                IN THE SUPREME COURT OF IOWA
                                 No. 18–0353

                          Filed February 14, 2020


MARK B. IRLAND,

      Appellant,

vs.

IOWA BOARD OF MEDICINE,

      Appellee.



      On review from the Iowa Court of Appeals.



      Appeal from the Iowa District Court for Polk County, Arthur E.

Gamble, Judge.



      Physician seeks further review of the decision of the court of appeals

that affirmed the district court’s dismissal of his petition for judicial review

of the Iowa Board of Medicine’s “Confidential Warning Letter” imposing

conditions on his return to practice. DECISION OF COURT OF APPEALS

VACATED; DISTRICT COURT JUDGMENT REVERSED AND CASE

REMANDED WITH DIRECTIONS.



      David L. Brown and Tyler R. Smith of Hansen, McClintock & Riley,

Des Moines, for appellant.



      Thomas J. Miller, Attorney General, and Jordan G. Esbrook (until

withdrawal) and Anagha Dixit, Assistant Attorneys General, for appellee.
                                        2

WATERMAN, Justice.

      In this appeal, we must determine whether the Iowa Board of

Medicine can use a “Confidential Letter of Warning” to impose conditions

on a physician’s return to the practice of medicine over his objection,

without a finding of probable cause, and without judicial review.

      The Board opened its investigation into an emergency room

physician after the death of a patient in his care. The physician voluntarily

ceased practicing medicine. The Board closed its investigation without a

finding of probable cause that the physician had violated any rule or

standard of practice, which is a prerequisite to imposing discipline. Yet

the Board issued a letter telling the physician that if he returns to

practicing   medicine,   the   Board    will   order    him   to    “complete    a

comprehensive clinical competency evaluation.”           The physician filed a

petition for judicial review alleging the Board’s letter constituted illegal

agency action. The Board moved to dismiss, arguing that its action is

unreviewable because it imposes no present discipline, closes the Board’s

investigation, and any future action is not ripe for review. The district

court agreed and granted the Board’s motion to dismiss. The court of

appeals affirmed the dismissal while acknowledging that the Board’s

action prevented the physician from freely resuming his practice.               We

granted the physician’s application for further review.

      On our review, we determine the district court erred by ruling the

Board’s letter was not judicially reviewable. The Board lacks the statutory

authority to impose discipline without finding probable cause of a violation

and without giving the physician an opportunity to challenge the alleged

violation.    The   warning    letter   effectively    imposed     discipline—the

competency evaluation—should the physician return to practice.               The

Board thereby circumvented the due process safeguards and public
                                         3

reporting requirements codified in the governing statutes. We vacate the

decision of the court of appeals, reverse the district court’s dismissal

ruling, and remand with directions for the district court to order the Board

to rescind the offending provisions in this letter without prejudice to the

Board’s ability to reopen its investigation into the physician’s conduct.

      I. Background Facts and Proceedings.

      Dr. Mark B. Irland, a licensed physician who practiced primarily in

Marengo, Iowa, received a “Confidential Letter of Warning” from the Iowa

Board of Medicine dated November 29, 2017.                   As the state agency

responsible for licensing and regulating physicians who practice medicine

in Iowa, the Board has the authority to investigate complaints against

physicians and impose disciplinary sanctions. See Iowa Code § 272C.3

(2017).

      The Board sent Dr. Irland the letter after reviewing a complaint

about his medical care.     The Board’s letter raised “serious concerns”

regarding his treatment of a twenty-nine-year-old male patient who died

after Dr. Irland “failed to recognize the seriousness of [the patient’s]

medical   condition[,]   ignored   the       concerns   of    other   health   care

professionals involved in his treatment,” and “failed to transfer him for

over six hours” despite the seriousness of his condition. The Marengo

Memorial Hospital conducted an internal investigation and revoked

Dr. Irland’s clinical privileges for emergency medicine “due to serious

concerns about [his] clinical competency, inadequate medical record

keeping    and    poor     documentation,         disruptive      behavior     and

unprofessionalism, and substandard care which may have contributed to

a catastrophic patient outcome.”         Dr. Irland appealed the hospital’s

disciplinary determination, and the hospital upheld the revocation.
                                      4

      The Board’s letter echoed the hospital’s concerns and “advise[d]”

Dr. Irland “to carefully review [his] treatment” of the patient, “take

appropriate steps to avoid similar concerns in the future,” and “submit a

paper to the Board describing what [he] learned from this matter” within

sixty days. The letter continues, in relevant part,

             The Board also noted that you are not practicing
      medicine at this time. Therefore, the Board has chosen not to
      initiate further action in this matter at this time. However,
      the Board advises that you provide it written notice at least
      sixty (60) days prior to returning to the practice of medicine.
      If you choose to return to the practice of medicine, the Board
      will take appropriate action, including but not limited to, issuing
      an order requiring you to complete a comprehensive clinical
      competency evaluation, to ensure that you are able to practice
      medicine with reasonable skill and safety. While the Board
      has chosen not to pursue formal disciplinary action in this
      matter at this time, please note that failure to conform to the
      minimal standard of care in the future may be grounds for
      formal disciplinary action against your Iowa medical license.
            Pursuant to Iowa Code chapter 272C, this
      CONFIDENTIAL LETTER OF WARNING does not constitute
      a formal disciplinary action, nor is it a public record. . . .

             This CONFIDENTIAL          LETTER      OF    WARNING
      concludes the Board’s investigation of this case. The Board
      reserves the right to review and reconsider this matter should
      it be deemed appropriate.

(Emphasis added.)     The Board sent its confidential letter to Dr. Irland

without his consent, without charging him with any disciplinary violation,

without opening contested case proceedings, and without any finding of

probable cause that Dr. Irland committed a violation.

      On December 29, Dr. Irland filed a petition for judicial review,

asserting that the letter constituted illegal agency action under Iowa Code

section 17A.19. The Board filed a motion to dismiss pursuant to Iowa

Code section 272C.3(1)(d), which states, “Notwithstanding the provisions

of [Iowa Code] chapter 17A, a determination by a licensing board that an

investigation . . . should be closed without initiating a disciplinary
                                     5

proceeding is not subject to judicial review pursuant to section 17A.19.”

On February 16, 2018, the district court determined that the letter’s

“advisory and warning language” were not disciplinary sanctions that

transformed it into a final agency action subject to judicial review. As

such, the district court concluded it was without authority to review the

letter and granted the Board’s motion to dismiss. Dr. Irland appealed, and

we transferred the case to the court of appeals.

      On March 6, 2019, the court of appeals affirmed.         The court of

appeals “acknowledge[d] the letter of warning is colored with advisories

that have the appearance of sanctions,” but it found the letter did not

amount to sanctions because there were no mandatory actions and no

identifiable repercussions if Dr. Irland did nothing (that is, if he never

resumed practicing medicine). Yet the court of appeals recognized the

letter effectively prevented Dr. Irland from again practicing medicine

without meeting the Board’s conditions.

      At oral argument, the Board acknowledged the letter sent to
      Irland was “a hybrid” because it did not inform him of what
      the Board may do in the future but what it will do, essentially
      freezing Irland in his current status of not practicing medicine
      in the State of Iowa. (“[T]he Board will take appropriate action,
      including . . . .”) But, by issuance of this hybrid letter of
      warning, the Board has effectively concluded there was no
      probable cause to file disciplinary charges. [Iowa Admin.
      Code] r. 653—24.2(5)(e). In light of these rules, we conclude
      the letter’s reference to the competency evaluation is a threat
      without teeth because the Board may not enter such an order
      without reconsideration of its prior decision, making a
      probable-cause determination, and affording due process to
      Irland, including a contested-case hearing. Thus, we do not
      view the unconventional letter as a sanction or a form of
      disciplinary action.

(First alteration in original.) The court of appeals determined that the

letter was not subject to judicial review because Dr. Irland had not been
                                      6

adversely affected by a final agency action given that nothing the Board

“advised” in the letter resulted in Board action or sanctions.

      We granted Dr. Irland’s application for further review.

      II. Standard of Review.

      We review a district court’s dismissal of a petition for judicial review

for correction of errors at law. LSCP, LLLP v. Kay-Decker, 861 N.W.2d 846,

854 (Iowa 2015). “We apply the standards set forth in the Administrative

Procedure Act, Iowa Code ch. 17A, to determine whether our conclusions

are the same as those of the district court.”       Doe v. Iowa Bd. of Med.

Exam’rs, 733 N.W.2d 705, 707 (Iowa 2007).

      The Board acted without commencing contested case proceedings.

Accordingly, “[t]he board’s action in this case constitutes ‘other agency

action,’ and as such, we review to determine whether the board committed

an error of law, or acted unreasonably, capriciously, or arbitrarily.” Id.

“Agency action is considered arbitrary or capricious when the decision was

made ‘without regard to the law or facts.’ ” Id. (quoting Greenwood Manor

v. Iowa Dep’t of Pub. Health, 641 N.W.2d 823, 831 (Iowa 2002)).

      III. Analysis.

      We must decide whether Dr. Irland is presently entitled to judicial

review of the Board’s letter that requires him to undergo a competency

evaluation if he resumes practicing medicine. The Board argues, and the

court of appeals and district court agreed, that the confidential letter is

not a reviewable final agency action because Dr. Irland has not yet been

adversely affected and any future discipline is not ripe for review. We

disagree. In our view, the letter by its plain language presently restricts

Dr. Irland’s ability to return to practicing his profession. The Board’s letter

makes clear it “will order” the competency evaluation should he resume

practicing medicine.     The Board cannot use a “confidential letter of
                                      7

warning” to sidestep procedural requirements for imposing and reporting

discipline.

      We begin by reviewing the Board’s authority to impose and report

on disciplinary violations. “Chapter 272C was enacted, in part, to protect

the public safety by ensuring competency in the medical profession. The

board is given broad discretion and great responsibility to fulfill this goal.”

Doe, 733 N.W.2d at 712. The Board is authorized under Iowa Code section

272C.3 to investigate complaints against licensees and issue licensee

discipline. In doing so, the Board is subject to its own rules. See Auen v.

Alcoholic Beverages Div. of the Iowa Dep’t of Commerce, 679 N.W.2d 586,

590 (Iowa 2004) (stating that the enabling act and rules constrain the

agency’s authority).

      The Board’s procedure for processing complaints and conducting

investigations is outlined in Iowa Administrative Code 653—24.2.           The

Board begins by opening a complaint file upon receiving “appropriate

information.”   Iowa Admin. Code r. 653—24.2(1).           If the Board has

jurisdiction over the complaint, the matter is assigned to its complaint

review committee. Id. r. 653—24.2(1)(a). The complaint review committee,

pursuant to the guidelines set out in rule 653—24.2(2)(c), then reviews the

complaint and may take one of four actions: (1) close the complaint file for

specified reasons, (2) recommend that the Board’s screening committee

close the file without an investigation, (3) “[r]equest an investigation by

seeking a letter of explanation from the physician, medical records, or

both,” or (4) “[r]equest a full investigation.” Id. r. 653—24.2(2)(b), (c). The

complaint review committee’s recommendation is then reviewed by a

screening committee that may take one of four actions: (1) recommend that

the Board close the complaint file without conducting an investigation;

(2) “[r]equest an investigation by seeking a letter of explanation from the
                                       8

physician, medical records, or both”; (3) review any letters of explanation

received and recommend that the Board close the investigative file with or

without issuing an informal letter; or (4) “[r]equest a full investigation for

board review.” Id. r. 653—24.2(3).

      Finally,    the    Board     reviews    the    screening     committee’s

recommendations.        After its review, the Board may (1) “[c]lose the

complaint file without investigation[;]” (2) “[c]lose the investigative file that

has been partially or fully investigated, with or without issuing an informal

letter[;]” or (3) “[r]equest further investigation.”      Id. r. 653—24.2(4).

Investigations are conducted pursuant to rule 653—24.2(5).                 If an

investigation occurs, the Board reviews the investigative record and may

take one of several actions. Id. r. 653—24.2(5)(e). The Board may (1) close

the investigative file without taking action; (2) “[r]equest further

investigation, including peer review;” (3) meet with the licensee to discuss

the pending investigation; (4) “[i]ssue an informal letter of warning or

education;” (5) file a statement of charges, which commences a contested

case proceeding; or (6) “[r]equest a combined statement of charges and

settlement agreement.” Id. r. 653—24.2(5)(e)(1)–(6).

      The Board argues that its letter to Dr. Irland is a valid letter of

warning under Iowa Administrative Code rule 653—24.2(5)(e)(4), which

states,

      If the board concludes that there is not probable cause to file
      disciplinary charges, the board may issue the licensee an
      informal letter of warning or education. A letter of warning or
      education is an informal communication between the board
      and the licensee and is not formal disciplinary action or a
      public document.

(Emphasis added.) As such, the Board asserts its letter to Dr. Irland is

not a “formal disciplinary action” subject to judicial review. Dr. Irland

contends the letter actually imposes discipline. We agree with Dr. Irland.
                                      9

The Board’s letter went beyond mere warnings, and it made clear that if

Dr. Irland resumes practicing medicine, then he must undergo the

competency evaluation.        The Board effectively imposed conditional

discipline without formal action or a finding of probable cause.           We

conclude the Board’s letter exceeds the scope of rule 24.2(5)(e)(4).

      We have recognized that the legislature may by statute expressly

exempt certain agency actions from judicial review under chapter 17A.

Lewis Cent. Educ. Ass’n v. Iowa Bd. of Educ. Exam’rs, 625 N.W.2d 687,

691 (Iowa 2001) (en banc).      Iowa Code section 272C.3(1)(d) is such a

statute, which allows the Board to “[d]etermine in any case whether an

investigation, or further investigation, or a disciplinary proceeding is

warranted.” Further, this statute explicitly states that the Board’s decision

to close an investigation without instituting disciplinary proceedings is not

subject to judicial review.

      Notwithstanding the provisions of chapter 17A, a
      determination by a licensing board that an investigation is not
      warranted or that an investigation should be closed without
      initiating a disciplinary proceeding is not subject to judicial
      review pursuant to section 17A.19.

Iowa Code § 272C.3(1)(d). The Board relied on section 272C.3(1)(d) in its

motion to dismiss and asserted that judicial review is unavailable because

it closed the investigation without initiating a disciplinary proceeding. The

district court and the court of appeals concluded this statute foreclosed

judicial review of the Board’s letter to Dr. Irland.

      Their determinations, in our view, rest on a flawed premise—that

the letter to Dr. Irland imposed no discipline.        The letter by its terms

de facto disciplined Dr. Irland by requiring a competency evaluation if he

returns to the practice of medicine. We will not allow licensing boards to

evade judicial review by placing disciplinary action within a “confidential
                                     10

letter of warning” that purports to close the investigation without initiating

a disciplinary proceeding. To do so elevates form over substance and, in

fact, allows discipline to be imposed without the procedural safeguards of

contested case proceedings and without the reporting obligations that

safeguard the public by disclosing disciplinary actions.

      When, as here, the Board’s letter actually imposes discipline, section

272C.3(1)(d) does not apply to preclude judicial review.             “Licensee

discipline” is defined as “any sanction a licensing board may impose upon

its licensees for conduct which threatens or denies citizens of this state a

high standard of professional or occupational care.”         Id. § 272C.1(4).

Section 272C.3(2) delineates permissible sanctions to be imposed as

licensee discipline apart from revocation and suspension of licenses,

including requiring “additional professional education or training, or

reexamination, or any combination, as a condition precedent to the

reinstatement of a license or of any privilege incident thereto.” Id.

§ 272C.3(2)(d)    (emphasis   added).     Indeed,   a   clinical   competency

examination is such a form of discipline.      Iowa Admin. Code r. 653—

25.25(1)(g).     The Board’s letter effectively imposed such discipline

requiring Dr. Irland to undergo a competency evaluation if he resumes

practicing medicine.

      In our view, the Board’s action violated its own rules. Rule 653—

24.4 governs the procedure for ordering a competency evaluation.           Id.

r. 653—24.4.      The rule requires that the Board issue an order that

specifies the “showing by the board that there is probable cause to order

the licensee to complete an evaluation.” Id. r. 653—24.4(1)(a). The order

must identify the nature of the evaluation, the facility to perform the

evaluation, and the time to complete it. Id. r. 653—24.4(1)(b)–(e). The

physician has a right to object to the evaluation order through a contested
                                               11

case hearing.            Id. r. 653—24.4(3).        Here, the Board is requiring a

competency evaluation upon Dr. Irland’s return to practice without any

finding of probable cause and without allowing him to object through the

procedure outlined in the Board’s own rule. 1

          We recognize that the Board and a physician can agree to

disciplinary measures through an informal settlement and without a

contested case procedure. See Iowa Code § 272C.3(4)(a). 2 But Dr. Irland

never consented to the discipline imposed in the Board’s confidential

letter.

          We agree with the court of appeals that the Board’s letter effectively

“freezes” Dr. Irland from practicing medicine. The Board’s clear statement

that it will take action against Dr. Irland if he tries to return to the practice

of medicine amounts to a sanction.

          If you choose to return to the practice of medicine, the Board
          will take appropriate action, including but not limited to,
          issuing an order requiring you to complete a comprehensive
          clinical evaluation, to ensure you are able to practice medicine
          with reasonable skill and safety.




          1The   Board’s letter also states,
                   The Board . . . advises that you submit a paper to the Board
          describing what you have learned from this matter. Please submit the
          paper to [the Legal Director of the Board of Medicine] within sixty (60) days
          of this letter.
        The Board cites no authority for this seemingly mandatory directive: “Please
submit the paper . . . within sixty (60) days . . . .” As with the competency evaluation, we
question the Board’s authority to require a physician to submit a potentially self-
incriminating letter when at the same time the Board is declining to conduct an actual
investigation.
          2Iowa   Code section 272C.3(4)(a) provides,
          Nothing contained in this section shall be construed to prohibit informal
          stipulation and settlement by a board and a licensee of any matter
          involving licensee discipline. However, licensee discipline shall not be
          agreed to or imposed except pursuant to a written decision which specifies
          the sanction and which is entered by the board and filed.
                                               12

(Emphasis added.)              In fact, it is a sanction specifically listed in the

Administrative Code under rule 653—25.25(1)(g). While the Board does

have the authority to impose the sanction of a clinical competency

evaluation, it may do so over the physician’s objection only after a

contested case proceeding.                See id. r. 653––25.25.         Dr. Irland never

received a contested case hearing.                  The Board bypassed the requisite

statement of charges and contested case hearing and instead imposed

discipline within a confidential letter of warning.                   The letter effectively

requires Dr. Irland to undergo a competency evaluation if he resumes

practicing medicine. The Board’s action has no support in its governing

statute or administrative rules.

        Imposing discipline through a confidential letter of warning

circumvents several reporting requirements. To protect the public from

incompetent physicians, board-imposed discipline is a public record. See

Iowa Code § 272C.3(4)(b) (“All health care boards shall file written

decisions which specify the sanction entered by the board with the Iowa

department of public health which shall be available to the public upon

request.”);          id.         § 272C.6(4)(a)          (A       decision        imposing

discipline      is         a     public      record.);        Board      Overview,     Iowa

Bd.       of         Med.,         https://medicalboard.iowa.gov/Board-overview

[https://perma.cc/JQ5X–9DFX] (“[T]he [B]oard is charged with enforcing

these rules and laws to protect the public from licensees who do not

practice medicine and acupuncture within prevailing and acceptable

standards of the practices . . . .”). The public can access this information

through a search engine on the Board’s website that is available to “find

or    verify   physicians”        where     “[l]icensing      details,   including   public

disciplinary action or sanctions taken by the Iowa Board of Medicine

against a license, will be displayed.” Find a Physician Search Engine, Iowa
                                               13

Bd.      of        Med.,      https://eservices.iowa.gov/PublicPortal/Iowa/IBM/

licenseQuery/LicenseQuery.jsp?Profession=Physician                         (last        visited

Feb. 10, 2020).

        Federal law also requires that regulators disclose discipline through

an adverse action report to the National Practitioner Data Bank (NPDB).

See Costa v. Leavitt, 442 F. Supp. 2d 754, 755–56 (D. Neb. 2006)

(reviewing federal NPDB reporting requirements); see, e.g., Leo v. Bd. of

Med. Exam’rs, 586 N.W.2d 530, 532 (Iowa Ct. App. 1998) (noting

physician’s discipline was reported to the NPDB).

        The Board must report adverse licensure actions to the NPDB, 3 and

hospitals and other health care entities must report adverse clinical

privileges actions.            Health Res. & Servs. Admin., U.S. Dep’t of

Health         &    Human          Servs.,    NPDB    Guidebook        E-31        to    E-34,

E-63     to    E-66        (Oct.   2018),     https://www.npdb.hrsa.gov/resources/

aboutGuidebooks.jsp;                 NPDB        Reporting       Requirements              and

Query         Access,       U.S.      Dep’t     of   Health      &     Human            Servs.,

https://www.npdb.hrsa.gov/resources/tables/reportingQueryAccess.jsp

        3Adverse    licensure actions that the Board must report include
        [a]ny adverse action taken by the state licensing or certification authority
        as a result of a formal proceeding, including: revocation or suspension of
        a license, certification agreement, or contract for participation in a
        government health care program; reprimand; censure; or probation.
Health Res. & Servs. Admin., U.S. Dep’t of Health & Human Servs., NPDB Guidebook
E-63    (Oct.    2018),  https://www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
Additionally, the Board must report, among other things,
        [a]ny negative action or finding by the state licensing or certification
        authority that, under the state’s law, is publicly available information,
        including, but not limited to, limitations on the scope of practice,
        liquidations, injunctions, and forfeitures. This definition also includes
        final adverse actions rendered by a state licensing or certification authority
        – such as exclusions, revocations, or suspension of license or certification
        – that occur in conjunction with settlements in which no finding of liability
        has been made (although such a settlement itself is not reportable).
Id. at E-64.
                                      14

[https://perma.cc/KG9M-6LN8].          Although NPDB reports are not

available to the public, they are accessible to state licensing boards and

health care entities.      NPDB About Us, U.S. Dep’t of Health &

Human Servs., https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp

[https://perma.cc/NG47-T4GD].

      In fact, hospitals are required to request information from the
      NPDB whenever a physician applies for a position on its
      medical staff or for clinical privileges, and also every two years
      to check the status of each physician who currently is on its
      medical staff or has clinical privileges.

Costa, 442 F. Supp. 2d at 756. The NPDB serves as a valuable “workforce

tool that prevents practitioners from moving state to state without

disclosure or discovery of previous damaging performance.” NPDB About

Us, U.S. Dep’t of Health & Human Servs. (stating the NPDB’s mission is

“[t]o improve health care quality, protect the public, and reduce health

care fraud and abuse in the U.S.”).

      Cloaking discipline within confidential warning letters undermines

the public’s right to know when a physician’s competence has been called

into question by a licensing board. We note Dr. Irland is not currently

practicing medicine.    What stops him from practicing in another state

without undergoing the competency evaluation that the Iowa Board of

Medicine ordered in secret? Conversely, why shouldn’t Dr. Irland be able

to presently challenge the obstacle the Board has imposed on his right to

practice?

      We next turn to whether the Board’s confidential letter is subject to

judicial review under Iowa Code section 17A.19.        “Except as expressly

provided otherwise by another statute referring to this chapter by name,”

section 17A.19 is the “exclusive means by which a person or party who is

aggrieved or adversely affected by agency action may seek judicial review
                                     15

of such agency action.” Iowa Code § 17A.19. Under section 17A.19(1), “[a]

person or party who has exhausted all adequate administrative remedies

and who is aggrieved or adversely affected by any final agency action is

entitled to judicial review thereof under this chapter.”     Id. § 17A.19(1).

“Agency action” is defined in chapter 17A as

      includ[ing] the whole or a part of an agency rule or other
      statement of law or policy, order, decision, license, proceeding,
      investigation, sanction, relief, or the equivalent or a denial
      thereof, or a failure to act, or any other exercise of agency
      discretion or failure to do so, or the performance of any agency
      duty or the failure to do so.

Id. § 17A.2(2).   “Under Iowa Code section 17A.23, all agency action is

subject to the Iowa Administrative Procedure Act, and thus to the judicial-

review provisions of section 17A.19.” Lewis Cent. Educ. Ass’n, 625 N.W.2d

at 691; see also Iowa Code § 17A.23.

      We determine the Board’s letter constitutes “agency action” under

section 17A.2(2). The Board has the authority to discipline a physician

after reviewing the investigative record, and it has discretion to determine

the proper action to be taken. See Iowa Admin. Code r. 653—24.2(5)(e).

The Board’s decision to impose sanctions for a licensee’s misconduct is

“within the statutory mandate of the agency [and is] peculiarly within its

discretion and area of expertise. Clearly, then, such matters constitute

agency action.” Genetzky v. Iowa State Univ., 480 N.W.2d 858, 861 (Iowa

1992). We also determine that the Board’s letter constitutes final agency

action given that it “conclude[d] the Board’s investigation of this case” and

imposed discipline without any path for Dr. Irland to appeal within the

agency. The Board has not identified any existing administrative remedies

available to challenge its letter that Dr. Irland failed to exhaust. Given the

Board’s position that its conditional future discipline was not ripe for

review, any effort by Dr. Irland to seek relief within the agency would have
                                    16

been futile. We conclude Dr. Irland was aggrieved or adversely affected by

the Board’s action because he is unable to resume practicing his chosen

profession without triggering the competency evaluation.

      We hold the Board’s letter is subject to judicial review under Iowa

Code section 17A.19(1). The district court erred by granting the Board’s

motion to dismiss.

      IV. Disposition.

      For the foregoing reasons, we vacate the decision of the court of

appeals and reverse the district court’s dismissal ruling. We remand this

case for entry of an order by the district court directing the Board to

rescind the provisions in its confidential letter of warning that require a

competency evaluation upon Dr. Irland’s return to practicing medicine.

Nothing in this opinion precludes the Board from reopening its

investigation into Dr. Irland’s conduct and following proper procedures to

determine if discipline is warranted.

      DECISION OF COURT OF APPEALS VACATED; DISTRICT COURT

JUDGMENT REVERSED AND CASE REMANDED WITH DIRECTIONS.

      All justices concur except McDonald, J., who takes no part.
