                  IN THE SUPREME COURT OF TENNESSEE
                             AT NASHVILLE
                                   June 3, 2011 Session

  JOSEPH EDWARD RICH, M.D. v. TENNESSEE BOARD OF MEDICAL
                       EXAMINERS

           Appeal by Permission from the Court of Appeals, Middle Section
                       Chancery Court for Davidson County
                     No. 08-229-II   Carol McCoy, Chancellor


                No. M2009-00813-SC-R11-CD - Filed October 10, 2011


        This is an appeal from an administrative hearing wherein the Tennessee Board of
Medical Examiners suspended a physician’s medical license for one year and imposed other
conditions after finding that, among other things, the physician had violated Tennessee Code
Annotated sections 63-6-214(b)(1),(4), and (12) (2010). Upon review, the trial court
affirmed the Board’s ruling; however, because the Board failed to articulate the applicable
standard of care in its deliberations, the Court of Appeals reversed the Board’s ruling. We
agree with the Court of Appeals that the Board was required to articulate the standard of care
in its deliberations. Therefore, we vacate the ruling of the trial court to the extent that it
affirms the Board’s decision that the physician violated Tennessee Code Annotated sections
63-6-214(b)(1),(4), and (12). However, rather than reversing the Board’s decisions, we are
remanding the matter to the Board and instructing it to conduct deliberations based on the
existing record and articulate the applicable standard of care as required by the statute.

    Tenn. R. App. P. 11 Appeal by Permission; Judgment of the Chancery Court
              Affirmed in Part and Vacated in Part; Cause Remanded

S HARON G. L EE, J., delivered the opinion of the Court, in which C ORNELIA A. C LARK, C.J.,
G ARY R. W ADE , and W ILLIAM C. K OCH, JR., JJ., joined. J ANICE M. H OLDER, J., filed a
dissenting opinion.

Robert E. Cooper, Jr., Attorney General and Reporter; Joseph F. Whalen, Associate Solicitor
General; and Sara E. Sedgwick, Senior Counsel, for the appellant, Tennessee Board of
Medical Examiners.

James C. Bradshaw, Nashville, Tennessee, and Jeffrey B. Levens, Chicago, Illinois, for the
appellee, Joseph Edward Rich, M.D.
                                                 OPINION

                                    Facts and Procedural History

       In August 1995, the Tennessee Board of Medical Examiners (“the Board”) granted
Dr. Joseph Edward Rich, M.D., a conditional license to practice medicine in Tennessee. Dr.
Rich opened the Center for Environmental and Integrative Medicine in Knoxville, eventually
including in his practice the administration of chelation therapy,1 intravenous hydrogen
peroxide therapy,2 and the use of methadone to treat patients suffering from opioid
dependency.

       In June 2005, the Division of Health Related Boards of the Tennessee Department of
Health filed a Notice of Charges against Dr. Rich, which were subsequently amended to
allege that Dr. Rich had committed acts or omissions constituting grounds for disciplinary
action under Tennessee Code Annotated §§ 63-6-214(b)(1), (4), (12) and (14);3 rules 0880-


        1
            “Chelation therapy” is defined as “the use of a chelator [binding agent] (as EDTA
[ethylenediaminetetraacetic acid]) to bind with a metal (as lead or iron) in the body to form a chelate so that
the metal loses its chemical effect (as toxicity or physiological activity). http://merriam-
webster.com/dictionary/chelation%20therapy. (last visited Aug. 18, 2011). Donna L. Seger, M.D. testified
in this case that chelation therapy involves the intravenous administration of a drug that “kind of grabs the
metals, pulls them out of your body - - out of the tissues, and then excretes them into the urine.”
        2
            “Hydrogen peroxide therapy” is defined as a type of oxygen/ozone therapy in which

                  hydrogen peroxide [is] administered via gas or water to kill disease
                  microorganisms, improve cellular function, and promote the healing of
                  damaged tissues. The rationale behind bio-oxidative therapies, as they are
                  sometimes known, is the notion that as long as the body’s needs for
                  antioxidants are met, the use of certain oxidative substances will stimulate
                  the movement of oxygen atoms from the bloodstream to the cells. With
                  higher levels of oxygen in the tissues, bacteria and viruses are killed along
                  with defective tissue cells. The healthy cells survive and multiply more
                  rapidly. The result is a stronger immune system. . . . In the 1920’s, an
                  American physician named William Koch experimented with hydrogen
                  peroxide as a treatment for cancer. He left the United States after a legal
                  battle with the FDA.

http://medical-dictionary.thefreedictionary.com/Ozone+Therapy. (last visited Aug. 18, 2011).
        3
           In pertinent part, Tennessee Code Annotated section 63-6-214(b) authorizes the Board to exercise
its disciplinary authority upon the following grounds:

                                                                                                  (continued...)

                                                      -2-
02-.14(6)(c) and (e)(3) of the Official Compilation of the Rules and Regulations of the
State of Tennessee;4 and 21 U.S.C. § 823(g)(1) (2000).5 During the lengthy hearing that




       3
           (...continued)
                   (1) Unprofessional, dishonorable or unethical conduct;
                   ....

                  (4) Gross malpractice or a pattern of continued or repeated malpractice,
                  ignorance, negligence or incompetence in the course of medical practice;

                  ....

                  (12) Dispensing, prescribing or otherwise distributing any controlled
                  substance or any other drug not in the course of professional practice, or
                  not in good faith to relieve pain and suffering, or not to cure an ailment,
                  physical infirmity or disease, or in amounts and/or for durations not
                  medically necessary, advisable or justified for a diagnosed condition;

                  ....

                  (14) Dispensing, prescribing or otherwise distributing any controlled
                  substance or other drug to any person in violation of any law of the state or
                  of the United States.
       4
           Rule 0880-02-.14(6)(c) of the Rules of the Tennessee Board of Medical Examiners provides as
follows:

                  If a physician provides medical care for persons with intractable pain, with
                  or without the use of opiate medications, to the extent that those patients
                  become the focus of the physician’s practice the physician must be
                  prepared to document specialized medical education in pain management
                  sufficient to bring the physician within the current standard of care in that
                  field which shall include education on the causes, different and
                  recommended modalities for treatment, chemical dependency and the
                  psycho/social aspects of severe, chronic intractable pain.

       Rule 0880-02-.14(e)(3) further provides as follows:

                  Prescribing, ordering, administering, or dispensing dangerous drugs or
                  controlled substances for pain will be considered to be for a legitimate
                  medical purpose if based upon accepted scientific knowledge of the
                  treatment of pain, including intractable pain, not in contravention of
                  applicable state or federal law, and if prescribed, ordered, administered, or
                                                                                                  (continued...)

                                                      -3-
followed, the Department introduced the expert testimony of Donna L. Seger, M.D., who
testified as to the standard of care for diagnosing heavy metal toxicity and the affidavit


      4
          (...continued)
                  dispensed in compliance with the following guidelines where appropriate
                  and as is necessary to meet the individual needs of the patient:

                 (i) After a documented medical history, which may be provided orally or
                 in writing by the patient, and a physical examination by the physician
                 providing the medication including an assessment and consideration of the
                 pain, physical and psychological function, any history and potential for
                 substance abuse, coexisting diseases and conditions, and the presence of a
                 recognized medical indication for the use of a dangerous drug or controlled
                 substance;

                 (ii) Pursuant to a written treatment plan tailored for the individual needs of
                 the patient by which treatment progress and success can be evaluated with
                 stated objectives such as pain relief and/or improved physical and
                 psychosocial function. Such a written treatment plan shall consider
                 pertinent medical history and physical examination as well as the need for
                 further testing, consultations, referrals, or use of other treatment modalities;

                 (iii) The physician should discuss the risks and benefits of the use of
                 controlled substances with the patient or guardian;

                 (iv) Subject to documented periodic review of the care by the physician at
                 reasonable intervals in view of the individual circumstances of the patient
                 in regard to progress toward reaching treatment objectives which takes into
                 consideration the course of medications prescribed, ordered, administered,
                 or dispensed as well as any new information about the etiology of the pain;

                 (v) Complete and accurate records of the care provided as set forth in
                 parts (i)-(iv) of this paragraph should be kept. When controlled substances
                 are prescribed, names, quantities prescribed, dosages, and number of
                 authorized refills of the drugs should be recorded, keeping in mind that pain
                 patients with a history of substance abuse or who live in an environment
                 posing a risk for medication misuse or diversion require special
                 consideration. Management of these patients may require closer
                 monitoring by the physician managing the pain and consultation with
                 appropriate health care professionals.
      5
          21 U.S.C. § 823(g)(1) provides in pertinent part as follows:

                 [P]ractitioners who dispense narcotic drugs to individuals for maintenance
                 treatment or detoxification treatment shall obtain annually a separate
                 registration for that purpose.

                                                       -4-
testimony of Benjamin Johnson, M.D., describing the standard of care for treating a patient
with methadone. The Department also submitted patient records from Dr. Rich’s office
documenting his diagnosis and treatment of patients with methadone. Dr. Rich testified in
his own behalf, but did not present any witnesses. After deliberation, the Board 6 issued its
final order setting forth findings of fact that included the following:

       • In June 1999, the Board placed Dr. Rich’s medical license on two years probation
with specified conditions because he failed to maintain the advocacy of another doctor and
the Tennessee Medical Foundation in accordance with the conditions of his Tennessee
licensure and because he instructed his eighteen-year-old receptionist to fill out pre-signed
prescriptions for Phentermine and Fenfluromine for patients while he was on vacation. In
May 2002, the Board ratified an agreed order finding that Dr. Rich had violated the
conditions of his probation and placed further conditions on his practice.7

        • Dr. Rich falsely claimed on the Center for Environmental and Integrative Medicine’s
website that he had been approved for participation in a National Institute of Health study
identified as “Trial to Access Chelation Therapy.”

       • Dr. Rich treated patient “M.H.” from August 2003 to March 2004. Lab tests ordered
by Dr. Rich dated August 15, 2003, showed that M.H. had a high blood triglyceride level of
232 mg/dL, a high blood glucose level of 147 mg/dL, and blood pressure of 164/88. A
diagnostic laboratory report ordered by Dr. Rich dated August 21, 2003, shows that M.H. had




       6
         The Tennessee Medical Practice Act establishes the Board of Medical Examiners, Tennessee Code
Annotated section 63-6-101(a)(1) (2010), and imposes upon it the duty of conducting disciplinary
hearings. Tenn. Code Ann. § 63-6-101(a)(3). Upon establishment of specified grounds, Tennessee Code
Annotated section 63-6-214(a) authorizes the Board to

               (1) Deny an application for a license to any applicant who applies for the
               same through reciprocity or otherwise;
               (2) Permanently or temporarily withhold issuance of a license;
               (3) Suspend, or limit or restrict a previously issued license for such time
               and in such manner as the board may determine;
               (4) Reprimand or take such action in relation to disciplining an applicant
               or licensee, including, but not limited to, informal settlements, private
               censures and warnings, as the board in its discretion may deem proper; or
               (5) Permanently revoke a license.
       7
          By agreed order of September 17, 2002, the Board terminated Dr. Rich’s probation of two years
with all conditions imposed on his practice to remain in full force.

                                                  -5-
a post-provocation urine level8 with six elements beyond the reference range of the report,
but acknowledges that “[e]lement reference ranges were developed from a healthy population
under non-provoked/non-challenged conditions,” that “[p]rovocation with challenge
substances is expected to raise the urine level of some elements,” and that “[t]his test has not
been cleared or approved by the U.S. Food and Drug Administration.” Dr. Rich diagnosed
M.H. with heavy metal toxicity and treated him on several occasions with both chelation
therapy and hydrogen peroxide therapy between September 2003 and March 2004. A
diagnostic report dated February 2004 shows that M.H.’s blood triglyceride level had
increased to 242 mg/dL and that his blood glucose level had increased to 297
mg/dL. Despite the fact that in August of 2003, M.H. had noted on his initial health history
a current medication history that included insulin, oral anti-hyperglycemic medications, an
anti-hypertensive agent, and a medication for hyperlipidemia, Dr. Rich did not document that
any of these medications were prescribed for M.H. during the time of his treatments, and he
“failed to document whether or not he advised M.H. to be treated and/or with or continue
treatment with these medications by another physician.” Finally, although Dr. Rich stated
in an interview with a Department investigator in March of 2003, that he always conducts
an electrocardiogram (“EKG”) on patients he treats with chelation therapy, at no time during
the treatment of M.H. with chelation therapy did he document conducting or interpreting an
EKG and there is no copy of an EKG included in the medical record.

       • Dr. Rich treated patient “R.H.” from January 2001 to February 2004. In January
2001, R.H. indicated a medical history of hypertension, epilepsy, and high cholesterol. In
April 2002, a pre-provocation urine analysis ordered by Dr. Rich indicated that none of the
elements tested for were beyond the reference range. Despite these normal test results and
without documenting that the test was repeated with different results, in May 2002, Dr. Rich
diagnosed R.H. with heavy metal toxicity and documented chelation therapy as the treatment
plan. Thereafter, from May 30, 2002, to December 2, 2003, he provided R.H. with
approximately 49 chelation treatments. In March 2003, a hair analysis indicated the presence
of multiple heavy metals beyond the reference range, and a January 2004 hair analysis
indicated that the level had increased in approximately fourteen categories. From September
9, 2003, through March 2, 2004, Dr. Rich provided R.H. with approximately six intravenous
hydrogen peroxide treatments. On March 2, 2004, although R.H. complained of feeling tired
and having pressure in his chest, Dr. Rich failed to document measuring R.H.’s heart and
respiration rates. An unconfirmed EKG on the same date indicated an inferior myocardial


        8
           Dr. Seger testified that “provoked” urine testing entails the administration of drugs (usually the
same drug used to chelate) that cause metals to be released through the urine, that anyone given a provoked
urine test would show metals in their urine and that “there hasn’t been a standard of normal setup [sic] for
provoked testing.” Dr. Seger testified that the standard for diagnosis of heavy metal toxicity is a non-
provoked urine test and then blood testing.

                                                    -6-
infarction, but Dr. Rich failed to document a confirmed or alternative interpretation of the
EKG. Dr. Rich, however, provided R.H. with a hydrogen peroxide treatment on that date,
but the treatment was terminated because of pain at the infusion site.

        • Dr. Rich treated patient “R.S.” from January 7, 2004, to March 9, 2004. On R.S.’s
initial progress note, his medical history included attention deficit hyperactivity disorder,
irritable bowel syndrome, and depression. Although Dr. Rich did not conduct a physical
exam of R.S., he made a preliminary diagnosis of heavy metal toxicity. A laboratory report
ordered by Dr. Rich dated January 23, 2004, showed that R.S. had a post-provocative urine
level with three elements beyond the reference ranges stated in the report. However, the
report noted that the “[e]lement reference ranges were developed from a healthy population
under non-provoked/non-challenged conditions” and that “[p]rovocation with challenge
substances is expected to raise the urine level of some elements. . . .” Despite these specified
qualifying conditions, on February 5, 2004, Dr. Rich diagnosed R.S. as having heavy metal
toxicity and decreased oxidative function. From February 12, 2004, through March 9, 2004,
he provided R.S. with six chelation treatments. When the treatment began on February 12,
2004, R.S. had a blood triglyceride level of 122 mg/dL and a calcium level of 9.1 mg/dL,
both within the reference range, but on March 2, 2004, R.S. had a blood triglyceride level of
233 mg/dL and a blood calcium level of 10.5 mg/dL, both designated as high on the
laboratory report. Dr. Rich failed to document that he consulted with or advised R.S. that
during the course of treatment his triglyceride and calcium levels had increased to a high
level nor did Dr. Rich make any medical recommendations or initiate any treatments in light
of these changes. Moreover, although a February 24, 2004, progress note states “severe
depression” and “father wants a consult with Dr. Rich today – wants to know what to do for
patient about depression,” there is no documentation that Dr. Rich consulted with or advised
either R.S. or his father or that he made any medical recommendations or initiated treatments
until March 9, 2004, when he provided R.S. with samples of the antidepressant Tofranil.

       • Although Dr. Rich did not at any relevant time have a license or certificate that
allowed him to provide detoxification treatment programs using methadone HCL, he treated
each of twelve additional identified patients in his clinic’s “detoxification program” with
multiple prescriptions for methadone. As to eleven of those patients, he also failed to obtain
copies of any medical records showing that any of them was suffering from any illness or
injury before prescribing methadone.

      The Board concluded that these facts describing Dr. Rich’s protocol with respect to
M.H., R.H., R.S., and the other twelve patients established the following:

      • Dr. Rich engaged in “[u]nprofessional, dishonorable or unethical conduct,” Tenn.
Code Ann. § 63-6-214(b)(1), and “[g]ross malpractice or a pattern of continued or repeated

                                              -7-
malpractice, ignorance, negligence or incompetence in the course of medical practice.” Tenn.
Code Ann. § 63-6-214(b)(4);

        • With respect to M.H., R.H., and R.S., Dr. Rich

                [d]ispens[ed], prescrib[ed] or otherwise distribut[ed] [a]
                controlled substance or . . . other drug not in the course of
                professional practice, or not in good faith to relieve pain and
                suffering, or not to cure an ailment, physical infirmity, or
                disease, or in amounts and/or for durations not medically
                necessary, advisable or justified for a diagnosed condition.

Tenn. Code Ann. § 63-6-214(b)(12) and had “[d]ispens[ed], prescrib[ed], or otherwise
distribut[ed] [a] controlled substance or other drug to [a] person in violation of [a] law of the
United States.” Tenn. Code Ann. § 63-6-214(b)(14).

       • Dr. Rich’s treatment of the other twelve patients constituted grounds for disciplinary
action under rules 0880-02-.14(6)(c) and (e)(3) of the Official Compilation of the Rules and
Regulations of the State of Tennessee and 21 U.S. C. § 823(g)(1).

        Noting Dr. Rich’s “multiple disciplinary violations over a long period, in addition to
[his] lack of regard for previous board actions which demonstrates a significant failure in his
judgment,” the Board suspended his license for one year and ordered him to be evaluated by
the Vanderbilt Comprehensive Assessment Program for Professionals and comply with its
recommendations, complete a Board-approved comprehensive course in pain management,
pay the costs incurred in the prosecution of his case, and ensure the transfer of all of his
patients to other medical providers.

       Dr. Rich petitioned the Chancery Court for Davidson County pursuant to Tennessee
Code Annotated section 4-5-3229 for review of the Board’s decision. After the Chancery
Court affirmed the Board’s judgment, Dr. Rich appealed to the Court of Appeals. The Court
of Appeals affirmed the Board’s findings that Dr. Rich had violated Tennessee Code
Annotated section 63-6-214(b)(14), rule 0880-02-.14(6)(c) and (e)(3) of the Official
Compilation of the Rules and Regulations of the State of Tennessee and 21 U.S.C. §


        9
          The Tennessee Uniform Administrative Procedures Act is codified at Tennessee Code Annotated
sections 4-5-101 to 4-5-325 (2005). Section 4-5-322(a)(1) governs the judicial review of the decision of a
state agency such as the Board, providing that “[a] person who is aggrieved by a final decision in a contested
case is entitled to judicial review under this chapter, which shall be the only available method of judicial
review.”

                                                     -8-
823(g)(1). However, upon determining that the Board was required by Tennessee Code
Annotated section 63-6-214(g) to articulate the applicable standard of care in its deliberations
and that it had failed to do so, the Court of Appeals reversed the Board’s ruling that Dr. Rich
had violated subsections (1), (4), and (12) of Tennessee Code Annotated section 63-6-214(b),
and remanded to the Board for reconsideration of sanctions. We granted the Board’s
application for permission to appeal and address the issue of whether the Board was required
by Tennessee Code annotated section 63-6-214(g) to articulate the applicable standard of
care in its deliberations.

        The sole issue we address is whether Tennessee Code Annotated section 63-6-214(g)
required the Board to articulate the applicable standard of care in its deliberations with regard
to whether Dr. Rich violated Tennessee Code Annotated section 63-6-214(b)(1), (4), and
(12).10

                                                 Analysis

        The issue before us is one of statutory construction. The rules of statutory
construction are well settled and require that we implement legislative intent without
broadening or restricting the statute beyond its intended scope. Houghton v. Aramark Educ.
Res., Inc., 90 S.W.3d 676, 678 (Tenn. 2002). We look to “the natural and ordinary meaning
of the statutory language within the context of the entire statute without any forced or subtle
construction that would extend or limit the statute’s meaning.” State v. Flemming, 19
S.W.3d 195, 197 (Tenn. 2000); see In re Adoption of A.M.H., 215 S.W.3d 793, 808 (Tenn.


        10
           In oral argument before this Court, Dr. Rich’s counsel stated that Dr. Rich is requesting that we
affirm the judgment of the Court of Appeals as to its reversal of the Board’s ruling that Dr. Rich violated
Tennessee Code Annotated section 63-6-214(b)(1), (4), and (12) and that he is not requesting that we reverse
the Board’s ruling that Dr. Rich violated Tennessee Code Annotated section 63-6-214(b)(14); rules 0880-02-
.14(6)(c) and (e)(3) of the Official Compilation of the Rules and Regulations of the State of Tennessee
and 21 U.S.C. § 823(g)(1). At oral argument, Dr. Rich’s attorney conceded that Dr. Rich was not seeking
review of the Board’s finding that he violated the four provisions not related to a standard of care:

                Counsel: I’m asking that Your Honors affirm the ruling of the Court of
                Appeals which held that the Board is required to articulate the standard of
                care if it is going to rule that a licensee has violated it. It’s nothing more
                than the same right that -

                Chief Justice Clark: But then your client still stands found to have four
                other charges, right? So, you’re not asking that these be reversed?

                Counsel: No, Your Honor. No.


                                                     -9-
2007) (“Where the statutory language is not ambiguous, . . . the plain and ordinary meaning
of the statute must be given effect.”). We “‘presume that the legislature says in a statute what
it means and means in a statute what it says there.’” Gleaves v. Checker Cab Transit Corp.,
15 S.W.3d 799, 803 (Tenn. 2000) (quoting BellSouth Telecomms., Inc. v. Greer, 972 S.W.2d
663, 673 (Tenn. Ct. App. 1997)). When we are called upon to construe the meaning of a
statute, our review is de novo without deference to the decision of the court below. Estate
of French v. Stratford House, 333 S.W.3d 546, 554 (Tenn. 2011).

      The statute at issue in this case, Tennessee Code Annotated section 63-6-214(g),
provides as follows:

              For purposes of actions taken pursuant to subdivisions (b)(4),
              (12) and (13) or any other subsection in which the standard of
              care is an issue, any Tennessee licensed physician serving as a
              board member, hearing officer, designee, arbitrator or mediator
              is entitled to rely upon that person’s own expertise in making
              determinations concerning the standard of care and is not subject
              to voir dire concerning such expertise. Expert testimony is not
              necessary to establish the standard of care. The standard of care
              for such actions is a statewide standard of minimal competency
              and practice that does not depend upon expert testimony for its
              establishment. However, to sustain actions based upon a
              violation of this standard of care, the board must, in the absence
              of admissions or other testimony by any respondent or such
              respondent’s agent to the effect that the standard was violated,
              articulate what the standard of care is in its deliberations.

(Emphasis added).

       Dr. Rich was charged with violation of the standard of care by failing to comply with
the requirements of Tennessee Code Annotated sections 63-6-214(b)(1),(4), and (12). Our
review of the record confirms that the Board, during its deliberations, did not articulate the
applicable standard of care as required by Tennessee Code Annotated section 63-6-
214(g). Siddall v. Tenn. Bd. Of Med. Exam’rs., No. M2004-02767-COA-R3-CV, 2006 WL
1763665, at *3 (Tenn. Ct. App. June 27, 2006) (“Although [the Board] is not required to
present expert testimony, it must still articulate a standard of care to establish a statewide
standard of minimum competency and practice.”).

       The Board asserts that under subsection (g), it is only required to articulate the
standard if there is no expert testimony as to the applicable standard of care and that it

                                              -10-
submitted the testimony of two experts establishing such standard. The language of the
statute does not support the construction urged by the Board. The statute’s language is clear
and unambiguous. According to its plain terms, we construe it to mean what it says – that
for purposes of any action taken based upon a subsection where the standard of care is an
issue, “the board must . . . articulate what the standard of care is in its deliberations.” Tenn.
Code Ann. § 63-6-214(g). The statute specifies only one exception to this requirement –
“admission or other testimony by any respondent or such respondent’s agent to the effect that
the standard of care was violated.” Id. Here, The standard of care was an issue and Dr. Rich
did not admit or testify that he ever violated the standard of care. Applying the canon of
construction “expressio unius est exclusio alterius,” which holds that the expression of one
thing implies the exclusion of others, we infer that had the legislature intended to allow the
additional exception asserted by the Board, it would have included specific language to that
effect. See Amos v. Metro. Gov’t of Nashville & Davidson Cnty., 259 S.W.3d 705, 715
(Tenn. 2008).

       The requirement that the Board articulate the applicable standard of care in its
deliberations serves a twofold purpose. It gives guidance to other physicians practicing
medicine in this state as to the standard to which they are expected to conform and informs
the reviewing court of the basis for the Board’s decision. Articulation of the adopted
standard of care is critical in cases where the Department and the respondent physician have
not agreed as to the applicable standard of care, and have submitted conflicting expert
testimony in that regard. And even where only one party has presented expert testimony to
establish the applicable standard, the Board may reject such testimony and determine a
different standard based on its own expertise. As this Court has recognized,

              “[e]xpert opinions are not ordinarily conclusive in the sense that
              they must be accepted as true on the subject of their testimony,
              but are generally regarded as purely advisory in character; the
              [triers of fact] may place whatever weight they choose upon
              such testimony and may reject it, if they find that it is
              inconsistent with the facts in the case or otherwise
              unreasonable.”

 Cocke Cnty. Bd. of Highway Comm’rs v. Newport Util. Bd., 690 S.W.2d 231, 235 (Tenn.
1985) (quoting Am. Jur. 2d Expert and Opinion Evidence § 138 (1967)); accord Gibson v.
Ferguson, 562 S.W.2d 188, 189-90 (Tenn. 1976). Moreover, the statute explicitly states that
“[e]xpert testimony is not necessary to establish the standard of care” and that “any
Tennessee licensed physician serving as a board member . . . is entitled to rely upon that
person’s own expertise in making determinations concerning the standard of care.” Tenn.
Code Ann. § 63-6-214(g). Whether the Board adopts the standard of care advanced by an

                                              -11-
expert witness or independently determines the standard of care based on its own expertise,
the Board must articulate the standard upon which its decision is based to allow the
reviewing court to know the standard and assess the validity of the Board’s
decision. Similarly, when the Board fails to designate the applicable standard of care, a
doctor seeking subsequent review of the Board’s decision is placed at an unfair disadvantage;
unless it is clear what standard the doctor is held to have violated, he or she cannot properly
assess the Board’s conclusions in that regard and prepare an effective argument on appeal. In
Webb v. State ex rel. Ariz. Bd. of Med. Exam’rs, 48 P.3d 505, 510 (Ariz. Ct. App. 2002), the
Arizona Court of Appeals, reviewing the board of medical examiners’ censure of a physician
for unprofessional conduct, recognizing these concerns, stated as follows:

              Not only must the Board identify the standard and articulate the
              alleged deviation in order to provide the physician under
              investigation a fair opportunity to respond to a charge of
              negligence; it must do so in order to provide a reviewing court
              an opportunity for meaningful review. “Without clearly
              articulated standards as a backdrop against which the court can
              review discipline, the judicial function is reduced to serving as
              a rubber-stamp for the Board’s action.” Woodfield v. Bd. of
              Prof’l Discipline of State Bd. of Med., 905 P.2d 1047, 1057
              (Idaho Ct. App. 1995).

       While we hold that the Board erred in failing to articulate the applicable standard of
care in its deliberations, this error does not warrant reversal of the Board’s ruling that Dr.
Rich violated Tennessee Code Annotated § 63-6-214(b)(1), (4), and (12). This case does not
involve an error or deficiency in the administrative hearing or the facts, but rather an error
of law and a deficiency in the record. A reviewing court may remand a case to an
administrative agency where the agency has committed an error of law or the record
presented to the court is inadequate. 73A C.J.S. Public Administrative Law and Procedure
§ 461 (2004). This procedure does not require a new hearing by the administrative agency,
but instead allows the agency to correct noted legal deficiencies based on the existing
administrative record. See Lewis v. Bedford Cnty. Bd. Of Zoning Appeals, 174 S.W.3d 241,
247 (Tenn. Ct. App. 2004) (holding that “[w]here the evidence has been preserved but the
board or commission has not exercised its responsibility in accordance with legal
requirements, a remand to the board for a hearing based on the existing record of the
evidence is appropriate”); Hoover, Inc. v. Metro. Bd. of Zoning Appeals for Davidson Cnty.,
955 S.W.2d 52, 55 (Tenn. Ct. App. 1997) (remanding case to agency with directions to
conduct a new hearing based on the existing record without introduction of additional factual
evidence and noting that “[r]eopening the record at this late stage would only give the parties
a second bite at the apple”). Accordingly, the error of the Board in failing to articulate the

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applicable standard of care is properly resolved by remand to the Board whereupon it is
directed to conduct deliberations based on the existing record and articulate during the
deliberations the applicable standard of care as required by the statute.

                                        Conclusion

        We hold that the Board was required by Tennessee Code Annotated section 63-6-
214(g) to articulate the applicable standard of care in its deliberations. The error warrants
remand for correction, rather than reversal, of any of the Board’s findings of
violations. Accordingly, we vacate the judgment of the trial court affirming the Board’s
findings that Dr. Rich violated Tennessee Code Annotated section 63-6-214(b)(1), (4), and
(12). We further vacate the judgment of the Court of Appeals to the extent it reverses the
Board’s findings that Dr. Rich violated Tennessee Code Annotated section 63-6-214(b)(1),
(4), and (12). Otherwise, the judgment of the Court of Appeals is affirmed, and the cause is
remanded to the Board with instructions that it conduct deliberations based on the existing
record and articulate the applicable standard of care in its deliberations. Costs are assessed
to the Tennessee Board of Medical Examiners, for which execution may issue if necessary.




                                                    ______________________________
                                                    SHARON G. LEE, JUSTICE




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