.\n\nI sign this Consent Order after having had an opportunity to consult with counsel,\nwithout reservation, and I fully understand and comprehend the language, meaning and\n\nterms of this Consent Order. I voluntarily sign this Consent Order, and understand its\n\nmeaning and effect.\n\n\\\\ [3 | \\&\nDate\n\n \n\n \n\nSTATE OF\n\nCITY/COUNTY OF\n\nI HEREBY CERTIFY thatonthis__day of , 2014, before\nme, the subscriber, a Notary Public for the State and City/County aforesaid, personally\nappeared Alexandra Gold, M.D., and made oath in due form of law that the execution of\nthe foregoing Consent Agreement was her voluntary act and deed.\n\nAS WITNESSETH my hand and my notarial seal\n\nNotary Public\nMY COMMISSION EXPIRES:\n\n‘J Wo baste4 CASE MANAGER,\n\nAuthorized by the Act of July 7, 1955, as\namended, to administer oaths (18 U.S.C. § 4004\n\nV]3faord. “Tey Col FES ep Abt, PA IGG\n\nOC te /\nEAL D HAD DOC UA penn, ¥Bo rich St P\n\fWhat we want to do is to make the text column easier to analyze. Let’s say we want to find out the most commonly used words. We’ll want to remove URLs from the text of the alerts since they aren’t actual words. Let’s use mutate to make that happen:
alerts <- alerts |>
mutate(text = gsub("http.*","", text))If you are trying to create a list of unique words, R will treat differences in capitalization as unique and also will include punctuation by default, even using its unique function:
a_list_of_words <- c("Dog", "dog", "dog", "cat", "cat", ",")
unique(a_list_of_words)[1] "Dog" "dog" "cat" "," Fortunately, this is a solved problem with tidytext, which has a function called unnest_tokens that will convert the text to lowercase and remove all punctuation. The way that unnest_tokens works is that we tell it what we want to call the field we’re creating with this breaking apart, then we tell it what we’re breaking apart – what field has all the text in it. For us, that’s the text column:
unique_words <- alerts |> select(text) |>
unnest_tokens(word, text)Now we can look at the top words in this dataset. Let’s limit ourselves to making a plot of the top 25 words:
unique_words |>
count(word, sort = TRUE) |>
top_n(25) |>
mutate(word = reorder(word, n)) |>
ggplot(aes(x = word, y = n)) +
geom_col() +
xlab(NULL) +
coord_flip() +
labs(x = "Count",
y = "Unique words",
title = "Count of unique words found in Maryland doctor discipline alerts")Selecting by n
Well, that’s a bit underwhelming - a lot of very common (and short) words. This also is a solved problem in working with text data, and words like “a” and “the” are known as “stop words”. In most cases you’ll want to remove them from your analysis since they are so common. Tidytext provides a dataframe of them that we’ll load, and then we’ll add some of our own.
data("stop_words")
stop_words <- stop_words |>
add_row(word = "respondent") |>
add_row(word = "board") |>
add_row(word = "panel") |>
add_row(word = "dr") |>
add_row(word = "maryland") |>
add_row(word = 'practice') |>
add_row(word = '1') |>
add_row(word = '2') |>
add_row(word = '3') |>
add_row(word = '14')Then we’re going to use a function we haven’t used yet called an anti_join, which filters out any matches. So we’ll anti_join the stop words and get a list of words that aren’t stop words.
From there, we can get a simple word frequency by just grouping them together and counting them. We can borrow the percent code from above to get a percent of the words our top 10 words represent.
unique_words |>
anti_join(stop_words) |>
group_by(word) |>
tally(sort=TRUE) |>
mutate(percent = (n/sum(n))*100) |>
top_n(10)Joining with `by = join_by(word)`
Selecting by percent# A tibble: 10 × 3
word n percent
<chr> <int> <dbl>
1 patient 8147 1.30
2 license 6301 1.01
3 disciplinary 5647 0.904
4 health 5526 0.885
5 medical 5051 0.809
6 medicine 4201 0.673
7 consent 4002 0.641
8 hearing 3625 0.581
9 respondent’s 3624 0.580
10 letter 3043 0.487Those seem like more relevant unique words. Now, here’s where we can start to do more interesting and meaningful analysis. Let’s create two dataframes of unique words based on time: one for all of 2023 and the other for all of 2022:
unique_words_2023 <- alerts |>
filter(year(date) == 2023) |>
select(text) |>
unnest_tokens(word, text)
unique_words_2022 <- alerts |>
filter(year(date) == 2022) |>
select(text) |>
unnest_tokens(word, text)Then we can create top 10 lists for both of them and compare:
unique_words_2023 |>
anti_join(stop_words) |>
group_by(word) |>
tally(sort=TRUE) |>
mutate(percent = (n/sum(n))*100) |>
top_n(10)Joining with `by = join_by(word)`
Selecting by percent# A tibble: 10 × 3
word n percent
<chr> <int> <dbl>
1 license 519 1.18
2 disciplinary 493 1.12
3 health 451 1.03
4 consent 381 0.867
5 hearing 374 0.851
6 medicine 335 0.762
7 medical 322 0.733
8 respondent’s 319 0.726
9 2022 277 0.630
10 suspension 274 0.624unique_words_2022 |>
anti_join(stop_words) |>
group_by(word) |>
tally(sort=TRUE) |>
mutate(percent = (n/sum(n))*100) |>
top_n(10)Joining with `by = join_by(word)`
Selecting by percent# A tibble: 10 × 3
word n percent
<chr> <int> <dbl>
1 disciplinary 935 1.04
2 health 920 1.02
3 patient 877 0.974
4 license 851 0.945
5 medical 774 0.859
6 respondent’s 675 0.749
7 medicine 668 0.742
8 care 659 0.732
9 consent 657 0.729
10 2021 581 0.645In the 2023 top 10 list, “suspension” appears in the top 10, but not in 2022.
29.1 Going beyond a single word
The next step in text analysis is using ngrams. An ngram is any combination of words that you specify. Two word ngrams are called bigrams (bi-grams). Three would be trigrams. And so forth.
The code to make ngrams is similar to what we did above, but involves some more twists.
So this block is is going to do the following:
- Use the alerts data we created above, and filter for pre-2024 releases.
- Unnest the tokens again, but instead we’re going to create a field called bigram, break apart summary, but we’re going to specify the tokens in this case are ngrams of 2.
- We’re going to make things easier to read and split bigrams into word1 and word2.
- We’re going to filter out stopwords again, but this time we’re going to do it in both word1 and word2 using a slightly different filtering method.
- Because of some weirdness in calculating the percentage, we’re going to put bigram back together again, now that the stop words are gone.
- We’ll then group by, count and create a percent just like we did above.
- We’ll then use top_n to give us the top 10 bigrams.
alerts |>
filter(date < '2024-01-01') |>
unnest_tokens(bigram, text, token = "ngrams", n = 2) |>
separate(bigram, c("word1", "word2"), sep = " ") |>
filter(!word1 %in% stop_words$word) |>
filter(!word2 %in% stop_words$word) |>
mutate(bigram = paste(word1, word2, sep=" ")) |>
group_by(bigram) |>
tally(sort=TRUE) |>
mutate(percent = (n/sum(n))*100) |>
top_n(10)Selecting by percent# A tibble: 10 × 3
bigram n percent
<chr> <int> <dbl>
1 health occ 2429 1.00
2 md code 1805 0.746
3 code ann 1656 0.684
4 summary suspension 973 0.402
5 medical records 960 0.397
6 health care 889 0.367
7 unprofessional conduct 822 0.340
8 ann health 744 0.307
9 participant rehabilitation 737 0.304
10 repl vol 655 0.271And we already have a different, more nuanced result. We can see that “summary suspension”, “unprofessional conduct” and “medical records” are among the top 2-word phrases. What about after 2023?
alerts |>
filter(date >= '2024-01-01') |>
unnest_tokens(bigram, text, token = "ngrams", n = 2) |>
separate(bigram, c("word1", "word2"), sep = " ") |>
filter(!word1 %in% stop_words$word) |>
filter(!word2 %in% stop_words$word) |>
mutate(bigram = paste(word1, word2, sep=" ")) |>
group_by(bigram) |>
tally(sort=TRUE) |>
mutate(percent = (n/sum(n))*100) |>
top_n(10)Selecting by percent# A tibble: 10 × 3
bigram n percent
<chr> <int> <dbl>
1 health occ 247 1.37
2 summary suspension 140 0.777
3 individual 4 115 0.638
4 md code 111 0.616
5 code ann 104 0.577
6 prehearing conference 99 0.549
7 individual 10 80 0.444
8 unprofessional conduct 71 0.394
9 health care 67 0.372
10 respondent’s license 66 0.366Pretty similar. You’ll notice that the percentages are very small; that’s not irrelevant but in some cases it’s the differences in patterns that’s more important.
There are some potential challenges to doing an analysis. For one, there are variations of words that could probably be standardized - maybe using OpenRefine - that would give us cleaner results. There might be some words among our list of stop words that actually are meaningful in this context.
29.2 Sentiment Analysis
Another popular use of text analysis is to measure the sentiment of a word - whether it expresses a positive or negative idea - and tidytext has built-in tools to make that possible. We use word counts like we’ve already calculated and bring in a dataframe of words (called a lexicon) along with their sentiments using a function called get_sentiments. The most common dataframe is called “bing” which has nothing to do with the Microsoft search engine. Let’s load it:
bing <- get_sentiments("bing")
bing_word_counts_2023 <- unique_words_2023 |>
inner_join(bing) |>
count(word, sentiment, sort = TRUE)Joining with `by = join_by(word)`bing_word_counts_2022 <- unique_words_2022 |>
inner_join(bing) |>
count(word, sentiment, sort = TRUE)Joining with `by = join_by(word)`Gauging the sentiment of a word can be heavily dependent on the context, and as with other types of text analysis sometimes larger patterns are more meaningful than individual results. But the potential with text analysis is vast: knowing what words and phrases that public officials employ can be a way to evaluate their actions and priorities. And those words and phrases are data.