Opinion ID: 2379408
Heading Depth: 1
Heading Rank: 5

Heading: Standard & Burden of Proof

Text: [¶ 15] In his first issue, Dr. Guier asserts that the burden of proof in his contested case hearing is controlled by the Wyoming Administrative Procedure Act, and that the hearing examiner erred by applying the burden of proof identified in the Medical Staff Bylaws. We note initially that the proper allocation of the burden of proof is a matter of law and is reviewed de novo. Penny v. State ex rel. Wyo. Mental Health Prof. Licensing Bd., 2005 WY 117, ¶ 13, 120 P.3d 152, 160 (Wyo.2005). [¶ 16] Prior to the contested case hearing, the parties stipulated that [t]he Medical Staff Bylaws of St. John's Medical Staff shall remain in full force and effect, and shall apply to the Contested Case Hearing except where they are in conflict with the WAPA, or other applicable law and this Stipulation, in which case the WAPA, or other applicable law and this Stipulation, shall control. The hearing examiner determined that the burden of proof in the Bylaws did not conflict with the WAPA and instructed the JRC to apply the burden of proof provided for in the Bylaws. The Bylaw governing the burden of proof at hearings provides, in pertinent part: VIII.D.7. BURDENS OF PRESENTING EVIDENCE AND PROOF ... [T]he professional review body that proposed the adverse recommendation or action shall present supporting evidence, but the Medical Staff appointee shall have the burden of proving, by a preponderance of the evidence, that the proposed adverse recommendation or action should be rejected and/or modified. (Emphasis added.) The hearing examiner instructed the JRC as follows: According to Section VIII.D.7 of the Bylaws, the MEC must first present evidence in support of its action and recommendation. To satisfy this initial obligation, the MEC does not have to prove that its action was the best or only action to take, or to establish that its decision was the correct one. Rather, to satisfy this initial obligation, the MEC only must show that its action and recommendation are supported by evidence or, in other words, that its action and recommendation are not arbitrary or capricious and are based on evidence that a reasonable mind might accept in support of the actions and recommendation. If you decide that the MEC has presented evidence in support of its action and recommendation, then, according to Section VIII.D.7 of the Bylaws, Dr. Guier has the burden of proving, by a preponderance of the evidence that the MEC's action and recommendation must be rejected or modified. (Emphasis added.) Dr. Guier asserts that the WAPA requires the MEC to prove its allegations by clear and convincing evidence. He contends that this burden of proof conflicts with the burden identified in the Bylaws and therefore supersedes the provision in the Bylaws pursuant to the parties' stipulation. [¶ 17] The language of the WAPA does not expressly provide a standard of proof in contested case hearings. See Wyo. Stat. Ann. § 16-3-114(c). We have previously recognized that the standard applicable to an adjudicatory hearing before an agency, unless otherwise stated, is the preponderance of the evidence standard customarily used in civil cases. Willadsen v. Christopulos, 731 P.2d 1181, 1184 (Wyo.1987). A preponderance of the evidence is defined as proof which leads the trier of fact to find that the existence of the contested fact is more probable than its non-existence. Judd v. State ex rel. Wyo. Workers' Safety & Comp. Div., 2010 WY 85, ¶ 31, 233 P.3d 956, 968 (Wyo.2010). We have also recognized that the preponderance of the evidence standard generally does not adequately protect the property interest one has in a professional license, and have instead required a licensing board to prove its disciplinary cases by clear and convincing evidence. Painter v. Abels, 998 P.2d 931, 940 (Wyo.2000). Dr. Guier contends that our cases applying the WAPA to the revocation of professional licenses required the Hospital to prove the allegations supporting revocation of his privileges by clear and convincing evidence. See, e.g., In re Greene, 2009 WY 42, ¶ 10, 204 P.3d 285, 290 (Wyo.2009) (suspension of chiropractor's license); Dorr v. Wyo. Bd. of Cert. Pub. Accountants, 2006 WY 144, ¶ 13, 146 P.3d 943, 949 (Wyo.2006) (suspension of certificate to practice public accounting); Devous v. Wyoming State Bd. of Med. Examiners, 845 P.2d 408, 416 (Wyo.1993) (suspension of medical license). The Hospital asserts that the clear and convincing standard does not apply because Dr. Guier faced the revocation of his medical staff privileges, not the revocation of his medical license. [¶ 18] A license is defined in the WAPA as any agency permit, certificate, approval, registration, charter or similar form of permission required by law. Wyo. Stat. Ann. § 16-3-101(b)(iii). The Hospital argues that staff privileges are not a medical license. It points out that Dr. Guier still has his license to practice medicine in the State of Wyoming, and is able to practice his profession at other facilities in the state. Dr. Guier asserts that staff privileges are required by law in order for him to perform operations, admit patients to a hospital, and treat patients, and that privileges therefore meet the definition of a license. He supports this position by citing to Bylaw § V.A.1 which prohibits any person from admitting a patient or providing medical treatment unless they have been granted privileges. That Bylaw also states that medical staff privileges are in the nature of a license. [¶ 19] Although medical staff privileges may be in the nature of a license, we find there is a clear and important distinction between hospital privileges and a medical license. Medical staff privileges allow a physician to use hospital facilities and be assisted by hospital staff. As Dr. Guier points out, this includes the authority to admit and treat patients. A medical license, however, confers a general right to practice medicine within the boundaries of a particular jurisdiction. The distinction between a medical license and staff privileges is acknowledged in Wyoming, as indicated by the fact that licensing and privileging decisions are granted to different administrative bodies. [¶ 20] Pursuant to statute, the Wyoming Board of Medicine, not the Judicial Review Committee or the Boards of Trustees of individual hospitals, oversees physician licensing matters. Title 33, Chapter 26 of the Wyoming statutes, known as the Medical Practice Act, provides rules relating to licensing of physicians. The Medical Practice Act empowers the Wyoming Board of Medicine to [g]rant, refuse to grant, suspend, restrict, revoke, reinstate or renew licenses to practice medicine, and lists more than thirty specific reasons justifying revocation, restriction, or suspension of a medical license. Wyo. Stat. Ann. §§ 33-26-202(b)(i), 33-26-402(a)(i)-(xxxiv). The Act provides a clear and convincing burden of proof and allocates the burden to the Wyoming Board of Medicine. Wyo. Stat. Ann. § 33-26-407. The Act defines a license as a license to practice medicine in this state issued by the board pursuant to this chapter and clearly distinguishes between a license and medical staff privileges. Wyo. Stat. Ann. § 33-26-102(a)(ix); see Wyo. Stat. Ann. §§ 33-26-202, -303 to -409. [¶ 21] Medical staff privileges, on the other hand, are addressed in the Wyoming Public Health and Safety statutes relating to hospitals and other care facilities. The statute governing hospital privileges expressly entrusts matters of staff admissions and privileges to hospital administration. As stated above, that statute provides that hospitals by appropriate bylaws shall promulgate reasonable and uniform rules and regulations covering staff admissions and staff privileges. Wyo. Stat. Ann. § 35-2-113. Staff privileges, in contrast to medical licenses, are specific to individual hospitals, and decisions regarding staff privileges are within the discretion of hospital management. The cases that Dr. Guier cites involving license suspensions are inapposite. In this case, Dr. Guier faced the revocation of his medical staff privileges. The Hospital, pursuant to its prerogative, decided that privileging decisions would be subject to a burden of proof expressly identified in the Bylaws, and the burden of proof set forth in those Bylaws was applied at the contested case hearing. Dr. Guier agreed to be bound by the Bylaws when he initially sought hospital privileges and in his subsequent application for reappointment. The Bylaws do not require a clear and convincing burden of proof and do not require the burden of proof to be carried by the Hospital. [¶ 22] Dr. Guier also asserts that his loss of privileges is similar to the loss of his medical license because it has impacted his ability to earn a living by practicing medicine. He stated that the termination of his privileges was reported to the National Practitioner Data Bank as required by federal law. 42 U.S.C. § 11133(a)(1)(A). As a result of the reporting and subsequent notification to other hospitals, Dr. Guier stated that he had lost privileges at a nearby hospital, and was called to hearings before the Wyoming and Montana Boards of Medicine. We note that Dr. Guier did not provide details of those hearings and did not testify that revocation of his hospital privileges resulted in revocation of his license to practice medicine in Montana or Wyoming. We do not dispute that the loss of privileges at a particular hospital or health care facility may seriously impact a physician's ability to maintain a medical practice. [¶ 23] Under Wyo. Stat. Ann. § 33-26-303(d), the Board of Medicine may deny licensure to a person whose privileges have been revoked at a particular health care facility on that basis alone. Also, under Wyo. Stat. Ann. § 33-26-402(a)(xxvi)(A), a license may be revoked based on any action by a health care entity that adversely affects clinical privileges for a period of thirty or more days. The fact that there may be additional consequences to a physician who loses staff privileges, however, does not impair the ability of a hospital to establish reasonable bylaws and requirements for physicians seeking hospital privileges at its facility, and does not transform a privilege to practice at a particular hospital into a medical license. In this case, Dr. Guier was aware that his professional behavior was under intense scrutiny, as indicated by the focused review of his performance, the Reappointment Agreement, and correspondence during the reappointment application process. He was aware that failure to abide by the Reappointment Agreement could result in the loss of privileges and consequently damage his career. In spite of the terms of his Reappointment Agreement, however, Dr. Guier continued to act in a manner that jeopardized his ability to practice at St. John's and other facilities where he had privileges. [¶ 24] The WAPA does not mandate a clear and convincing burden of proof for suspension of hospital privileges. Wyo. Stat. Ann. § 35-2-113 provides broad discretion to a hospital in determining requirements for the ability to practice at a particular hospital. We have previously recognized that a hospital is entitled to great deference in the management of its facility and we afford great deference to the hospital's determination of standards relating to hospital privileges. Garrison, 795 P.2d at 193. In sum, the Hospital was entitled to establish the burden of proof to be applied. While it is not the level of proof that every hospital might adopt, we cannot find that it is unreasonable or that it conflicts with the WAPA. [¶ 25] Dr. Guier also argues that, even if a clear and convincing standard of proof does not apply, Bylaw § VIII.D.7 is not reasonable because it places the burden on the physician facing charges to show that the adverse recommendation should be rejected or modified. Pursuant to the Bylaws, the Medical Executive Committee has the burden of producing evidence supporting its recommendation. Once that evidence is produced, the burden shifts to the medical staff appointee to persuade the JRC that the action should not be taken. Dr. Guier asserts that the burden-shifting under the Bylaws logically requires him to carry both the burden of production and the burden of persuasion, and that the practical effect of requiring the MEC to produce some evidence supporting its decision does not in any way assuage his burden. However, our conclusion that the Hospital has discretion to enact reasonable and uniform rules and regulations, based on an express statutory grant of that power, obviates the need for a discussion regarding the effect of burden-shifting under the Bylaws. As indicated above, we do not find that the Hospital's decision to place the burden of proof on the medical staff appointee, and to require that the burden be met by a preponderance of the evidence, is unreasonable.