Title: Kirbens v. Wyoming State Bd. of Medicine

State: wyoming

Issuer: Wyoming Supreme Court

Document:

Kirbens v. Wyoming State Bd. of Medicine1999 WY 158992 P.2d 1056Case Number: 98-233Decided: 12/06/1999Supreme Court of Wyoming
 
DREW 
J. KIRBENS, M.D., Appellant (Petitioner),

v.

WYOMING STATE BOARD OF 
MEDICINE; ROBERT L. McGUIRE, M.D., in his official capacity as a Board member; 
and DUANE E. ABELS, D.O., in his official capacity as a Board member, Appellees 
(Respondents).

 

W.R.A.P. 12.09(b) 
Certification from the District Court of Laramie County, Honorable Edward L. 
Grant, Judge.

Eldon E. 
Silverman of Preeo, Silverman & Green, P.C., Denver, Colorado, 
representing Appellant.

Don W. Riske, 
Special Assistant Attorney General, Cheyenne, Wyoming, representing 
Appellees.

Before 
LEHMAN, C.J., and THOMAS, MACY, GOLDEN and HILL, JJ.

Golden, 
Justice.

[¶1]      This appeal 
presents novel issues as to whether state and federal statutes offer protection 
to an impaired physician facing disciplinary action for misconduct that he 
claims resulted from disability. The Wyoming Board of Medicine (Board) revoked 
Appellant Drew J. Kirbens' medical license following a contested case hearing. 
Although he admits that he poses a significant threat to the safety of the 
public, he appeals the decision to revoke, asserting that his disability 
entitled him to voluntarily relinquish his license and seek treatment in an 
appropriate program.

[¶2]      Determining that 
neither state nor federal statute protects Kirbens from disciplinary action upon 
an admission that he poses a significant threat to the safety of the public, we 
affirm the decision of the Board.

ISSUES

[¶3]      Kirbens presents 
the following issues for our review:

1. Does the 
plain meaning of W.S. § 33-26-404(a) and (b) compel the Board to accept the 
license of a medical doctor who voluntarily relinquishes it and not engage in a 
punitive course of action?

2. Does the 
Board's action in requiring a contested hearing and levying penalties violate 
the Americans with Disabilities Act?

3. In any event, 
is the Board's finding of willfulness supported by the 
record?

4. Did the Board 
violate its own rules and regulations by publicizing its Findings and 
Conclusions?

The Board 
rephrases the issues as:

1. Whether the 
Wyoming Board of Medicine is required to accept the voluntary relinquishment of 
a license when the licensee is the subject of a pending disciplinary 
proceeding.

2. Whether the 
disciplinary proceeding before the Wyoming Board of Medicine against Appellant 
violated the Americans with Disabilities Act.

3. Whether the 
Findings of Fact, Conclusions of Law and Order issued by the Wyoming Board of 
Medicine in this case are supported by substantial evidence found in the record 
of the agency proceeding.

4. Whether the 
Wyoming Board of Medicine violated its own rules by publicly disclosing the 
Findings of Fact, Conclusions of Law and Order issued by it in this 
case.

FACTS

[¶4]      As Kirbens was a 
licensed Wyoming medical doctor, his license was subject to the provisions of 
the Wyoming Medical Practice Act and the Board's Rules and Procedure. On January 
2, 1997, representatives of the Board filed a first complaint against Kirbens, 
notifying him that it would hold a contested case hearing to consider 
disciplinary action. As grounds for disciplinary action, the complaint asserted 
that Kirbens' negligence and malpractice violated statutory prohibitions against 
willful and consistent utilization of medical service or treatment which was 
inappropriate or unnecessary pursuant to Wyo. Stat. Ann. § 33-26-402(a)(xxii) 
and Wyo. Stat. Ann. § 33-26-402(a)(xviii). An amended complaint was then filed 
on February 27, 1997, asserting that Ivinson Memorial Hospital in Laramie, 
Wyoming, had taken an adverse action against Kirbens' privileges as of January 
14, 1997, by suspending him for an indefinite period, which is also statutory 
grounds for discipline, pursuant to Wyo. Stat. Ann. § 33-26-402(a)(xxvi). A 
second amended complaint was filed asserting other violations of the Act arising 
out of a surgery, on or about June 9, 1997, at Memorial Hospital of Converse 
County, in which a patient subsequently died.

[¶5]      In July of 1997, 
Kirbens agreed to temporary restrictions of his practice, including a 
prohibition from surgical or invasive procedures. A third amended complaint was 
filed by representatives of the Board on October 20, 1997, asserting the same 
violations but invoking the names of patients in addition to the ones previously 
listed and asserting a stipulated suspension from Memorial Hospital of Converse 
County.

[¶6]      Following the 
filing of the third amended complaint, the hearing examiner continued the 
hearing until January 8, 1998. At that time, the hearing examiner approved the 
continued restrictions on Kirbens' practice until final disposition of the 
complaint. In early November, 1997, Kirbens attended a Professional Assessment 
Program at Abbott Northwestern Hospital in Minneapolis, Minnesota, for alcohol 
and drug screening. Those results proved negative, and the program recommended 
that Kirbens enter a Physicians in Crisis Program at the Menninger Clinic in 
Topeka, Kansas. He did so on December 15, 1997. In a letter dated December 31, 
1997, Dr. Richard R. Irons stated that he had diagnosed Kirbens with bipolar 
affective disorder Type II and narcissistic personality disorder and was 
treating him for those conditions.

[¶7]      On January 6, 
1998, Kirbens claimed that the applicable Wyoming statute authorized voluntary 
relinquishment and requested the Board to allow him to relinquish his license, 
or alternatively, to agree to temporary suspension. He also filed a motion to 
stay or continue the contested hearing, contending that Wyoming statutes and the 
Americans with Disabilities Act (ADA) permitted a stay. Kirbens' motions 
asserted that he was an impaired physician as defined under Wyo. Stat. Ann. § 
33-26-102(a)(vii) because he could not practice medicine with reasonable skill 
and safety due to mental illness or physical illness. He claimed that he was a 
qualified individual with a disability entitled to protection under the ADA and 
its applicable regulations. The hearing examiner presented these motions for 
consideration by the Board. At the hearing, Kirbens stipulated to the Board's 
jurisdiction, admitted wrongful acts that he claimed were not intentional or 
willful and requested the Board's help with his physical and mental impairment. 

[¶8]      At the hearing, 
Kirbens attempted to explore whether the Board's conducting a contested case 
hearing would violate the ADA. He questioned the Board's executive secretary to 
ascertain whether the Board permitted physicians impaired by substance abuse to 
voluntarily relinquish their licenses and receive treatment from a Board 
program. He succeeded in establishing that a substance abuse treatment program 
existed, and when he was not allowed to continue, made an offer of proof that 
Wyoming did not provide similar treatment assistance for physicians with 
physical or mental illness. Dr. Irons testified that Kirbens was an impaired and 
disabled physician who, because of his disability, posed a significant risk to 
the health or safety of others and recommended that Kirbens not practice 
medicine in any form at this time. In Dr. Irons' medical opinion, Kirbens was 
competent to decide to relinquish his license to the Board. Kirbens' counsel 
then argued that Wyoming and federal law required the Board to accept the 
relinquishment of his license. The Board's counsel argued that a contested case 
hearing should be held to establish all of the facts in the event of a request 
for reinstatement. The hearing examiner reserved decision on the motion for 
relinquishment and held the contested case hearing.

[¶9]      The Board issued 
an order denying the stay and request for relinquishment on the grounds that no 
evidence showed Kirbens was impaired at the time of the acts that were the 
subject of the complaint; the request was not timely; and that Kirbens was not 
covered by the ADA. The Board revoked Kirbens' medical license and ordered he 
pay a civil penalty of $5,000.00. Kirbens filed a petition for judicial review 
on both of these orders, and the district court certified the case to this 
Court. Kirbens also asserted that the Board had published its findings of fact 
and conclusions of law in violation of Wyo. Stat. Ann. § 33-26-408(c). The 
district court issued an order permitting all records except the final order be 
filed under seal.

DISCUSSION

Standard of 
Review

[¶10]   Wyoming's Medical Practice Act 
(Act) empowers the Board to govern the practice of medicine in Wyoming and 
discipline its physicians and surgeons. Wyo. Stat. Ann. § 33-26-101 through § 
410 (LEXIS 1999). The Act provides for judicial review of the actions of the 
Board under the Wyoming Administrative Procedure Act. Wyo. Stat. Ann. § 
33-26-407 (LEXIS 1999). We review its actions under Wyo. Stat. Ann. 16-3-114(c) 
(LEXIS 1999):

(c) To the 
extent necessary to make a decision and when presented, the reviewing court 
shall decide all relevant questions of law, interpret constitutional and 
statutory provisions, and determine the meaning or applicability of the terms of 
an agency action. In making the following determinations, the court shall review 
the whole record or those parts of it cited by a party and due account shall be 
taken of the rule of prejudicial error. The reviewing court 
shall:

(i) Compel 
agency action unlawfully withheld or unreasonably delayed; 
and

(ii) Hold 
unlawful and set aside agency action, findings and conclusions found to 
be:

(A) Arbitrary, 
capricious, an abuse of discretion or otherwise not in accordance with 
law;

(B) Contrary to 
constitutional right, power, privilege or immunity;

(C) In excess of 
statutory jurisdiction, authority or limitations or lacking statutory 
right;

(D) Without 
observance of procedure required by law; or

(E) Unsupported 
by substantial evidence in a case reviewed on the record of an agency hearing 
provided by statute.

Right of 
Relinquishment

[¶11]   Kirbens contends that Wyoming 
statute compels the Board to accept his voluntary relinquishment of his medical 
license and prohibits a hearing when a license is voluntarily relinquished. He 
asserts that the Board's refusing to accept the voluntary relinquishment of his 
license and conducting the contested case hearing was contrary to law. The 
applicable statute, Wyo. Stat. Ann. § 33-26-404(a) and (b) (LEXIS 1999), 
states:

(a) A licensee 
may request the Board, in writing, to accept the voluntary relinquishment, 
restriction or suspension of his license.

The Board may 
accept the relinquished license, grant the request for restriction or 
suspension, attach conditions to the license or waive the commencement of any 
proceedings under this article. Removal of a voluntary relinquishment, 
restriction or suspension is subject to the procedure for reinstatement of a 
license as provided in this article.

(b) Unless the 
licensee has voluntarily relinquished or restricted his license, the Board shall 
conduct any proceeding to deny, refuse to renew or reinstate, revoke, restrict 
or suspend a license on the grounds that a licensee is impaired or has engaged 
in errant conduct as a contested case under the Wyoming Administrative Procedure 
Act.

(emphasis 
added). The Board refers us to the discretionary language used in the statute 
and its discretionary power to accept or reject a relinquishment found in the 
Rules of Practice and Procedure for Disciplinary Complaints Against Physicians 
of the Board at Chapter 4, Section 4(h).

[¶12]   An issue of statutory 
interpretation presents a question of law. Butts v. Wyoming State Bd. of 
Architects, 911 P.2d 1062, 1065 (Wyo. 1996); Parker Land & Cattle Co. v. 
Wyo. Game and Fish Comm'n, 845 P.2d 1040, 1042 (Wyo. 1993). In interpreting 
statutes, we primarily determine the legislature's intent. State ex rel. Motor 
Vehicle Div. v. Holtz, 674 P.2d 732, 736 (Wyo. 1983). If the language is 
sufficiently clear, we do not resort to rules of construction. Id. We apply our 
general rule that we look to the ordinary and obvious meaning of a statute when 
the language is unambiguous. Parker Land, 845 P.2d  at 
1042.

[¶13]   Plainly, in stating that a licensee 
may request the Board to accept his voluntary relinquishment, this statutory 
language authorizes such a procedure; yet, providing that the Board may accept 
that relinquishment grants the Board the discretionary authority to accept or 
reject it. In the event that a voluntary relinquishment is neither made nor 
accepted, the statute directs the Board that it shall proceed with the 
particular disciplinary proceeding as a contested case hearing. Acting within 
its statutory discretion to reject Kirbens' request to voluntarily relinquish 
his license, the Board was statutorily required to hold a contested case 
hearing. The Board's order denying the request for relinquishment and stay of 
contested case proceedings was not contrary to law.

Americans With 
Disabilities Act

1. Applicability 
in Disciplinary Proceedings.

[¶14]   The Wyoming Medical Practice Act 
defines an "impaired" physician as:

(vii) "Impaired" 
means a person who cannot practice medicine with reasonable skill and safety to 
patients by reason of one (1) or more of the following:

(A) Medical 
incompetence;

(B) Mental 
illness;

(C) Physical 
illness, including but not limited to deterioration through the aging process or 
loss of motor skill;. . . .

Wyo. Stat. Ann. 
§ 33-26-102(a)(vii) (LEXIS 1999). Kirbens states in his brief "he is an impaired 
physician, and thus, his continued practice of medicine would constitute a 
significant risk to the health or safety of the public." He contends, however, 
that the ADA required the Board to permit him relief under state statutes 
assisting physically and mentally impaired physicians. He relies upon the 
statute permitting voluntary relinquishment of his license, or, alternatively, 
Wyo. Stat. Ann. § 33-26-202(a)(xii), mandating that the Board provide a program 
to assist physically and mentally impaired physicians. He directs our attention 
to Wyo. Stat. Ann. § 33-26-202(b) (ix), obliging the Board to comply with all 
federal law. Evidentiary rulings at the hearing prevented him from establishing 
the applicability of the ADA, although his offer of proof at the hearing 
established that the sole state-sponsored physicians' assistance program exists 
for physicians impaired by substance abuse. He requests that the Board's order 
be set aside until he determines whether any discipline against him (other than 
voluntary relinquishment of his license) is discriminatory under the ADA. 
Precisely, he contends that the ADA does not permit the Board to treat him 
differently from doctors with an alcohol or drug dependence issue for whom the 
Board may have established a state sponsored rehabilitative program as provided 
for in Wyo. Stat. Ann. § 33-26-202(b)(xii).

[¶15]   The Board contends that the ADA 
does not protect a physician who is not a "qualified individual with a 
disability" under the ADA. It claims a physician who poses a significant risk to 
the health or safety of others by virtue of his disability is not "qualified." 
Because Kirbens' witness, Dr. Irons, testified that Kirbens did pose a 
significant risk to the health and safety of others because of his disability, 
the Board asserts that Kirbens is not qualified under the ADA, the ADA does not 
protect him, and the ADA does not apply to Board proceedings and final 
orders.

[¶16]   Wyo. Stat. Ann. § 33-26-202 (LEXIS 
1999) states in relevant part:

(a) The board 
shall pass upon the qualifications and determine the fitness of all persons 
desiring to practice medicine in this state.

(b) The board is 
empowered and directed to:

(i) Grant, 
refuse to grant, suspend, restrict, revoke, reinstate or renew licenses to 
practice medicine;

(ii) Investigate 
allegations and take disciplinary action on the following 
grounds:

(A) A licensee 
is impaired or has engaged in errant conduct;

(B) A person has 
violated an applicable provision of this chapter or the board's 
regulations.

(iii) Conduct 
informal interviews and contested case proceedings;

* * 
*

(ix) Comply with 
all applicable federal law;

* * 
*

(xii) 
Participate in and contribute to a program to assist in the return to practice 
of licensees who are physically or mentally impaired;

(xiii) Take all 
reasonable action, including the promulgation of rules and regulations, 
necessary to enforce this chapter.

(emphasis 
added). Kirbens does not contend that section (xii) in and of itself entitles 
him to avoid revocation of his license and be placed in a treatment program. 
Rather, he argues that because a public entity program apparently exists for 
disabled physicians, the ADA requires that he be treated similarly to other 
disabled physicians.

[¶17]   Kirbens asserts that the applicable 
federal law is Title II of the ADA and those regulations implementing its 
provisions. Title II is one of five titles contained in the ADA: Employment 
(Title I), Public Services (Title II), Public Accommodations and Services 
Operated by Private Entities (Title III), Telecommunications (Title IV), and 
Miscellaneous Provisions (Title V). Zimmerman v. Oregon Dept. of Justice, 170 F.3d 1169, 1172 (9th Cir. 1999) (citing Americans with Disabilities Act of 1990, 
Publ.L. No. 101-336, 104 Stat. 327, 327-28 (1990)). As a whole, Congress 
intended that the ADA "provide a clear and comprehensive national mandate for 
the elimination of discrimination against individuals with disabilities." 
Olmstead v. L.C., ___ U.S. ___, 119 S. Ct. 2176, 2182, 144 L. Ed. 2d 540 (1999) 
(quoting 42 U.S.C. § 12101(b)(1)) (1994)). Bipolar disorder is a disability 
under the ADA. The Florida Bar v. Clement, 662 So. 2d 690, 699 (Fla. 1995), cert. 
denied, 517 U.S. 1210 (1996). The Title II provision at issue 
states:

[N]o qualified 
individual with a disability shall, by reason of such disability, be excluded 
from participation in or be denied the benefits of the services, programs, or 
activities of a public entity, or be subjected to discrimination by any such 
entity.

42 U.S.C. § 
12132 (1994). Title II defines "public entity" as any state or local government 
and any department, agency, or special purpose district. 42 U.S.C. § 12131(A), 
(B) (1994). At the hearing, the Board conceded that it is a public agency within 
this definition. The ADA defines "qualified individual with a disability" 
as:

an individual 
with a disability who, with or without reasonable modifications to rules, 
policies, or practices, the removal of architectural, communication, or 
transportation barriers, or the provision of auxiliary aids and services, meets 
the essential eligibility requirements for the receipt of services or the 
participation in programs or activities provided by a public 
entity.

42 U.S.C. § 
12131(2) (1994).

[¶18]   Kirbens directs us to an 
accompanying regulation promulgated under the ADA, 
providing

[a] public 
entity may not administer a licensing or certification program in a manner that 
subjects qualified individuals with disabilities to discrimination on the basis 
of disability, nor may a public entity establish requirements for the programs 
or activities of licensees or certified entities that subject qualified 
individuals with disabilities to discrimination on the basis of 
disability.

28 C.F.R. § 
35.130(b)(6) (1999). Virginia interprets this provision as specifically 
prohibiting public entities from acting discriminatorily in administering 
licensing programs. Clark v. Virginia Bd. of Bar Examiners, 880 F. Supp. 430, 
442 (E.D. Va. 1995). Kirbens asserts this regulation prohibits the Board from 
assisting substance dependent physicians while denying assistance to him for his 
particular disability, and discriminatorily refusing to allow him to voluntarily 
relinquish his license.

[¶19]   Maintaining its position that 
Kirbens is not a qualified individual under ADA, the Board relies upon Alexander 
v. Margolis, 921 F. Supp. 482 (W.D. Mich. 1995), affirmed on appeal, 98 F.3d 1341 (6th Cir. 1996), and quotes the following passage:

Considering the 
text of section 12132(2), it is questionable whether the Board's duty to license 
physicians can be characterized as a "service" being denied to plaintiff or 
whether the Board's refusal to reinstate his license denies him participation in 
"programs or activities provided" by a state entity. The Board of Medicine is, 
if anything, a service, program or activity provided for the public's benefit 
and safety, not for the benefit of any given individual who does not meet the 
state's requirements for practicing medicine.

In any event, 
plaintiff is not a "qualified individual with a disability" under the ADA. The 
very nature of the police powers exercised by state boards of medicine 
require[s] the state to discriminate on the basis of, among other 
considerations, a mental condition harmful to the public's safety. By the very 
nature of the practice of medicine, given the physician's necessary independence 
to "practice" his art, no reasonable modification can be made to a policy of 
restricting medical practice to those without evidence of mental 
disabilities.

Id. at 
488.

[¶20]   The Board directs our attention to 
Doe v. Univ. of Maryland Medical System Corp., 50 F.3d 1261 (4th Cir. 1995),1 which held:

[A] hospital 
does not violate § 504 of the Rehabilitation Act or Title II of the ADA when it 
terminates an HIV-positive neurosurgical resident based upon the risk of 
transmission of the disease during performance of exposure-prone procedures. 
Such individuals pose a significant risk to the health or safety of their 
patients that cannot be eliminated by reasonable accommodation, and therefore 
are not otherwise qualified within the meaning of the Rehabilitation Act and the 
ADA.

Id. at 1267. 
Kirbens distinguishes Doe as a Title I employment termination case inapplicable 
to a request of voluntary relinquishment on Title II disability grounds. We 
agree that Kirbens' contentions must be examined under Title II of the ADA which 
is applicable to public entities, rather than Title I, which is applicable to 
employment. Nevertheless, we find that the federal regulations promulgated under 
the ADA support the Board's position.

[¶21]   "Because Congress explicitly 
authorized the Attorney General to implement Title II through these regulations, 
see 42 U.S.C. § 12134, they `must be given legislative and hence controlling 
weight unless they are arbitrary, capricious, or plainly contrary to the 
statute.'" Medical Society of New Jersey v. Jacobs, 1993 WL 413016 at *5 (D.N.J. 
Oct. 5, 1993) (quoting United States v. Morton, 467 U.S. 822, 834 (1984)). The 
federal regulations discuss the relationship between safety questions and 
protecting disabled individuals under the ADA in this way:

Where questions 
of safety are involved, the principles established in § 36.208 of the 
Department's regulation implementing title III of the ADA, to be codified at 28 
C.F.R., part 36, will be applicable. That section implements section 302(b)(3) 
of the Act, which provides that a public accommodation is not required to permit 
an individual to participate in or benefit from the goods, services, facilities, 
privileges, advantages and accommodations of the public accommodation, if that 
individual poses a direct threat to the health or safety of 
others.

A "direct 
threat" is a significant risk to the health or safety of others that cannot be 
eliminated by a modification of policies, practices, or procedures, or by the 
provision of auxiliary aids or services. . . . Although persons with 
disabilities are generally entitled to the protection of this part, a person who 
poses a significant risk to others will not be "qualified," if reasonable 
modifications to the public entity's policies, practices, or procedures will not 
eliminate that risk.

28 C.F.R. pt. 
35, App. A at 481 (1999) (emphasis added).

[¶22]   The regulatory language establishes 
that the ADA will not protect a disabled individual whose disability constitutes 
a direct safety threat to the public. Other jurisdictions have determined that 
the ADA does not prevent disciplining disabled attorneys whose misconduct 
substantially harmed or threatened their clients. State ex rel. Oklahoma Bar 
Ass'n v. Busch, 919 P.2d 1114, 1119-20 (Okla. 1996); Matter of Wolfgram, 1995 WL 
506002 at *7 (Cal. Bar. Ct. Aug. 22, 1995). We agree that the appropriate rule 
in Kirbens' case should be that the ADA will not protect him from Board 
disciplinary proceedings if his conduct significantly risks the health or safety 
of others.

[¶23]   Under a standard of clear and 
convincing evidence, the Board concluded that Kirbens had violated several 
provisions of the Act by performing inappropriate or unnecessary surgeries upon 
several patients. Kirbens' treating physician, Dr. Irons, testified that in his 
opinion, Kirbens cannot practice medicine with reasonable skill and safety and 
would pose a significant risk to the health and safety of others by virtue of 
his disability. Based on this opinion, the Board concluded that a physician 
cannot be "qualified" under the ADA if he poses a significant risk to the health 
or safety of others by virtue of his disability. From hospital records of 
adverse actions against Kirbens, the Board concluded two hospitals suspended his 
privileges because of either possible incompetence or misconduct. The Board 
established that Kirbens cannot practice medicine without substantial harm or 
threat to his patients. Kirbens does not challenge either these findings or 
conclusions. We agree that the ADA does not consider Kirbens as a "qualified 
individual with a disability." We hold that the ADA did not prevent the Board 
from revoking Kirbens' medical license.

2. Limitation of 
Disciplinary Proceedings.

[¶24]   Despite the Board's finding that 
Kirbens had significantly harmed patients, Kirbens maintains that, under the 
ADA, his disability entitled him to avoid revocation by voluntarily 
relinquishing his license and receiving treatment under a state sponsored 
rehabilitation program. This assertion is questionable because in its 
individualized assessment upon his motion requesting that he be allowed to 
voluntarily relinquish his license, the Board determined that Kirbens' acts were 
not shown to have been caused by his disability and that he was not otherwise 
protected by the ADA. Furthermore, Kirbens does not refer us to any provision of 
the ADA which would require the Board to make the requested accommodation. See 
Wolfgram, at *7. Assuming without deciding that the ADA applies, the Colorado 
Supreme Court has ruled that the ADA did not prevent it from exercising 
discretion and rejecting the proposed disciplinary measures of an attorney found 
to have committed serious misconduct and harm. People v. Reynolds, 933 P.2d 1295, 1305 (Colo. 1997). We agree that the ADA defers to the licensing 
authority, and uphold the exercise of the Board's discretion in rejecting 
Kirbens' proposed disciplinary measures. See Theriault v. Flynn, 162 F.3d 46, 50 
(1st Cir. 1998). Under these circumstances, we hold that the Board is not acting 
discriminatorily by refusing to allow Kirbens to voluntarily relinquish his 
license or by not placing him in a state-sponsored rehabilitation 
program.

Finding of 
Willfulness

[¶25]   The Board decided that Kirbens 
violated Wyo. Stat. Ann. § 33-26-402(a)(xviii) by willful and consistent 
utilization of medical service or treatment which is inappropriate or 
unnecessary. Kirbens contends the record does not show by clear and convincing 
evidence that his actions constituted willful misconduct. He contends the 
statutory term "willful" is to be defined as "willful misconduct." He provides a 
definition of willful misconduct from the criminal case of Norfolk v. State, 360 P.2d 605, 607 (Wyo. 1961):

Willful 
misconduct implies at least the intentional doing of something either with a 
knowledge that serious injury is a probable (as distinguished from a possible) 
result, or the intentional doing of an act with a wanton and reckless disregard 
of its possible result.

(emphasis 
omitted.) The Board does not contest the application of this definition, relying 
instead on those portions of the record supporting its findings and conclusions 
that Kirbens' actions were not accidental, and were, therefore, willful actions 
in violation of the statute. We apply our general rule that we look to the 
ordinary and obvious meaning of a statute when the language is unambiguous. 
Parker Land, 845 P.2d  at 1042.

[¶26]   The term "willful misconduct" as 
used in the criminal context generally means an act done with a bad purpose. 
Blacks Law Dictionary 1600 (6th ed. 1990). In the civil context, it "often 
denotes an act which is intentional, or knowing, or voluntary as distinguished 
from accidental." Id. In the professional licensing context, the Board is not 
required to prove patient injury to establish willful acts nor should it be 
defined as in tort. See Medical Licensing Bd. of Indiana v. Ward., 449 N.E.2d 1129, 1141 (Ind. App. 4 Dist. 1983); Dixon v. State Bd. of Optometric Examiners, 
565 P.2d 960, 963 (Colo. App. 1977). Because it is inappropriate to apply 
definitions from either a criminal or tort context, we review the Board's 
finding on the issue of "willful" to determine if the evidence establishes 
intentional, or knowing, or voluntary acts as distinguished from 
accidental.

[A]gency action 
will be set aside if it is not supported by substantial evidence. Substantial 
evidence is relevant evidence which a reasonable mind might accept in support of 
the conclusions of the agency. The entire record is to be examined to determine 
if there is substantial evidence to support the agency's findings. The reviewing 
court does not substitute its judgment for that of the agency with respect to 
findings of fact if they are supported by substantial evidence. When the case 
comes before the supreme court, the findings of the agency are reviewed without 
according any special deference to the decision of the district court. The 
burden is assigned to the party challenging the sufficiency of the evidence to 
demonstrate that the Board's decision is not supported by substantial 
evidence.

Devous v. 
Wyoming State Bd. of Medical Examiners, 845 P.2d 408, 414 (Wyo. 1993) (citations 
omitted).

[¶27]   The Board considered expert 
testimony, CT scans, medical records, and the "April 1997 Assessment Report of 
the Colorado Personalized Education for Physicians Program in its review of the 
treatment provided to three patients. In its review, the experts testified that 
the records showed that Kirbens failed to properly document his diagnosis of and 
medical justification for the surgeries. Each patient's medical records and CT 
scans did not indicate sinus disease to the extent required which would justify 
surgery. The experts offered opinions that the CT scans and medical records 
indicated deficient medical decision making. One expert testified that of ten 
patients who had come to see him for a second opinion after Kirbens had 
recommended they undergo surgery, only one demonstrated a physical condition 
warranting surgery. The third expert who reviewed the same materials expressed 
the opinion that Kirbens had not performed unnecessary surgeries and that his 
conduct and medical judgment were within the applicable standard of care. That 
same expert, however, described the medical records as "sketchy" and 
"inadequate" and he was unable to tell from the records what Kirbens' "thought 
processes were," Kirbens' "judgment was not reflected in the notes;" and Kirbens 
"goes straight to a conclusion without the supportive history." From the medical 
records alone, the expert stated that it would be difficult to justify the 
surgery performed on one patient. From these facts, the Board concluded there 
was clear and convincing evidence that Kirbens' conduct exhibited willful and 
consistent utilization of medical services that were inappropriate and 
unnecessary. We find the Board's conclusion is justified from the underlying 
facts and affirm the decision that Kirbens violated this portion of the 
statute.

Confidentiality

[¶28]   In his final contention, Kirbens 
argues that the Board improperly disclosed the findings of fact and conclusions 
of law along with the final order in violation of Wyo. Stat. Ann. § 
33-26-408(c). The Board contends that these three components comprise an 
integrated document that is considered a final order and required to be 
published under its rules.

[¶29]   Wyo. Stat. Ann. § 33-26-408(c) 
(LEXIS 1999) states:

All board 
records except final orders are not subject to public disclosure or discovery 
and are not admissible in any nonboard proceeding except when necessary for 
further board action or upon judicial review of a board 
order.

The Act does not 
define the statutory terms "Board records" or "final orders." In another section 
of the Act, the Board is instructed to enter its order and findings pursuant to 
the Wyoming Administrative Procedure Act when it refuses to renew or reinstate, 
revokes, restricts or suspends a license. Wyo. Stat. Ann. § 33-26-405(a) (LEXIS 
1999). Similarly, the section governing reinstatement of licenses directs the 
Board to issue "specific findings of facts, conclusions of law and a final 
order." Wyo. Stat. Ann. § 33-26-406(d) (LEXIS 1999). The intent apparent from 
the various sections of the Act supports the Board's contention that it may 
consider the findings of fact and conclusions of law as well as an order of the 
action taken in a particular matter to be the final order. Patient 
confidentiality was appropriately protected within these documents, and we find 
the Board did not act in violation of the statute by publishing its findings of 
facts and conclusions of law as well as the action taken against 
Kirbens.

[¶30]   We affirm the order revoking 
Kirbens' medical license.

Footnotes

1 Without 
analysis, Doe assumed that Title II of the ADA applied in the public employment 
context. Since its publication, one court has disagreed that Title II applies to 
public employment. Zimmerman, 170 F.3d  at 1183.