Arora v. Iowa Bd. of Medical Examiners, 96-279

• Decision Date: 21 May 1997
• Docket Number: No. 96-279,96-279
• Citation: 564 N.W.2d 4
• Parties: Vasu ARORA, Appellee, v. IOWA BOARD OF MEDICAL EXAMINERS, Appellant.
• Court: Iowa Supreme Court

Page 4

564 N.W.2d 4

Vasu ARORA, Appellee, v. IOWA BOARD OF MEDICAL EXAMINERS, Appellant.

No. 96-279.

Supreme Court of Iowa.

May 21, 1997.

Rehearing Denied June 16, 1997.

Thomas J. Miller, Attorney General, and Linny Emrich, Theresa O'Connell Weeg, and Heather L. Adams, Assistant Attorneys General, for appellant.

Michael J. Gau of Kane, Norby & Reddick, P.C., Dubuque, for appellee.

Considered by McGIVERIN, C.J., and LARSON, CARTER, SNELL, and TERNUS, JJ.

LARSON, Justice.

The Polk County District Court reversed a decision of the Iowa Board of Medical Examiners, which had suspended the medical license of the respondent, Vasu Arora, for substandard care of patients. The district court concluded that the board's decision lacked substantial evidence and was unreasonable and arbitrary. See Iowa Code §§ 17A.19(8)(f), (g) (1991). The court also concluded that the board committed an error of law by refusing the respondent an opportunity to personally present his argument to the board as provided by Iowa Code section 148.7(6). The court ordered the board to reinstate respondent's license.

We conclude that the board's decision was supported by substantial evidence and that its finding of substandard care by the respondent was not arbitrary or capricious. For that reason and because the board erroneously denied Arora an opportunity to personally address the board as required by Iowa Code section 148.7(6), we reverse the judgment of the district court and remand for further proceedings.

I. Scope of Review.

We review a contested administrative proceeding for errors of law. Iowa Code § 17A.19(8); Sahu v. Board of Med. Exam'rs, 537 N.W.2d 674, 676 (Iowa 1995). Our review under Iowa Code section 17A.20 is limited to determining whether the district court correctly applied the law in exercising its judicial review function under Iowa Code section 17A.19(8). Glowacki v. Board of Med. Exam'rs, 516 N.W.2d 881, 884 (Iowa 1994).

Because Iowa Code chapter 17A delegates fact-finding to agencies, "we defer to an agency's fact-finding if supported by substantial evidence." Glowacki v. Board of Medical Examiners, 516 N.W.2d 881, 884 (Iowa 1994). The question is whether there is substantial evidence to support the finding actually made, not whether evidence might support a different finding. Eaves v. Board of Medical Examiners, 467 N.W.2d 234, 237 (Iowa 1991). The burden of proof is a preponderance of the evidence. Id. Evidence is not substantial "when a reasonable mind would find the evidence inadequate to reach" the conclusion reached by the agency. Fisher [v. Board of Optometry Exam'rs ], 510 N.W.2d [873,] 877 [ (Iowa 1994) ]. We are bound by the agency's factual findings "unless a contrary result is demanded as a matter of law." Eaves, 467 N.W.2d at 237.

Sahu, 537 N.W.2d at 676-77.

II. The Substantial Evidence Issue.

Arora was charged with rendering substandard care in twelve cases, and the board found that five of the twelve charges were proven. The district court reversed, finding that there was no substantial evidence to support any of the charges. We will refer to the cases, as did the board, as Patients 1, 2, 3, 4, and 8.

A. Patient 1. Patient 1 was a ninety-four-year-old woman who was admitted to a hospital with a diagnosis of vascular occlusion. The respondent's treatment included intravenous Heparin (a blood thinner) and intramuscular injections of Demerol for pain. In the days following her admission, the patient began to bleed excessively, and her hemoglobin level dropped. She also developed multiple hematomas at the sites of her intramuscular injections.

An expert testified that the respondent's care was substandard because, despite the patient's increased bleeding, hematomas, and a drop in hemoglobin, Arora ordered an increase in Heparin. The witness stated:

Once bleeding was established to being caused by the Heparin--that is, the development of a large hematoma, multiple hematomas, as noted by both the doctor and the nursing staff--the Heparin should have been stopped or significantly decreased. Instead, Dr. Arora continued to increase the dose of Heparin.... The patient continued to bleed and continued to need further blood transfusions.

The board agreed that this amounted to substandard care.

B. Patient 2. Patient 2 was a ninety-three-year-old man admitted with auricular fibrillation and an irregularly rapid heartbeat. The board found that Arora provided substandard care by failing to perform adequate initial diagnostic testing and laboratory monitoring. Specifically, it criticized him for treating the patient's symptoms without determining or addressing their cause. He failed to order a chest x-ray, which could aid in the diagnosis of such contributing conditions as congestive heart failure, pulmonary edema, or enlargement of the heart. No laboratory tests were performed to rule out a recent myocardial infarction. When the patient's complaints of dizziness subsided, he was discharged without further diagnosis or treatment. The board concluded that this, also, amounted to substandard care.

C. Patient 3. This patient was an eighty-year-old woman with a medical history of palpitations, diabetes, and hypertension. The board did not make extended findings with respect to this patient, but it concluded that the respondent failed to perform a complete diagnostic workup and failed to monitor the effectiveness of therapy by utilizing chest x-rays and serial EKGs as diagnostic tools. The respondent's reliance on a single EKG was not sufficient, according to the board, in light of the patient's serious condition and the more effective diagnostic procedures available.

D. Patient 4. This patient was a seventy-eight-year-old woman admitted with cardiac palpitations and in a poorly nourished and emaciated condition. The respondent administered Lasix, which the board concluded exacerbated the patient's dehydration. No diagnostic blood tests were ordered to determine the degree of dehydration and no effort was made to replenish the patient's body fluids. An expert testified:

This patient at the time was severely hypotensive, likely to be severely dehydrated, and Lasix would actually make the dehydration and the blood pressure response worse. And, so, yes this drug probably contributed to the patient's demise.... Lasix is a powerful loop diuretic. It creates in the kidney a transfer of fluids ... into the collecting system, and it causes a diuresis. Upon doing that, the blood volume will decrease in a patient that's probably already having very poor volume status.

The board found this to constitute substandard care.

E. Patient 8. Patient 8 was a sixty-four-year-old diabetic admitted from a nursing home because his blood sugar was fluctuating widely. The respondent's admitting diagnosis included uncontrolled diabetes, mild dehydration, and peripheral vascular insufficiency. The patient was discharged back to the nursing home without achieving adequate control of his diabetes during his hospital stay. The board concluded that discharging the patient from the hospital under these circumstances amounted to substandard care based in part on this testimony by the expert:

I don't see where the patient really changed any clinically and to know what was gained by being in the hospital as compared to being in the nursing home and having the same types of sugars drawn and analyzed, but nonetheless, if sugars from the lab results really didn't change very much, and there was only one blood sugar in all those blood tests that was really acceptable, and that was the very last one. Is that a fluke, or if that is going to be the new pattern for this patient is unknown.

We conclude that substantial evidence supported the board's findings as to all five patients and therefore reverse that part of the district court's judgment concluding otherwise.

III. The Alleged Unreasonableness and Arbitrariness.

The district court found the board's actions to be unreasonable and arbitrary under Iowa Code section 17A.19(8)(g). "Unreasonableness" is defined as action in the face of evidence as to which there is no room for difference of opinion among reasonable minds, or action not based on substantial evidence. Stephenson v. Furnas Elec. Co., 522 N.W.2d 828, 831 (Iowa 1994). An agency's...