Case Title: Welter v. Bd. of Registration in Medicine

Citation: 

Docket Number: SJC-13236

State: massachusetts

Court: Massachusetts Supreme Court

Date: 2022-10-20T00:00:00Z

Document:
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SJC-13236 
 
RYAN J. WELTER  vs.  BOARD OF REGISTRATION IN MEDICINE. 
 
 
 
Suffolk.     September 7, 2022. - October 20, 2022. 
 
Present:  Budd, C.J., Gaziano, Lowy, Cypher, Kafker, 
& Wendlandt, JJ. 
 
 
Board of Registration in Medicine.  Due Process of Law, 
Administrative hearing, Suspension of license to practice 
medicine.  Administrative Law, Agency's interpretation of 
regulation.  Regulation.  Doctor, License to practice 
medicine.  Advertising.  Fraud.  Deceit. 
 
 
 
Petition filed in the Supreme Judicial Court for the county 
of Suffolk on April 13, 2021. 
 
The case was reported by Lowy, J. 
 
 
Alycia M. Kennedy (Paul Cirel also present) for the 
petitioner. 
Samuel Furgang, Assistant Attorney General, for the 
respondent. 
 
 
 
WENDLANDT, J.  "First, do no harm."  While apocryphal, this 
storied quotation attributed to Hippocrates, the father of 
modern medicine, embodies a higher standard to which we often 
hold our physicians.  See Travers, Primum Non Nocere:  Origin of 
2 
 
a Principle, 71 S.D. J. Med. 64, 65 (Feb. 2018), quoting 
Hippocrates, 1 Epidemics in Adams, The Genuine Works of 
Hippocrates (1849) ("to do good or to do no harm").  This case 
implicates that higher standard; it concerns the question 
whether due process requires that the Board of Registration in 
Medicine (board) find the common-law elements of fraud, 
including, inter alia, the elements of intent and reliance, 
before it may suspend a physician's license to practice medicine 
on the basis that the physician violated 243 Code Mass. Regs. 
§ 2.07(11)(a)(1) (2012), prohibiting "[a]dvertising that is 
false, deceptive, or misleading," and 243 Code Mass. Regs. 
§ 1.03(5)(a)(10) (2012), prohibiting "engaging in conduct which 
has the capacity to deceive or defraud."  Because the board's 
regulations, which by their plain terms do not require proof of 
the common-law elements of fraud, are rationally related to the 
Commonwealth's legitimate interest in protecting public 
confidence in the integrity of the medical profession and thus 
have a rational tendency to promote the health and safety of the 
public, we conclude that the regulations do not offend due 
process.  Further concluding that the board's findings that the 
petitioner physician violated these regulations were supported 
by substantial evidence and that neither the findings nor the 
sanction imposed were arbitrary or capricious, we affirm the 
board's decision. 
3 
 
 
1.  Background.  a.  Facts.  The following facts were found 
by the administrative magistrate for the Division of 
Administrative Law Appeals (DALA) and are generally undisputed. 
 
The petitioner, Dr. Ryan J. Welter, was licensed to 
practice medicine in Massachusetts in 2000 and has a 
certification in family medicine from the American Board of 
Family Medicine.  He is the founder and manager of Tristan 
Medical Enterprises, P.C., which does business as New England 
Center for Hair Restoration (New England Hair).  In 2011, Welter 
received an employment inquiry from Clark Tan, who attended 
medical school in the Philippines but who was not licensed to 
practice in the United States.1  Welter does not dispute that he 
knew Tan was not licensed to practice in the United States.  
Welter consulted with the Massachusetts Medical Society (MMS), 
however, and concluded that MMS regulations permitted him to 
delegate work to Tan as a nonlicensee.  Welter hired Tan as a 
nonprofessional assistant, and Tan worked for New England Hair 
between January 2015 and November 1, 2017. 
 
Welter maintained a website for New England Hair.2  Although 
Welter was the only licensed physician who worked at New England 
 
1 Tan was not eligible to be licensed to practice in the 
United States because he completed his medical residency abroad. 
 
 
2 The website was created by an outside consultant based on 
information Welter provided and with his approval. 
4 
 
Hair during the relevant time period, the website contained 
statements indicating that multiple doctors and surgeons worked 
at New England Hair, proclaiming under the heading "What Sets Us 
Apart" that "our surgeons" had been solving hair loss problems 
for years, that "Dr. Ryan Welter and Dr. Clark Tan [are] 
'doctors' doctors,'" and that the center's "doctors" could 
correct other surgeons' work.  Tan's website biography 
identified him as "Clark Tan, M.D.," and stated that "Dr. Tan 
received his medical degree from Far Eastern University 
Institute of Medicine" and was a diplomat at East Avenue Medical 
Center.  The biography did not indicate that the institute and 
center are located outside the United States or that Tan was not 
a physician licensed to practice in the United States.  
Throughout the website, Welter and Tan were repeatedly referred 
to in tandem.  For example, the website stated:  "Dr. Ryan 
Welter and Dr. Clark Tan have gained recognition in the field of 
hair restoration for their surgical skills."  The website also 
included Welter's biography, which stated, "Dr. Welter is board 
certified, trained and licensed to perform hair restoration 
procedures for men and women."  The biography did not specify 
that his certification is in family medicine. 
 
Consistent with the website's suggestions that Tan was a 
licensed physician, Tan introduced himself to staff and patients 
in the offices of New England Hair as "Dr. Tan," and staff 
5 
 
referred to him as "Dr. Tan."3  Welter permitted Tan to 
distribute business cards to patients identifying him as "Clark 
Tan, M.D."  Consent forms drafted or approved by Welter included 
language that the signer would "authorize Dr. Ryan Welter, his 
associate doctors and/or such assistants as may be selected by 
him" to perform procedures.4 
 
Welter delegated initial consultations to Tan.5  The consent 
form for these consultations stated that measurements of hair 
density "were taken by a doctor."  Tan also sent an e-mail 
message to at least one patient considering New England Hair; 
the message touted the benefits of New England Hair over other 
clinics, stating that "[c]onsultation is done by a doctor and 
not by a salesperson as what typically happens in other 
centers." 
 
In 2016, upon learning that Tan was not a licensed 
physician, two of New England Hair's patients -- each of whom 
was a physician -- complained to the board.  After Welter 
 
3 Welter explained that he referred to Tan as "Dr. Tan" 
because Tan was a medical school graduate. 
 
4 Welter did not employ any licensed associate doctors. 
 
5 Initial consultations are handled by nonmedically trained 
salespeople in some other hair restoration practices; Welter 
reviewed Tan's assessments following initial consultations.  
Further, when Tan met with patients alone, Welter would review 
Tan's notes and schedule the patient for a follow up if he had 
any concerns.  The hair procedures themselves were scheduled for 
times when Welter was physically present at New England Hair. 
6 
 
learned about the complaints, he removed all references to Tan 
from New England Hair's website and changed Tan's position so 
that he would no longer conduct consultations, assist with 
procedures, or have contact with patients. 
 
b.  Procedural history.  The board initiated a formal 
adjudicatory proceeding against Welter and referred the matter 
to DALA.  After a review of the evidence and a multiday hearing, 
the administrative magistrate concluded that the board had met 
its burden of proving by a preponderance of the evidence its 
allegations with regard to false advertising on New England 
Hair's website and deceptive conduct that enabled Tan to present 
himself as a licensed physician from 2015 to 2017.6 
 
The magistrate found that Welter had violated 243 Code 
Mass. Regs. § 2.07(11)(a), which prohibits "[a]dvertising that 
is false, deceptive, or misleading."  The magistrate found the 
website statements referring to the plural "doctors," even if 
intended to be aspirational,7 could falsely lead the reader to 
believe that there were multiple licensed physicians at New 
 
 
6 The administrative magistrate also concluded that the 
board had not met its burden of proving its allegations related 
to improper delegation of medical services, fraudulent filing of 
license renewal applications, or the creation and maintenance of 
false medical records.  The magistrate referred to the 
allegations of improper delegation as the "most serious 
allegation." 
 
7 Welter maintained that he referred to "doctors" because it 
had been his intent to hire additional doctors. 
7 
 
England Hair.  The magistrate found that the use of the plural 
was compounded by Tan's biography, suggesting that Tan was a 
licensed physician.  In placing Tan on the same level as Welter 
by repeatedly referring to the two in tandem, the website 
deceptively implied that Tan was a licensed physician, 
particularly given that it obscured that he was educated and 
trained in the Philippines.  The magistrate found, "Although the 
description of Tan's qualifications may have been technically 
accurate, even a careful reader might conclude that the East 
Avenue Medical Center, with its generic English name, is in the 
United States."  The failure to disclose where Tan studied and 
trained prevented readers from understanding that the references 
to "doctors" and "surgeons" could not include Tan. 
 
The magistrate also found it misleading not to disclose 
that Welter's board certification was in family medicine.  The 
magistrate explained, "Although each element of the sentence is 
true by itself -- Dr. Welter is board certified, he is trained 
in hair restoration procedures, and he does possess the 
appropriate licensure to do those procedures -- together the 
adjectives describing Dr. Welter convey the message that Dr. 
Welter is board-certified in hair restoration techniques, either 
as a surgeon or as a plastic surgeon."8 
 
 
8 The board explained at oral argument that there is no 
board certification in hair restoration, but it takes the 
8 
 
 
Welter argued that the false advertising regulation, 243 
Code Mass. Regs. § 2.07(11)(a), required more than just an 
advertising claim that is false, deceptive, or misleading; he 
contended that case law required the consideration of the 
common-law fraud elements of knowledge and intent to deceive, 
materiality, and reliance to the other party's detriment.  The 
magistrate concluded that there was no reason to "depart from 
the well-established rule of regulatory construction" that the 
clear meaning of the regulation's words should be applied unless 
doing so would lead to an illogical result, citing Massachusetts 
Fine Wines & Spirits, LLC v. Alcoholic Beverages & Control 
Comm'n, 482 Mass. 683, 687 (2019).  The magistrate thus declined 
to import additional elements into the regulation's plain 
meaning. 
 
The magistrate also found that Welter violated 243 Code 
Mass. Regs. § 1.03(5)(a)(10), which prohibits "[p]racticing 
medicine deceitfully, or engaging in conduct which has the 
capacity to deceive or defraud."  The magistrate found that 
Welter's conduct facilitated the impression that Tan was a 
licensed physician, and thus had the capacity to deceive.  
Welter contended that Tan was, in fact, a doctor and therefore 
 
position that Welter's website would mislead readers because a 
reasonable reader might not know that there is no certification 
in hair restoration. 
9 
 
that Welter's conduct in referring to Tan as such was accurate, 
but the magistrate found that the business cards, consent forms, 
and conduct of office staff "created a false and misleading 
impression concerning Tan's licensure status." 
 
The magistrate also found four mitigating factors:  that 
Welter (1) changed his website after learning of the complaints, 
(2) changed Tan's position after learning that the board 
disagreed with his construction of the delegation regulation, 
(3) had no history of discipline, and (4) had a reputation for 
honesty and integrity in his church community. 
 
The board, after considering the parties' objections, 
adopted the magistrate's findings of fact and conclusions of 
law.  Following consideration of the parties' memoranda on 
disposition, the board issued an indefinite suspension of 
Welter's license to practice medicine, which it immediately 
stayed upon Welter's entering into a probation agreement 
pursuant to which Welter arranged and paid for monitoring of his 
credentialing applications, advertising, and media 
communications.  The board indicated that Welter could petition 
for termination of the suspension after two years of monitoring.  
In determining its sanction, the board noted that false and 
deceptive statements on a physician's website deprive those 
seeking medical care of the opportunity to make informed choices 
10 
 
as consumers and that false and deceptive statements on a 
consent form bar patients from giving informed consent. 
 
Welter filed a petition for review of the board's order in 
the county court, pursuant to G. L. c. 112, § 64, and a single 
justice reserved and reported the matter to the full court.  
Welter urges the court to reverse or revise the board's decision 
on several grounds:  (1) the suspension of his medical license 
violates his substantive due process right to practice medicine, 
(2) the board's construction of its regulations is incorrect, 
(3) the board's decision was arbitrary or capricious as contrary 
to the evidence, and (4) the sanction was arbitrary or 
capricious as excessive.  We address each in turn. 
 
2.  Discussion.  a.  Standard of review.  A person whose 
license to practice medicine has been suspended, revoked, or 
cancelled by the board may petition this court to "enter a 
decree revising or reversing the decision of the board, in 
accordance with the standards for review provided in [G. L. 
c. 30A, § 14 (7)]."  G. L. c. 112, § 64.9  Section 14 (7), in 
 
 
9 Welter's argument that we should review the board's 
decision pursuant to the certiorari statute, G. L. c. 249, § 4, 
misreads the holding of Hoffer v. Board of Registration in Med., 
461 Mass. 451 (2012).  In Hoffer, the court conducted review 
under G. L. c. 249, § 4, rather than G. L. c. 112, § 64, because 
the petitioner did not challenge the decision suspending her 
license, but rather an order denying a stay of her suspension, 
which the court analyzed as analogous to a denial of 
reinstatement of an already suspended or revoked license.  Id. 
at 456.  By contrast, Welter challenges the decision of 
11 
 
turn, instructs us to set aside or modify the decision only if 
the substantial rights of a party may have been prejudiced 
because the agency decision is "(1) in violation of 
constitutional provisions; (2) in excess of the board's 
authority; (3) based on an error of law; (4) unsupported by 
substantial evidence; or (5) arbitrary or capricious, an abuse 
of discretion, or otherwise not in accordance with law."  Duggan 
v. Board of Registration in Nursing, 456 Mass. 666, 673 (2010), 
citing G. L. c. 30A, § 14 (7).  A plaintiff bears "a heavy 
burden," for we "give due weight to the [board's] expertise, as 
required by § 14 (7)."  Massachusetts Ass'n of Minority Law 
Enforcement Officers v. Abban, 434 Mass. 256, 263-264 (2001). 
 
b.  Substantive due process.  "[T]he right to engage in any 
lawful occupation is an aspect of the liberty and property 
interests protected by the substantive reach of the due process 
clause of the Fourteenth Amendment to the United States 
Constitution and analogous provisions of our State 
Constitution."  Blue Hills Cemetery, Inc. v. Board of 
Registration in Embalming & Funeral Directing, 379 Mass. 368, 
372 (1979) (Blue Hills Cemetery).  But "[t]he right to engage in 
a particular occupation is not a 'fundamental right infringement 
of which deserves strict judicial scrutiny.'"  Id. at 371 n.6, 
 
suspension; accordingly, G. L. c. 30A, § 14, provides the 
correct standard of review.  See G. L. c. 112, § 64. 
12 
 
quoting Commonwealth v. Henry's Drywall Co., 366 Mass. 539, 542 
(1974).  For nonfundamental rights, such as the right at issue 
here, "[t]he due process clause of the Fourteenth Amendment to 
the United States Constitution demands that a statute [or 
regulation] bear a 'reasonable relation to a permissible 
legislative objective.'"  Blue Hills Cemetery, supra at 373, 
quoting Pinnick v. Cleary, 360 Mass. 1, 14 (1971).  "Under the 
analogous provisions of our State Constitution, we must 
determine whether [the statute or regulation] 'bears a real and 
substantial relation to the public health, safety, morals, or 
some other phase of the general welfare.'"  Blue Hills Cemetery, 
supra, quoting Sperry & Hutchinson Co. v. Director of the Div. 
on the Necessaries of Life, 307 Mass. 408, 418 (1940).  Although 
"the State and Federal standards are phrased in virtually 
identical terms, we have noted that '[t]he Constitution of a 
State may guard more jealously against the exercise of the 
State's police power.'"  Blue Hills Cemetery, supra at 373 n.8, 
quoting Coffee-Rich, Inc. v. Commissioner of Pub. Health, 348 
Mass. 414, 421 (1965).  Here, however, we have little difficulty 
in concluding that the challenged regulations bear a real and 
substantial relation to a permissible legislative objective 
related to the general welfare, satisfying both the Federal and 
State Constitutions. 
13 
 
 
Welter argues that the board deprived him of substantive 
due process by indefinitely suspending his license to practice 
medicine without first finding the elements of common-law fraud, 
specifically that he had an intent to deceive and that patients 
relied on any misleading statements to their detriment.  See 
Masingill v. EMC Corp., 449 Mass. 532, 540 (2007), quoting 
Kilroy v. Barron, 326 Mass. 464, 465 (1950) ("To recover for 
fraudulent misrepresentation, a plaintiff 'must allege and prove 
that the defendant made a false representation of a material 
fact with knowledge of its falsity for the purpose of inducing 
the plaintiff to act thereon, and that the plaintiff relied upon 
the representation as true and acted upon it to [her] damage'").  
See also Restatement (Second) of Torts § 525 (1977) ("One who 
fraudulently makes a misrepresentation of fact, opinion, 
intention or law for the purpose of inducing another to act or 
to refrain from action in reliance upon it, is subject to 
liability to the other in deceit for pecuniary loss caused to 
him by his justifiable reliance upon the misrepresentation").  
He asserts that suspending his license without these findings 
"in no way promotes or protects the public health and is not 
rationally related to that end."  The board contends that its 
action was rationally related to public health and safety, in 
light of the board's "broad authority to 'protect the image of 
the medical profession,'" which "is not limited to disciplining 
14 
 
conduct involving direct patient care, criminal activity, or 
deceit."  Sugarman v. Board of Registration in Med., 422 Mass. 
338, 343 (1996), quoting Raymond v. Board of Registration in 
Med., 387 Mass. 708, 713 (1982).  We agree with the board. 
 
The board has "broad authority to regulate the conduct of 
the medical profession," and this authority "includes its 
ability to sanction physicians for conduct which undermines 
public confidence in the integrity of the medical profession" 
even where the physicians did not "engage in any wrongdoing" or 
"deceit."  Sugarman, 422 Mass. at 342-343.  Holding physicians 
to a high standard in their advertising and other conduct is 
rationally related to that end.  See Commonwealth v. Brown, 302 
Mass. 523, 527 (1939), quoting McMurdo v. Getter, 298 Mass. 363, 
367 (1937) ("Learned professions 'are characterized by . . . the 
adherence to a standard of ethics higher than that of the market 
place . . ."). 
 
It is instructive that the United States Supreme Court has 
recognized, at least as it pertains to the legal profession, 
which similarly is held to a higher standard than the general 
marketplace, that "advertising by the professions poses special 
risks of deception -- 'because the public lacks sophistication 
concerning legal services, misstatements that might be 
overlooked or deemed unimportant in other advertising may be 
found quite inappropriate in legal advertising.'"  In re R.M.J., 
15 
 
455 U.S. 191, 200 (1982), quoting Bates v. State Bar of Ariz., 
433 U.S. 350, 383 (1977).  The same concern for the public in 
connection with the selection of physicians permits the board to 
impose a high standard on physicians.  Thus, the board may, 
consistent with due process, place the burden on physicians to 
ensure that their advertising not only is technically accurate, 
but also is not deceptive or misleading; similarly, the board 
may demand that physicians conduct themselves in a manner that 
does not have the capacity to deceive or defraud without 
offending the State or Federal Constitution.10 
 
c.  Board's construction of regulations.  Welter next 
contends that the board committed legal error by construing its 
regulations so as not to require proof of the common-law 
 
 
10 Notably, other jurisdictions hold physicians to similarly 
high standards.  See, e.g., Barnett v. Maryland State Bd. of 
Dental Examiners, 293 Md. 361, 370-371 (1982) (upholding board's 
finding that advertising statements were "of a character tending 
to deceive or mislead the public" where reasonable person could 
be convinced there was "possibility" that lay person would make 
wrong conclusion); Gale v. North Dakota Bd. of Podiatric Med., 
1997 ND 83, ¶ 39 (upholding board's finding where "a reasoning 
mind could reasonably find [the doctor's] advertisement 
contained representations that in reasonable probability would 
cause an ordinary, prudent person to misunderstand or be 
deceived"); In re Campbell, 19 Wash.2d 300, 311 (1943) 
(upholding revocation of license even in absence of evidence 
that anyone was actually deceived where "the advertisements 
speak for themselves and reveal their own peculiar tendency to 
deceive the public").  We see nothing in either the Federal or 
State Constitution that would require the board to hold 
physicians licensed to practice medicine in the Commonwealth to 
a less exacting standard. 
16 
 
elements required to prove fraud.  "We interpret a regulation in 
the same manner as a statute, and according to traditional rules 
of construction."  Massachusetts Fine Wines & Spirits, LLC, 482 
Mass. at 687, quoting Warcewicz v. Department of Envtl. 
Protection, 410 Mass. 548, 550 (1991).  The first rule of 
construction is that "we look to the text of the regulation, and 
will apply the clear meaning of unambiguous words unless doing 
so would lead to an absurd result."  Massachusetts Fine Wines & 
Spirits, LLC, supra.  See DeCosmo v. Blue Tarp Redev., LLC, 487 
Mass. 690, 699 (2021) ("If the regulation is plain and 
unambiguous, it should be interpreted according to its terms"). 
 
Fatal to Welter's claim is the fact that neither regulation 
expressly requires proof of fraud; instead, the regulations 
prohibit "[a]dvertising that is false, deceptive, or 
misleading," 243 Code Mass. Regs. § 2.07(11)(a)(1), and 
"engaging in conduct which has the capacity to deceive or 
defraud," 243 Code Mass. Regs. § 1.03(5)(a)(10).  Whether 
something is advertising "that is" deceptive or misleading and 
whether conduct "has the capacity to deceive" are objective 
inquiries that do not necessarily depend on intent, knowledge, 
materiality, or reliance.11  Accordingly, we decline Welter's 
 
 
11 Given the disjunctive nature of the regulation, we need 
not reach the issue whether "conduct which has the capacity to 
. . . defraud" requires proof of the common-law elements.  243 
Code Mass. Regs. § 1.03(5)(a)(10). 
17 
 
invitation to inject these elements from the common law where 
they are absent from the plain words of the regulations.  See 
Pyle v. School Comm. of S. Hadley, 423 Mass. 283, 285 (1996) 
("Where the language of a statute is clear and unambiguous, it 
is conclusive as to legislative intent"); New England Med. Ctr. 
Hosp., Inc. v. Commissioner of Revenue, 381 Mass. 748, 750 
(1980) (where "statutory language . . . is sufficiently clear 
. . . we need not seek further enlightenment from other 
sources"). 
 
Our conclusion is further buttressed by neighboring 
provisions that expressly require intent or knowledge.  See 
Commonwealth v. Keefner, 461 Mass. 507, 511 (2012), quoting 
Wolfe v. Gormally, 440 Mass. 699, 704 (2004) ("Significantly, a 
statute [or regulation] must be interpreted 'as a whole'; it is 
improper to confine interpretation to the single section to be 
construed").  For example, 243 Code Mass. Regs. § 1.03(5)(a)(1) 
(2012) expressly prohibits "[f]raudulent procurement of [a 
physician's] certificate of registration or its renewal" 
(emphasis added), and 243 Code Mass. Regs. § 1.03(5)(a)(6) 
(2012) expressly bars "[k]nowingly permitting, aiding or 
abetting an unlicensed person to perform activities requiring a 
license" (emphasis added).  The absence of these elements in the 
regulations in question is thus further indication that our 
construction is proper. 
18 
 
 
Our construction of G. L. c. 93A, § 2 (a), which prohibits 
"deceptive acts or practices," is instructive.  We have 
concluded that G. L. c. 93A, § 2 (a), focuses on whether the 
advertising or conduct itself is objectively deceptive, not 
whether there was an intent to deceive or whether anyone was 
subjectively deceived.  See Aspinall v. Philip Morris Cos., 442 
Mass. 381, 394 (2004) ("Whether conduct is deceptive is 
initially a question of fact, to be answered on an objective 
basis" and "does not require proof that a plaintiff relied on 
the representation, or that the defendant intended to deceive 
the plaintiff, or even knowledge on the part of the defendant 
that the representation was false" [citations omitted]).  
Accordingly, we have concluded that a practice is "deceptive" if 
it "could reasonably be found to have caused a person to act 
differently from the way he [or she] otherwise would have 
acted."  Id., quoting Purity Supreme, Inc. v. Attorney Gen., 380 
Mass. 762, 777 (1980). 
Similarly, examining a regulation of the Board of 
Registration of Chiropractors "prohibit[ing] 'deceptive, 
confusing, misleading, or unfair' advertising," we rejected the 
argument that the regulation required showing that a consumer 
was actually deceived.  See Langlitz v. Board of Registration of 
Chiropractors, 396 Mass. 374, 382 (1985) ("Advertisements which 
are inherently misleading or deceptive are prohibited by [233 
19 
 
Code Mass. Regs. § 4.11], irrespective of any resulting harm to 
the public").  Accordingly, we rejected the argument that a 
violation of the regulation required testimony that a member of 
the public was actually deceived by an advertisement.  Id. 
 
Accordingly, we conclude that the challenged regulations 
are unambiguous -- they do not require any showing as to the 
common-law elements of fraud, namely intent, knowledge, 
materiality, or reliance.  Instead, they require only an 
objective assessment whether the advertisement is "deceptive" or 
"misleading," 243 Code Mass. Regs. § 2.07(11)(a)(1), and whether 
the conduct at issue has the "capacity to deceive," 243 Code 
Mass. Regs. § 1.03(5)(a)(10). 
 
d.  Whether the board's decision was arbitrary or 
capricious or contrary to the evidence.  Welter further contends 
that his advertising was not deceptive and his conduct did not 
have the capacity to deceive.  He maintains that the website and 
conduct were not deceptive because the references to "doctors" 
and "surgeons" were aspirational; it was not inaccurate to 
describe Tan, who was medically trained in the Philippines, as a 
doctor; and Welter is board certified. 
 
The scope of our review under the Administrative Procedure 
Act, G. L. c. 30A, § 14, is limited:  "we will uphold the 
[agency's] decision 'as long as the findings by the authority 
are supported by substantial evidence in the record considered 
20 
 
as a whole.'"  Costello v. Department of Pub. Utils., 391 Mass. 
527, 539 (1984), quoting 1001 Plays, Inc. v. Mayor of Boston, 
387 Mass. 879, 885 (1983).  "'Substantial evidence' means such 
evidence as a reasonable mind might accept as adequate to 
support a conclusion."  G. L. c. 30A, § 1 (6).  "[A]n agency's 
conclusion will fail judicial scrutiny if 'the evidence points 
to no felt or appreciable probability of the conclusion or 
points to an overwhelming probability of the contrary.'"  Cobble 
v. Commissioner of the Dep't of Social Servs., 430 Mass. 385, 
390-391 (1999), quoting New Boston Garden Corp. v. Assessors of 
Boston, 383 Mass. 456, 466 (1981). 
Applying this standard, the record amply supports the 
board's finding.  The website and conduct in question, even if 
technically accurate, reasonably could be found to have been 
deceptive or misleading, 243 Code Mass. Regs. § 2.07(11)(a)(1), 
and to have the capacity to deceive, 243 Code Mass. Regs. 
§ 1.03(5)(a)(10).  See Aspinall, 442 Mass. at 394-395 (in G. L. 
c. 93A context, "advertising need not be totally false in order 
to be deemed deceptive" because it "may consist of a half truth, 
or even may be true as a literal matter, but still create an 
over-all misleading impression through failure to disclose 
material information").  A reasonable prospective patient could 
reasonably read the website and believe that New England Hair 
employed multiple doctors, that Tan was licensed to practice in 
21 
 
the United States, and that Welter was board certified in hair 
restoration.  And a reasonable prospective patient could further 
be misled as to Tan's licensing status by the consent forms, the 
business cards, and the practice of calling Tan a doctor.  
Indeed, the two complaining patients, who themselves were 
physicians, were misled precisely in this manner. 
 
e.  Whether the board's sanction was arbitrary or 
capricious.  As a sanction for Welter's conduct, the board 
indefinitely suspended his license but immediately stayed the 
suspension upon Welter's entry into a two-year probationary 
agreement pursuant to which Welter arranged and paid for 
monitoring of his credentialing applications, advertising, and 
media communications.12  On appeal, Welter maintains that the 
board's sanction was excessive and thus arbitrary or capricious.  
In particular, he contends that because the board did not prove 
its more serious allegations against him, see note 6, supra, the 
sanction was disproportionately harsh when compared to sanctions 
in other comparable cases. 
 
A court cannot substitute its discretion for an agency's, 
"nor can the reviewing court interfere with the imposition of a 
penalty by an administrative tribunal because in the court's own 
 
12 Given the probationary agreement, we do not address here 
whether imposition by the board of an indefinite suspension 
(absent an agreed-upon probationary period) for Welter's conduct 
would be excessive. 
22 
 
evaluation of the circumstances the penalty appears to be too 
harsh."  Vaspourakan, Ltd. v. Alcoholic Beverages Control 
Comm'n, 401 Mass. 347, 355 (1987), quoting Levy v. Board of 
Registration & Discipline in Med., 378 Mass. 519, 529 (1979).  
"A court will interfere with the agency's discretion in this 
area 'only . . . in the most extraordinary of circumstances.'"  
Vaspourakan, supra, quoting Levy, supra at 528-529.  In 
assessing whether the sanction is arbitrary or capricious, we 
search for comparable cases.  See Herridge v. Board of 
Registration in Med., 420 Mass. 154, 166-167 (1995), S.C., 424 
Mass. 201 (1997) (finding board did not abuse its discretion 
where "the sanction imposed was not disproportionate to 
sanctions imposed in other cases" of similar conduct). 
 
In pressing his claim that the sanction imposed on him was 
excessive, Welter chiefly relies on Matter of Reynolds, 
Adjudicatory Case No. 89-11-ST (Aug. 16, 1989).13  In that case, 
the physician employed an unlicensed medical school graduate and 
failed to disclose three malpractice suits on his license 
renewal; the physician received a reprimand and a fine.  The 
 
13 Welter also cites consent orders involving fraudulent 
conduct where the offending physician received a reprimand and a 
fine.  See, e.g., Matter of Asis, Adjudicatory Case No. 2006-06-
5 (Dec. 20, 2006) (insurance fraud); Matter of Prasad, 
Adjudicatory Case No. 2006-018 (Apr. 16, 2006) (altering patient 
medical records to conceal accidental administration of overdose 
and making misrepresentations concerning event to medical peer 
review committee). 
23 
 
Reynolds decision is distinguishable because the disciplined 
physician in that matter believed the graduate had a license; 
here, Welter knew that Tan was not a licensed physician but 
nonetheless presented Tan in a manner to suggest to the public 
that Tan was licensed in the United States. 
 
Welter also relies on a decision of a single justice of 
this court, reversing a five-year revocation of a license by the 
board as being excessive, and thus arbitrary or capricious and 
an abuse of discretion.  See Brockington vs. Massachusetts Bd. 
of Registration in Med., Supreme Judicial Ct., No. SJ-2012-0510 
(Suffolk County Oct. 30, 2014).  In that case, the board 
sanctioned the physician on the basis that his actions amounted 
to "gross misconduct" under G. L. c. 112, § 5, and 243 Code 
Mass. Regs. § 1.03(5) (2012).  Id. at 3.  But the board did not 
explain why it adopted a "gross misconduct" standard.  Id. at 
10.  Moreover, the single justice determined that the five-year 
license revocation seemed "significantly inconsistent with prior 
sanctions," and thus arbitrary and an abuse of discretion "[i]n 
the absence of an adequate explanation of why the case 
warrant[ed] this level of discipline in comparison to other 
cases."  Id.  The single justice concluded, based on comparable 
cases, that the years of revocation should have been reduced, or 
else the board should have imposed the lesser sanction of 
24 
 
license suspension.  Id. at 12.14  Here, we are not addressing a 
five-year revocation.  Importantly, the board has explained both 
its reasoning in imposing the sanction based on a comparable 
case as well as the reasons for deviation from the cases upon 
which Welter relies, the most recent of which are from 2006. 
 
More specifically, the board primarily relied on Matter of 
Bergus, Adjudicatory Case No. 2017-004 (June 27, 2019).  In the 
Bergus case, as with the present case, the board imposed an 
indefinite suspension stayed upon entry into a probation 
agreement.15  The physician misrepresented to a health care 
facility the circumstances surrounding the end of his residency 
program, incorrectly informed a health maintenance organization 
that he was board certified in a specialty when he was not, and 
inaccurately claimed in an advertisement that he had received 
board certification in areas where he had not.  The physician 
had already agreed with the Rhode Island Board of Medical 
Licensure and Discipline to pay a $10,000 administrative fee, 
receive a reprimand, and be placed on probation for two years 
during which time he attended an ethics course and retained and 
 
 
14 On remand, the board revoked the physician's license, but 
allowed him to petition for reinstatement after three years upon 
demonstration of his competency to practice medicine.  Matter of 
Brockington, Adjudicatory Case No. 2008-017 (Apr. 16, 2015). 
 
15 The board in the Bergus case also imposed a $10,000 fine.  
Matter of Bergus, Adjudicatory Case No. 2017-004. 
25 
 
cooperated with monitors.  Matter of Bergus, Adjudicatory Case 
No. RM-17-054 (Aug. 9, 2018). 
 
In its decision, the board explained that Welter's 
statements and conduct deprived patients of the opportunity to 
make informed choices and to give informed consent.  At oral 
argument, the board further explained its rationale for the 
sanction imposed on Welter, which it acknowledged deviated in 
severity from the earlier cases relied on by Welter; in 
particular, the board argued that the broader reach of, and the 
public's increasing reliance on, Internet advertising in 
connection with selecting a physician merited the sanction 
imposed on Welter. 
 
Although we agree with Welter that the Bergus case is not 
squarely on all fours with the present case, given our highly 
deferential standard, we cannot say that the sanction here was 
arbitrary or capricious.16 
 
3.  Conclusion.  For the reasons stated, we affirm the 
order of the board. 
 
 
 
 
 
 
 
So ordered. 
 
 
16 Contrary to Welter's contention, the board properly 
considered mitigating factors in determining its sanction.