An oral surgeon tested positive for methamphetamine.

An on-call pediatrician arrived to work with a blood alcohol level of 0.296 percent.

A urologist consumed alcohol while on call, urinated in public and was then arrested.

All are North Dakota-licensed physicians disciplined by the State Board of Medical Examiners in 2013.

In each case, the doctor's license was suspended for one year, but the suspension won't be served as long as he or she completes required evaluations and treatment.

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A review of discipline orders issued by the state board found several cases where doctors who misused alcohol or drugs are allowed to continue practicing medicine.

It's a slightly more common practice as drug and alcohol screenings become more sophisticated, said Duane Houdek, executive secretary of the state Board of Medical Examiners.

"We allow those otherwise competent physicians to return to practice," Houdek said. "They're offering skills that are good for the public, but only if they can do it with the assurance that they're dealing with that (drug or alcohol) issue and certainly not using."

Many state medical boards use unenforced, or stayed, suspensions when they deal with physicians who struggle with substance abuse issues. These doctors typically enter a physician health program, a combination of treatment and monitoring over several years.

A legislative change this year will move North Dakota's physician health program out from under the state Board of Medical Examiners to a newly created nonprofit organization.

The hope is family, friends or colleagues - or the doctors themselves - will feel more comfortable reporting concerns about substance abuse earlier, before it crosses a line where discipline is necessary.

"We tend to see them once they've already gone too far," Houdek said.

Critics, however, worry unenforced suspensions and treatment programs not tied to a disciplining entity create additional risks for patient safety.

"It's a bit like playing roulette," said Dr. Sidney Wolfe, founder and senior adviser of the Public Citizen's Health Research Group in Washington, D.C. "With the best of intentions of a rehab program, such a person is more likely to go back to drugs or alcohol than someone without a problem. The question is: Is there going to be a patient around when that happens?"

Protecting the public

The North Dakota Board of Medical Examiners licenses more than 3,600 physicians. About 1,700 are in state, and another 1,900 live out of state but treat patients in North Dakota.

Houdek described the board's ultimate goal as protecting the public. It does so through the licensing process, requiring and monitoring continuing medical education and discipline, he said.

On average, the board receives 70 to 80 complaints a year, Houdek said, and 10 to 15 percent of those result in discipline.

North Dakota consistently ranked among the 10 best state medical boards in a listing by the Public Citizen's Health Research Group based on the number of serious discipline actions per 1,000 physicians.

The state slipped to 14th for the years 2009-2011. The group has not published a list since than because the Federation of State Medical Boards stopped releasing the data publicly.

Wolfe noted North Dakota's drop in ranking could be worrisome. He said the best boards do more discipline year in and year out.

Since 2009, the North Dakota board has issued between 11 and 16 discipline orders each year, including license suspensions, revocations, denials and censures.

Of the 64 total disciplinary orders issued during those five years, 17 related to alcohol use, including the three 2013 orders previously mentioned.

- Dr. Mansureh Iravani, an oral and maxillofacial surgeon in Bismarck, left the scene after hitting a sign with a vehicle on May 19, 2012. When later found, she appeared impaired. A urine analysis was positive for methamphetamine, the Board of Medical Examiners' complaint stated.

An immediate suspension of Iravani's license in November 2012 was not imposed provided she wore a drug-testing skin patch and submitted to daily urine tests, board documents stated.

A stipulation, signed by Iravani on March 21, 2013, required she abstain from alcohol and mood-altering substances not prescribed by her physician, be subject to random testing, complete aftercare and enter the five-year physician health program.

Separately, the North Dakota Board of Dental Examiners has been discussing a complaint against Iravani, its meeting minutes show.

A statement released by Iravani's attorney, Jeff Weikum of Bismarck, said evaluators determined she did not have a substance addiction issue, "but needs to make appropriate choices in her personal life and work to ensure that she maintains her personal health."

The statement said she has been entirely compliant with the medical board's plan.

"Dr. Iravani made some regrettable choices which affected her personal life during non-work hours," the statement said.

"It is important to emphasize that Dr. Iravani's patient care and quality of service were never at issue."

- When Dr. Katherine Knoll Klein, a Bismarck pediatrician, presented for on-call duty at 5:30 p.m. on Nov. 29, 2012, nursing staff noticed her speech was slurred and she swayed when she walked. The April 2013 complaint also said Klein was "talking very loud to the point it seemed as though she was shouting when talking to the patient and his family."

She was asked to leave and submit to a blood test, which showed her blood alcohol level was 0.296 percent, the complaint said.

Conditions to avoid the suspension of Klein's license include random drug and alcohol testing, attending three 12-step meetings a week for one year, as well as the physician health program, the board order said.

A message left on Klein's clinic voicemail was not returned.

- Dr. Paul Barber Jr. a locum, or temp doctor, said he consumed three glasses of wine and eight beers on Feb. 12, 2013, a day he was the on-call urologist in Grand Forks. He was arrested for disorderly conduct in the overnight hours for urinating in public, the board complaint said.

Board documents also state Barber made a false statement on his 2012 license application. He indicated he had never been arrested or charged with a crime, but twice had been convicted of driving under the influence in Rhode Island.

His July 2013 order required a psychological and substance abuse evaluation, and that he comply with recommendations of the evaluation facility. He was not allowed to practice medicine in the state while awaiting the evaluation results.

Barber, who lives in Rhode Island, said he has had the evaluation and is able to practice in North Dakota, though doesn't foresee doing so.

Barber, who was recently doing temp work in Indiana, said he will report to the Indiana board for the Grand Forks incident.

He said the DUIs the board said he failed to report happened 20 years ago.

"I am a very good physician," Barber said. "If you do your job right as a physician, you may run into some episodes like I run into for different reasons. It makes it difficult for all parties involved. Were mistakes made? Yes. Was I treated fairly? Yes. Was I treated appropriately for this day and age? Yes."

High rate of abuse

Not all doctors who are disciplined for drug or alcohol misuse are allowed to continue practicing, even with conditions.

Three North Dakota-licensed doctors - Dr. Michael Schmit, Dr. Ronald Wagner and Dr. Blair Nelson - had their licenses suspended indefinitely in 2013, documents show.

Each complaint referenced ongoing or repeat drug or alcohol use.

Schmit applied for reinstatement in November 2013, but was denied by the board, which "concluded that it is not convinced Dr. Schmit had demonstrated he can return to practice safely at this time," a second order said.

Houdek said an issue the board deals with all the time is determining whether a physician who has misused drugs or alcohol can practice without posing any greater risk than usual to the patient.

"If the doctor is using a drug or alcohol habitually and is in the midst of addiction, they are not always approaching medicine the way they should be," Houdek said.

A study released in 2012 found 15.4 percent of surgeons have alcohol abuse or dependency problems, higher than the general population rate of 9.4 percent, said the study published in JAMA Surgery.

"Surgeons reporting a major medical error in the previous three months were more likely to have alcohol abuse or dependence," the study results said.

The study also said the prevalence of alcohol-use disorders among physicians is unknown, though various sources put it in the range of 10 percent to 15 percent.

The Federation of State Physician Health Programs and the Federation of State Medical Boards both distinguish between illness, including excessive use or abuse of drugs and/or alcohol, and impairment. They say illness typically predates impairment, often by many years.

"Most physicians who become ill are able to function effectively even during the earlier stages of their illness due to their training and dedication," the Chicago-based Federation of Physician Health Programs said in a public policy sheet. "Even if illness progresses to cause impairment, treatment usually results in remission and restoration of function."

Stayed suspensions are a valuable tool as they allow physicians to practice while being monitored by a state's physician health program, said Drew Carlson, director of communications for the Federation of State Medical Boards. The state boards can quickly enforce the suspension if a physician does not comply with the health program or violates the agreement with the board.

Working with physicians

Area health systems generally allow doctors who have a stayed suspension on their licenses to continue to work there.

"We work with them to hopefully maintain their practice," said Dr. James Volk, a hospitalist and chief medical officer for Sanford Health in Fargo. "As long as they're cooperating with the PHP program, we would be very happy to work with them to maintain their practice as much as possible."

Sanford has quality assurance and improvement programs that monitor the practice of all physicians. Volk said these monitoring systems should help reassure the public of patient safety.

"Typically these are physicians that we have had a relationship with for some time," Volk said. "We know the quality of their work is exemplary, otherwise we would have dealt with any other issues previously."

Dr. Eric Lunn, chief medical officer and a pediatrician at Altru Health System in Grand Forks, said not every situation is the same, and the health system would consider on a case-by-case basis whether a physician with an unenforced suspension would be allowed to practice.

"We would most likely put in extra safeguards to monitor that physician very closely," Lunn said.

Dr. Greg Glasner, president and chief medical officer for Essentia Health's West Region, said the health system works closely with the state medical board and complies with the monitoring plan that is usually put in place.

"As long as they're compliant, they should be able to do their job," Glasner said. If the doctor is not complying with the program, "then they can't practice medicine. They can't interact with patients."

Wolfe, however, has concerns with stayed suspensions.

He said in many states, boards stay suspensions because of "clever lawyering" and/or convincing by the doctor, whose income depends on continuing to see patients.

Allowing doctors who have issues with drugs or alcohol "adds an additional risk to the diagnosis and treatment of patients," he said.

"People who are addicted need to be helped and need to show that they have fought successfully their addiction and have not had any use for a while," Wolfe said. "I think then, and only then, is it safe for them to see patients."

Doctor health program

Houdek said, typically, disciplined physicians who are allowed to continue practicing successfully return to medicine. Repeat offenders are rare, he said.

"These are people who have much at stake and are very smart people," Houdek said.

He said the physician health program, a five-year contract that includes treatment and monitoring, has a success rate of over 90 percent. Elements of the model have been used in programs for commercial pilots and attorneys.

In the last legislative session, the North Dakota Senate and House, in nearly unanimous votes, authorized the state Board of Medical Examiners to transfer the physician health program to a 501(c)(3) nonprofit corporation that is currently being created.

North Dakota and Arizona were the only two states that had its physician health program underneath its licensing board, Houdek said.

The nonprofit will have its own board of directors and staff, none overlapping with the Board of Medical Examiners.

Houdek said this will allow for earlier intervention.

The nonprofit will be required to report to the disciplining board in certain cases. If the physician's drug or alcohol use affects patients, "we have to know about it," Houdek said.

Volk, with Sanford, said he is pleased about the separation of the physician health program from the board. That is the model in South Dakota, and in talking to his Sioux Falls counterpart, Volk said he believes they have had an excellent experience.

"I think the earlier we can intervene with providers having problems, I think the better off everybody is," he said.

Wolfe, however, does not believe this sort of separation is a good idea.

"This is really saying without them saying it ... 'We trust a private not-for-profit board to be able to handle this quietly,'" he said.

Readers can reach Forum reporter Sherri Richards at (701) 241-5556