Plaintiff, State of Oregon, by and through the Board of Medical Examiners, petitions the court for a show cause hearing and order requiring defendant to appear and show cause why defendant should not be enjoined from operating the Cascade Health Group without a licensed physician present on the premises whenever the clinic is open and engaging in the unlicensed practice of medicine in the State of Oregon. Plaintiff, by and through Assistant Attorney General, Warren G. Foote, respectively requests oral argument. It is estimated argument will take approximately 30 minutes; the services of a court reporter are not required. This motion is supported by the affidavits which are incorporated into this motion and attached as Exhibit Nos. 1-5. In support of this motion, Plaintiff states:
1. This proceeding is brought on behalf of the Board of Medical Examiners pursuant to ORS 677.325 and ORS 180.060(1)(d).
2. Defendant, Paula Bickle, has a Ph.D.
in nutrition. Defendant is not licensed to practice medicine
in the State of Oregon. Defendant and her husband, Howard Bickle,
own the Cascade Health Group, a health clinic located in Portland,
Oregon. Defendant is responsible for the daily
operation of the clinic. In the course of clinical operations, defendant sees and provides services to patients. Such services include nutritional counseling, which involves identifying nutritional "deficiencies and dietary problems, recommending changes in the patient's diet and" recommending dietary supplements. Defendant also evaluates patients for heavy metal toxicity, such as mercury. Although defendant has employed successive physicians, licensed to practice medicine in Oregon, to serve as Medical Director of the Cascade Health Group, defendant has, on occasion, ordered laboratory tests, rendered medical diagnosis, prescribed medication and directed the treatment of patients without the review, direction or approval of the Medical Director.
3. The practice of medicine is defined by ORS 677.085. Defendant's manner of operating the Cascade Health Group constitutes the unlicensed practice of medicine and represents an ongoing pattern of behavior that threatens the health, safety and welfare of the people of this State. The Board of Medical Examiners is charged with the responsibility to regulate the practice of medicine, and to protect the public from the practice of medicine by unauthorized or unqualified persons pursuant to ORS 677.015. The following evidence is presented to demonstrate that defendant has engaged in the unlicensed practice of medicine at the Cascade Health Group.
a. Rosemarie Ann Otis, M.D., began working at the Cascade Health Group clinic on May 20, 1997, and later became the clinic's Medical Director until November 14, 1997. She states that defendant engaged in the unlicensed practice of medicine by assessing and diagnosing patients, ordering laboratory work, interpreting laboratory reports and implementing treatment plans. Defendant would also sign a physician's name to laboratory orders and administer medications to patients under pre-existing written orders from physicians who no longer worked at the clinic. Exhibit 1.
b. Pam Floener states that over a five-day period she worked in the Cascade Health Group in July of 1997. She observed new patients at the Cascade Health Group being brought to the laboratory for testing complete with a diagno.sis and orders for medications without being seen by a physician. She also observed defendant countermand Dr. Otis' standing orders by instructing her staff to schedule new patients with defendant without them first being seen by a physician. Exhibit 2.
c. Mark Steinhauer, M.D., began working at the Cascade Health Group as a physician in March 1997 until July 30, 1997. He states that intravenous treatments were administered to patients at the clinic without a physician's review and on some occasions, without a physician present in the clinic. He believes that defendant sought a physician to serve as a figurehead for her clinic in order to protect herself against a charge of practicing medicine without a license. Exhibit 3.
d. Bruce A. Farmer, M.D., began working at the Cascade Health Group in mid November 1997 and served as the full time medical director until August 1998. He found that his working relationship with defendant deteriorated over time as she pressured him to spend less time with patients and refer more patients to defendant for treatment and involvement in her mercury research project that involves chelation treatments. [Footnote: Chelation treatment is an alternative medicine philosophy used to treat perceived heavy metal poisoning. A chelating agent removes heavy metal ions from the body.] He states that based on his experience at the clinic, it is his firm belief that defendant will not conform to acceptable protocols and will involve herself in the unlicensed practice of medicine by exceeding the authority granted her by a licensed physician serving as medical director. Exhibit 4.
e. On January 29, 1998, the State of Washington Department of Health, Secretary of Health, Office of Professional Standards accepted and entered Stipulated Findings of Fact and Conclusions of Law and Agreed Order (Order). Defendant's conduct in operating the clinic in Oregon is substantially similar to her conduct in the State' of Washington, which formed the basis for the Washington order. The Order found that defendant owned and operated Cascade Park Health Group in Vancouver, Washington, and provided health care to patients and that defendant engaged in unprofessional conduct by violating the Revised Code of Washington and the Washington Administrative Code. As a result, defendant's certificate to practice as a health care assistant in the State of Washington was suspended for five years; however, this suspension was stayed for a period for up to five years provided she complies with certain requirements. Exhibit 5.
Plaintiff requests an order as follows:
(a) Enjoining defendant from engaging in the unlicensed practice of medicine;
(b) Enjoining defendant from ordering laboratory tests or ordering, recommending or prescribing medications or medical treatment for patients;
( c) Enjoining defendant from providing any service to a patient without the prior approval of a licensed physician;
(d) Enjoining defendant from providing any patient diagnosis of a health related condition or ordering or recommending treatment of a health related condition;
(e) Enjoining defendant from operating the clinic unless there is a physician licensed in the State of Oregon present on the premises at all times during business hours, or whenever patients receive health care at the clinic.
DATED this 12th day of March, 1999.
Warren Gray Foote-OSB #77176
Assistant Attorney General
Of Attorneys for Plaintiff
Department of Justice
1162 Court Street NE
Salem, Oregon 97310
Telephone: (503) 378-6003
STATE OF OREGON, by and through the
PAULA R. BICKLE,
Case No. 9903-02683
STIPULATED JUDGMENT AND DECREE
This Court has found that Plaintiff State of Oregon, acting by and through the Board of Medical Examiners (BME, hereafter) and represented by Assistant Attorneys General Warren G. Foote and Daniel H. Rosenhouse, and Defendant Paula Ruth Bickle, represented by Roscoe C. Nelson, II, have stipulated and agreed to the matters set out below in Paragraphs 1 through 5.
1. The Board of Medical Examiners has a statutory obligation to protect the public from the practice of medicine by unauthorized or unqualified persons and to that end, the Board of Medical Examiners has the authority to maintain a suit for injunction against any person violating ORS 677.080(4).
2. Defendant is the owner and operator of Cascade Health Group, which is presently located at 9310 S.B. Stark Street, Portland, Oregon. The terms of this Stipulated Judgment and Decree, however, are not restricted to the Cascade Health Group, but extend to any clinic which provides medical services in which Defendant has an ownership interest, or which she manages, operates, or participates in some capacity, including as a nutritionist.
3. The practice of medicine is defined by ORS 677.085, and includes advertising or holding oneself out to the public as being authorized to practice medicine; for compensation, prescribing, giving or administering any drug or medicine for the use of another person; offering or undertaking to perform any surgical operation upon any person; offering or undertaking to diagnose, cure or treat in any manner, or by any means, methods, devices or instrumentalities, any disease, illness, pain, wound, fracture, infirmity, deformity, defect or abnormal physical or mental condition of any person; and using the words "Doctor," "Physician," "Surgeon," or any abbreviation or combination thereof, in connection with the name of a person in the conduct of any occupation or profession pertaining to the diagnosis or treatment of human diseases or conditions mentioned in this paragraph.
4. The Board of Medical Examiners has been advised, as represented by their pleadings in this case, that defendant Paula Bickle on or about January 29, 1998 entered into Stipulated Findings of Fact, Conclusions of Law and Agreed Order with the Washington Department of Health, which include specific practice protocols relating to defendant's practices as a health care provider. The Board of Medical Examiners has also conducted its own investigation and has gathered evidence that provides it a good faith basis to believe that Defendant has, on occasion prior to January 28, 1998, in her capacity as owner and operator of the Cascade Health Group, engaged in activities that constitute the unlicensed practice of medicine. BME's investigation also leads it to a good faith belief that such activities may have been repeated thereafter. The parties stipulate that the intent of this Stipulated Judgment and Decree is to allow the Oregon Board of Medical Examiners, as well as the Department of Health, State of Washington, to enforce these practice protocols for the purposes of avoiding any activities on the part of the defendant that would constitute the unlicensed practice of medicine under the laws of either the State of Oregon or the State of Washington.
5. Defendant specifically consents to the continued jurisdiction of the Circuit Court under the terms and conditions of this Stipulated Judgment and Decree for a period of not less than five years, beginning on the date this document is executed by the Court, subject to further extension by the court in its discretion.
Based upon the foregoing and the stipulation of the parties, IT IS HEREBY ORDERED, ADJUDGED AND DECREED as follows:
6. In order to insure that there is compliance with the terms of this STIPULATED JUDGMENT AND DECREE, Defendant specifically consents to ongoing monitoring by BME's Investigation Committee.
7. Defendant shall immediately, but in no case more than 10 days thereafter, notify the Investigation Committee in writing of any changes in the identity and/or qualifications of her Medical Director and any other physician that provides medical services at any facility in which she has an ownership interest or management responsibilities.
8. Defendant shall notify the Investigation Committee in writing of any change in her employment in the health care field or her place of business or any change or addition in the location of any clinic that Defendant owns, operates, or in which she participates as an owner, operator, employee, or employer. The notification shall be made within 20 days of the change and shall include Defendant's complete new address and telephone number.
9. Defendant shall notify the Investigation Committee in writing of any change in her current residence address or telephone number; the notification shall be made within 20 days of the change and shall include Defendant's complete new address and telephone number.
10. Defendant shall give a copy of this STIPULATED JUDGMENT AND DECREE to each physician and to each health care practitioner that is associated with any health care clinic or facility that is owned or operated by Defendant or in which Defendant participates in some other capacity.
11. Defendant shall not advertise or publicize her services to the public in such a way as to suggest that she may provide health care services of a type or in a manner inconsistent with the terms of this STIPULATED JUDGMENT AND DECREE.
12. All health care provided to patients and consumers in any fashion by Defendant during the term of this STIPULATED JUDGMENT AND DECREE shall be provided according to the following terms:
(a) All health care provided by Defendant to patients and consumers in the State of Oregon shall be provided only under proper delegation and supervision by a physician licensed in the State of Oregon to practice medicine under chapter 677 of the Oregon Revised Statutes or a naturopathic physician licensed under chapter 685 of the Oregon Revised Statutes.
(b) All health care provided by Defendant to patients and consumers shall be provided in conformity with the following practice protocols:
(1) Before being referred to Defendant, each new patient will be seen in the clinic by the licensed physician or naturopathic physician who is serving as Medical Director of as a supervising physician (referred to hereafter as Medical Director). The Medical Director will assess the patient's symptoms, order appropriate laboratory tests, perform an appropriate physical examination, and take an appropriate medical history, all as determined to be necessary in his or her professional judgment.
(2) Any protocols, treatment plans or standing orders established by a Medical Director expire at the end of the last day of employment for that Medical Director. Patient care and treatment based upon such protocols, treatment plans or standing orders will not be provided until a successor Medical Director reviews and revises or reauthorizes said protocols, treatment plans or standing orders.
(3) The Medical Director may direct Defendant to assess the patient for nutritional deficiency, nutritional education, and possible entry into specific research protocols and programs, and to make other clinical recommendations to the Medical Director related to nutrition.
(4) The Medical Director shall determine, in the exercise of his or her professional judgment, whether to implement Defendant's recommendations. If the Medical Director concurs with Defendant's recommendations, the Medical Director shall so signify in the patient's medical record and shall have the responsibility to make additions or corrections to Defendant's recommendations, as he or she deems necessary.
(5) The Medical Director may schedule a patient for follow-up visits with Defendant for any of the following purposes: dietary modification, nutritional supplementation, monitoring of compliance with treatment plans, nutritional educational purposes, and for such further consultations and recommendations to the patient supplementation, monitoring of compliance with treatment plans, nutritional educational purposes, and for such further consultations and recommendations as the Medical Director deems appropriate.
(6) It is not within Defendant's scope of activity to diagnose, prescribe, or alter a course of treatment for disease or other physical conditions requiring a medical diagnosis. However, Defendant may participate in taking the patient's physical and medical history and make nutritional recommendations to the patient. Defendant may make any recommendation to the Medical Director in the exercise of her professional judgment as a nutritionist.
(7) Defendant shall not administer treatment, or any drug or medicinal preparation except as specifically directed by the Medical Director. Defendant shall not undertake to diagnose, care, or treat any disease, ailment, injury, infirmity, pain, or other condition except as specifically authorized and delegated to her by the Medical Director. Without limiting the foregoing, Defendant shall not undertake or perform any invasive treatment, including intravenous treatments unless a Medical Director is on the premises at the time of treatment.
(8) The Defendant shall inform the BME in writing of any research programs in which she participates and provide copies to the BME of protocols for such research. [needs confidentiality]
(c) Notwithstanding other provisions in this subsection (b) of Paragraph 12, Defendant is authorized to provide nutritional counseling, as described in subsection (b)(3), to a patient upon written referral from a licensed physician or naturopathic physician, even if not employed by Defendant.
(d) Any violation of the terms of this STIPULATED JUDGMENT AND DECREE may be cause for an enforcement action under the laws of the State of Oregon, including proceedings for contempt of court.
13. For a period of five years from the date of the entry of this STIPULATED JUDGMENT AND DECREE, and for a longer period if so ordered by the court for cause or otherwise extended by law, Defendant consents to compliance audits conducted by the staff of the Board of Medical Examiners. Such audits, although conducted during reasonable business hours, may be conducted without prior notice not more than twice per year; and may be conducted more often if allowed by a court for cause shown ex parte, or if conducted upon 72 hours prior notice, or if prompted by a complaint providing a reasonable basis to undertake such an audit. Such audits may include the review and inspection of patient records. Defendant shall have the right to be present at each and every compliance audit. If the audit is prompted by a complaint, the BME shall disclose the nature of the complaint within a reasonable time after the initiation of the audit unless such disclosure is prohibited by ORS 676.175 , ORS 677.425, or regulations duly promulgated and adopted thereunder. In addition to the compliance audits, BME may conduct undercover investigations that do not interrupt Defendant's normal business operations, without notice and at its discretion.
14. Defendant shall assume all costs of complying with this Stipulated Judgment and Decree, including all reasonable costs associated with the audits provided for herein, but not to exceed $1000 per year.
15. This STIPULATED JUDGMENT AND DECREE applies to any acts undertaken by Defendant as a health care provider in the State of Oregon.
16. Defendant is ordered to pay a fine to the BME in the amount of $5,000, suspended for a period of five years. In the event there is a violation of the terms of this Consent Order and Agreement during the course of those five years, even if discovered and determined thereafter, the suspension will be automatically vacated and the fine immediately due, upon findings of violation by this court or any other court of competent jurisdiction. In the event there is no violation, this order to pay the fine shall be null and void. This fine amount, while not a reimbursement, reflects a portion of the costs of investigating and processing this matter.
17. Defendant shall obey all federal, state and local laws and all administrative rules governing providing health care to persons in Oregon.
18. All communications with BME required by this STIPULATED JUDGMENT AND DECREE shall be made to the following address or telephone number:
Board of Medical Examiners
1500 SW First Street, Suite 620
Portland, Oregon 97201-5826
19. The provisions of this decree may be enforced via contempt proceedings and by any other means allowed by law. Until further notice to the Board of Medical Examiners, any notice or service of process upon Defendant made pursuant to this STIPULATED JUDGMENT AND DECREE shall be deemed effective if reasonably attempted at the business or home address given by Defendant pursuant to Sections 8 or 9, above.