03-001615PL Department Of Health, Board Of Osteopathic Medicine vs. David Vastola, D.O. Status: Closed Recommended Order on Wednesday, October 1, 2003.

Summary: Doctor failed to keep adequate medical records and to timely order appropriate follow-up tests.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, BOARD OF )

OSTEOPATHIC MEDICINE, )

)

Petitioner, )

)

vs. ) Case No. 03 - 1615PL

)

DAVID VASTOLA, D.O., )

)

Respondent. )

)

RECOMM ENDED ORDER

Pursuant to notice, a final hearing was conducted on

June 24 and 25, 2003, in West Palm Beach, Florida, before

Administrative Law Judge Claude B. Arrington of the Division of

Administrative Hearings.

APPEARANCES

For Petitioner: Kim M. K luck, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

For Respondent: Roy R. Watson, II, Esquire

Adams, Coogler, W atson, Merkel,

Barry and Kellner, P.A.

Regions Financial Tower, Suite 1600

1555 Palm Beach Lakes Boulevard

West Palm Beach, Florida 33402 - 2069

STATEMENT OF THE ISSUE

Whether Respondent, a doctor of osteopathic medicine,

committed the offenses alleged in the Amended Administrative

Complaint and the penalties, if any, that should be imposed.

PRELIMINARY STATEMENT

Petitioner's "Amended [sic] Administrative Compl aint" (AAC)

against Respondent dated February 5, 2003, alleged certain facts

pertaining to Respondent's care of a male patient who will be

referred to as R.S. R.S. is now deceased.

Count One of the AAC alleged that Respondent violated the

provisions of Se ction 459.015(1)(x), Florida Statutes (1999), by

failing to practice osteopathic medicine with the level of care,

skill, and treatment recognized by a reasonably prudent similar

osteopathic physician as being acceptable under similar

circumstances. Specif ically, paragraph 52 of the ACC charged as

follows:

52. Respondent failed to practice

osteopathic medicine with that level of

care, skill and treatment, which is

recognized by a reasonably prudent similarly

situated osteopathic physician, in one or

more of the following ways:

(a) Respondent did not order additional

tests to determine the cause of the lesion

visible on the November 9, 1999, chest x -

ray, January 25, 2000, chest x - ray, February

11, 2000, chest x - ray, and May 25, 2000,

chest x - ray taken o f Patient R.S.;

(b) When a radiologist dictated a report,

on or about September 11, 2000, indicating a

questionable rounded area of density on the

September 11, 2000, chest x - ray, Respondent

waited six weeks before further evaluating

Patient R.S. to det ermine the cause; and

(c) Respondent failed to evaluate Patient

R.S. in order to determine the cause of

repeated abnormal elevated serum calcium

levels.

Count Two of the AAC alleged that Respondent violated

Section 459.015(1)(o), Florida Statutes (19 99), by failing to

keep legible medical records that justify the course of

treatment of R.S. Specifically, paragraph 56 of the AAC charged

as follows:

56. Respondent failed to keep medical

records that justify the course of treatment

in one or more of the following ways:

(a) Respondent failed to document the

lesion visible on the November 9, 1999,

January 25, 2000, February 11, 2000, and May

25, 2000, chest x - rays;

(b) Respondent failed to document

justification for failing to further

evaluate Pat ient R.S. to determine the cause

of the lesion visible on four repeated chest

x - rays;

(c) Respondent failed to document in his

medical records justification for waiting

six weeks before further evaluating the area

of density noted by a radiologist who v iewed

the September 11, 2000, chest x - ray; and

(d) Respondent failed to document

justification for failing to determine the

cause of repeated elevated serum calcium

levels.

Respondent denied the material allegations of the AAC, the

matter was referre d to the Division of Administrative Hearings,

and this proceeding followed.

At the final hearing, the parties offered two joint

exhibits, both of which were composite exhibits and both of

which were admitted into evidence. Joint Exhibit 1 consists of

med ical records from Respondent's office for R.S. Joint

Exhibit 2 consists of x - rays taken of R.S. by Respondent.

Petitioner presented the testimony of E.S., 1 Dr. Lionel J.

Gatien, and, by deposition, Dr. Daniel Siragusa. Petitioner

offered two exhibits, e ach of which was admitted into evidence.

Respondent testified on his own behalf, and presented the

additional testimony of Gail Vastola (Respondent's wife), Dr.

Allen Marcus, and Dr. Norman Henry Pevsner. Respondent offered

five exhibits, four of which w ere admitted into evidence.

A Transcript of the proceedings, consisting of three

volumes, was filed on July 30, 2003. Each party filed a

Proposed Recommended Order, which has been considered by the

undersigned in the preparation of this Recommended Orde r.

All statutory citations are to Florida Statutes (2002),

unless otherwise indicated.

FINDINGS OF FACT

1. Petitioner is the agency of the State of Florida

charged with regulating the practice of medicine pursuant to

Section 20.43, Chapter 456, and Ch apter 459.

2. At all times material to this proceeding, Respondent

has been licensed as an osteopathic physician in the State of

Florida, having been issued license number OSSO3793.

3. Respondent is board - certified in internal medicine and

gastroent erology and has been in the private practice of

medicine in Palm Beach County, Florida, since 1978.

4. Respondent was the primary care physician for Patient

R.S. from 1994 to November 2000. R.S., a male born in November

1936, was a retired physician at the times material to this

proceeding. R.S. was a compliant, informed patient while under

Respondent's care.

5. R.S.’s medical history included elevated serum calcium

levels, prostate cancer, thyroidectomy, and chronic, obstructive

pulmonary disease, r eferred to as COPD. In addition, R.S.

suffered from bipolar disorder and was a long - time user of

Lithium. At the times pertinent to this proceeding, R.S. was

being followed by the doctor in Seattle, Washington, who treated

his prostate cancer, and by an endocrinologist in West Palm

Beach, Florida. In addition to the foregoing history, when he

was a teenager, R.S. had a melanoma on his back that was

surgically removed. Respondent testified, credibly, that he did

not know of that melanoma at the times mat erial to this

proceeding.

6. As the primary care physician, Respondent was

responsible for providing the patient's basic care, performing

routine physical examinations, performing diagnostic testing as

indicated, keeping his prescription medicines curr ent, and

coordinating specialty care when needed.

Serum Calcium

7. Serum calcium is a necessary mineral in the body that

forms a matrix for bones and controls other reactions in the

body. It is controlled by the parathyroid glands. With slight

variatio ns among testing laboratories, the values considered to

be in the normal range are from 8.8 to 10.5.

8. Lab studies dated February 24 and March 24, 1998,

reflected, among other information, that R.S. had an elevated

serum calcium level. The values re flected by these studies were

11.4 and 11.3, respectively.

9. R.S.'s medical history contained several conditions

that could have a potential impact on his serum calcium level.

The thyroidectomy included the removal of most of the

parathyroids and shou ld have lowered the serum calcium levels.

In addition, R.S.’s long - time use of Lithium could have caused

an elevation of serum calcium levels.

10. An elevated serum calcium level can be the result of a

variety of causes, including malignancies, hematol ogical

disorders, and medications (Lithium and hyperthyroid

medications).

11. Respondent concluded that Respondent's elevated serum

calcium level was the result of taking Lithium without

investigating other causes for the elevated reading.

12. Ther e was a conflict between Dr. Gatien, an expert on

behalf of Petitioner, and Dr. Marcus, an expert on behalf of

Respondent, as to whether Respondent practiced below the

standard of care in concluding that Lithium was causing the

elevated serum calcium readi ngs without further investigation.

The undersigned has carefully considered the conflicting

testimony of these two experts and the underlying evidence and

rationale that support their respective opinions. Succinctly

stated, Dr. Gatien opined that because Respondent did not look

for other causes of the elevated calcium serum readings, he

could not know what caused the elevated readings. Dr. Marcus,

on the other hand, opined that Respondent had sufficient

information based on his knowledge of the patient t o reasonably

conclude that Lithium caused the elevated readings and that

further testing was unnecessary. Dr. Gatien opined that

Respondent failed to meet the standard of care; but Dr. Marcus

opined that Respondent met the standard of care. The

undersign ed finds both experts to be qualified and sincere in

their testimony. The undersigned further finds no reason to

credit one expert's testimony over that of the other. 2

Consequently, the undersigned finds that the evidence does not

clearly and convincingl y establish the violation alleged in

subsection (c) of paragraph 52 of the AAC.

13. Respondent's medical records merely noted the elevated

readings, but they did not set forth Respondent's theory of

causation or explain why Respondent believed that furth er

testing was unnecessary. Petitioner proved by clear and

convincing evidence the violation alleged in subsection (d) of

paragraph 56 of the AAC.

X - Rays

14. In November 1999, R.S. presented to Respondent with

complaints of a cough. The complaints of a cough persisted

between November 1999 and October 2000.

15. A chest x - ray is of limited diagnostic value. An MRI

of the chest (involving magnet imaging) typically is of higher

diagnostic value. A CT of the chest (involving computer

technology) typic ally is of even higher diagnostic value, but is

considerably more expensive than either an x - ray or an MRI.

16. In November 1999, Respondent recommended that R.S.

undergo a CT of the chest. Respondent testified that R.S.

declined that recommendation. Respondent’s medical records do

not reflect that R.S. refused the recommended test or mention

any reason for his decision.

17. Respondent took chest x - rays of R.S. on the following

dates between November 9, 1999, and October 23, 2000:

November 9, Jan uary 24, January 25, February 11, May 25,

September 11, and October 23. Each x - ray was taken in

Respondent's office using Respondent's equipment, and the x - rays

were of varying quality. The x - rays taken January 24 were the

only x - rays that could not be r ead because of the poor quality

of the film. On each date at least two views were taken. The

x - rays included a front to back view or a back to front view and

a lateral view. The front to back view is referred to as an AP

(anterior to posterior) view, wh ile the back to front view is

referred to as a PA (posterior to anterior) view.

18. An over - read of an x - ray occurs when one doctor reads

the film and then a radiologist reads it a second time (the

over - read). Dr. Pevsner, a board - certified radiologist , and

Respondent testified that Dr. Pevsner over - read all chest x - rays

taken by Respondent at his office, including the x - rays at issue

in this proceeding. 3 Dr. Pevsner furnished Respondent a written

report for the x - rays taken January 24, January 25, and

September 11. He did not furnish Respondent a report for the

other x - rays, and he had no independent recollection of having

reviewed them.

19. Certain assumptions have been built in to the

arrangement between Dr. Pevsner and Respondent. Dr. Pevsner

a ssumed that he read all of Respondent's chest x - rays and that

he had found nothing worth reporting if he did not generate a

written report. Respondent assumed, for the x - rays that had no

report, that Dr. Pevsner had received the x - ray, had reviewed

the x - ray, and had found nothing worth reporting. 4

20. The x - rays taken November 9, 1999, depicted an

abnormal density. 5 The standard of care required Respondent to

order follow - up testing for R.S. The follow - up x - rays taken on

January 25 met the standard o f care.

21. The x - rays taken January 24, 2000, could not be read

because of their poor quality. Dr. Pevsner’s report to

Respondent recommended that the x - rays be repeated.

22. The x - rays taken January 25, 2000, depicted an

abnormal density in the sa me region as the density depicted on

the November 9 x - ray. Dr. Pevsner's report referred to this as

a "nodular density" that "may be artifact or merely vessel" and

concluded with the following recommendation:

. . . Recommend repeat PA view and

comparison to old films to see if this is a

nodule or a vessel on the blurred lateral.

23. Respondent found the January 25 x - rays to be clear.

Respondent went over the x - rays with R.S. and E.S. and told them

that the x - rays were okay. Respondent testified that he

believed the density to be a blood vessel.

24. Respondent followed Dr. Pevsner's recommendation to

repeat the PA view. Respondent was entitled to rely on

Dr. Pevsner's written recommendation, and he practiced within

the standard of care in ordering f ollow - up x - rays, which were

taken February 11.

25. There was a dispute as to whether the x - rays taken

February 11 showed an abnormal density. The greater weight of

the credible evidence clearly and convincingly established that

those x - rays showed an a bnormal density in the same location as

the previous x - rays. There was no apparent change from the

January 25 x - rays as far as the size and shape of the density.

26. Respondent found the chest x - rays taken February 11 to

be normal. As he had done in J anuary, Respondent went over the

x - rays with R.S. and E.S. and told them that the x - rays were

okay. Respondent testified at trial that he believed the

density to be a pulmonary vein.

27. Dr. Pevsner did not submit a written report for the x -

rays taken February 11. Dr. Pevsner testified while he would

have routinely over - read the February 11 x - rays, he did not

submit a written report, and he had no independent recollection

of having over - read those x - rays. Dr. Pevsner reviewed the

February 11 x - rays at the final hearing and agreed with

Dr. Gatien and Dr. Siragusa that the x - rays depicted a

questionable density.

28. Respondent should have been able to see the

questionable density on the February 11 films observed by

Dr. Pevsner, Dr. Gatien, and Dr. Si ragusa. The standard of care

required that Respondent proceed with a more definitive test,

either an MRI or a CT, following the chest x - rays taken

February 11.

29. There was a dispute as to whether the x - rays taken

May 25 showed an abnormal density. T he greater weight of the

credible evidence clearly and convincingly established that

those x - rays showed an abnormal density in the same location as

the previous x - rays. The density was slightly larger than

previously seen. Respondent testified at trial that he believed

the area in question to be the head of a rib. Dr. Pevsner

testified while he would have routinely over - read the May 25

x - rays, he did not submit a written report, and he had no

independent recollection of having over - read those x - rays.

Dr. Pevsner reviewed the May 25 films at the final hearing and

testified that they depicted an area of questionable density.

Dr. Pevsner further testified that the finding was too vague to

make any conclusion and that he may not have detected the area

of the questionable density if it had not been marked by some

unknown person who had previously reviewed the films.

30. The chest x - rays taken September 11 continued to show

an area of questionable density in the location of the prior

chest x - rays. This area appeared to have increased from 14

millimeters in May to 18 millimeters in September. Dr. Pevsner

found the x - rays of September 11 to contain an area of

questionable density and recommended that Respondent compare the

film to prior x - rays or take fo llow - up x - rays that were better

penetrated.

31. Although Respondent viewed the September 11 x - rays as

being clear, he ordered follow - up x - rays for October 23.

Because he was acting on the recommendation of Dr. Pevsner, it

is found that Respondent acted within the standard of care in

ordering follow - up x - rays instead of ordering more definitive

tests.

32. The greater weight of the credible evidence, including

the prior abnormal x - rays and the fact that R.S. continued to

complain of a persistent cough, established clearly and

convincingly that Respondent deviated from the standard of care

by waiting approximately six weeks for the follow - up x - rays.

33. The chest x - rays taken October 23 continued to show an

area of questionable density in the location of the prior chest

x - rays.

34. Respondent ordered an MRI, which was performed on

October 24. A CT scan followed on October 26. Those tests

revealed the presence of an abnormality. A subsequent biopsy

confirmed the presence of a malignant melanoma. Specialists

treated R.S. after the discovery of the malignant melanoma.

35. The melanoma detected in October 2000 was located in

different part of the chest than the area of questionable

density that had been revealed by x - ray. There was no evidence

th at there existed any connection between the melanoma and the

areas of questionable density that had been detected by the

x - rays involved in this proceeding. 6

36. A melanoma in the lungs is a fast - moving malignancy

that inevitably results in death, us ually within a year of its

discovery. Had Respondent ordered an MRI or CT scan prior to

October 2000, it is doubtful that the melanoma would have been

detected. Clearly, the detection of the melanoma at an earlier

date would not have altered the ultimate outcome, which was the

death of R.S.

37. Petitioner did not prove by the clear and convincing

evidence that Respondent's failure to meet the standard of care

as set forth above caused harm to the patient.

38. The CT scan taken October 26 revealed no abnormality

in the area of questionable density detected by the x - rays

discussed above. 7

Medical Record

38. Respondent did not document in his medical records the

existence of a questionable density on the x - rays taken

November 9, January 25, February 11, and May 25, and he did not

document justification for not further evaluating the

questionable density because he did not believe a questionable

density existed on those films. The failure to detect the area

of questionable density and to order approp riate follow - up

testing constituted practice below the standard of care. There

was no justification for that failure.

39. Petitioner charged Respondent with failing to document

justification for waiting six weeks before further evaluating

the area of den sity noted by Dr. Pevsner following his reading

of the September 11 x - rays. That delay has been found to be

below the standard of care. Consequently, there was no

justification for the delay.

CONCLUSIONS OF LAW

40. The Division of Administrative Hearin gs has

jurisdiction over the subject matter of and the parties to this

cause pursuant to Sections 120.569 and 120.57(1).

41. Chapter 459 creates the Board of Osteopathic Medicine

and regulates the practice of osteopathic medicine in Florida.

Section 459. 015(1), Florida Statutes (1999), provides, in

pertinent part, as follows:

(1) The following shall constitute

grounds for which the disciplinary actions

specified in subsection (2) may be taken:

* * *

(o) Failing to keep legible, as defined

by d epartment rule in consultation with the

board, medical records that … justify the

course of treatment of the patient,

including, but not limited to, patient

histories; examination results; test

results; records of drugs prescribed,

dispensed, or administer ed; and reports of

consultations and hospitalizations.

* * *

(x) Gross or repeated malpractice or the

failure to practice osteopathic medicine

with that level of care, skill, and

treatment which is recognized by a

reasonably prudent similar osteop athic

physician as being acceptable under similar

conditions and circumstances. … As used in

this paragraph, "gross malpractice" or "the

failure to practice osteopathic medicine

with that level of care, skill, and

treatment which is recognized by a

reason ably prudent similar osteopathic

physician as being acceptable under similar

conditions and circumstances" shall not be

construed so as to require more than one

instance, event, or act. Nothing in this

paragraph shall be construed to require that

an osteo pathic physician be incompetent to

practice osteopathic medicine in order to be

disciplined pursuant to this paragraph. A

recommended order by an administrative law

judge or a final order of the board finding

a violation under this paragraph shall

specify whether the licensee was found to

have committed "gross malpractice, "repeated

malpractice," or "failure to practice

osteopathic medicine with that level of

care, skill, and treatment which is

recognized as being acceptable under similar

conditions and ci rcumstances," or any

combination thereof, and any publication by

the board shall so specify.

42. Petitioner has the burden of proving by clear and

convincing evidence the allegations against Respondent. See

Ferris v. Turlington , 510 So. 2d 292 (Fla. 198 7); Evans Packing

Co. v. Department of Agriculture and Consumer Services , 550 So.

2d 112 (Fla. 1st DCA 1989); and Inquiry Concerning a Judge , 645

So. 2d 398 (Fla. 1994). The following statement has been

repeatedly cited in discussions of the clear and con vincing

evidence standard:

Clear and convincing evidence requires

that the evidence must be found to be

credible; the facts to which the witnesses

testify must be distinctly remembered; the

evidence must be precise and explicit and

the witnesses must be l acking in confusion

as to the facts in issue. The evidence must

be of such weight that it produces in the

mind of the trier of fact the firm belief of

[sic] conviction, without hesitancy, as to

the truth of the allegations sought to be

established. Slomo witz v. Walker , 429 So.

2d 797, 800 (Fla. 4th DCA 1983).

43. Petitioner proved by clear and convincing evidence

that Respondent violated the provisions of Section

459.015(1)(o), Florida Statutes (1999), by failing to document

justification for failing to determine the cause of repeated

elevated serum calcium levels as alleged in subsection (d) of

paragraph 56 of the AAC.

44. There are no medical records that Respondent could

have kept that would have justified the failures alleged in

subsections (a), (b ), and (c) of paragraph 56 of the AAC.

Consequently, no separate violations should be found based on

those allegations.

44. Petitioner proved by clear and convincing evidence

that Respondent violated the provisions of Section

459.015(1)(x), Florida Sta tutes (1999), by failing to practice

osteopathic medicine with that level of care, skill, and

treatment which is recognized by a reasonably prudent similar

osteopathic physician as being acceptable under similar

conditions and circumstances as alleged in s ubsections (a) and

(b) of paragraph 52 of the AAC. The violation pertaining to

subsection (a) of paragraph 52 is limited to the failure to

timely order more definitive follow - up exams (an MRI or a CT)

following the February 11 x - rays.

45. Petitioner di d not prove by clear and convincing

evidence the violation alleged in subsection (c) of paragraph 52

of the AAC.

45. Rule 64B15 - 19.002, Florida Administrative Code,

provides disciplinary guidelines pertinent to this proceeding.

For a first violation of S ection 459.015(1)(o), the guideline is

from a minimum of reprimand and a $5,000 fine to a maximum of

probation and a $5,000 fine.

46. For a first violation of Section 459.015(1)(x), the

guideline is from a minimum of probation and a $5,000 fine to a

max imum of suspension followed by probation and a $7,500 fine.

47. Rule 64B15 - 19.003, Florida Administrative Code,

provides aggravating and mitigating circumstances pertinent to

this proceeding. There are no aggravating circumstances. There

are, however, mitigating circumstances that have been considered

by the undersigned in the recommended penalty set forth below.

The first mitigating factor is that Respondent has practiced in

Florida for many years without prior discipline. The second

mitigating fact or is that there was no damage to the patient,

physical or otherwise, caused by the violations found in this

proceeding.

48. Because of the mitigating factors, the undersigned

concludes that Petitioner should not place Respondent on

probation, nor shoul d it impose an administrative fine against

him.

RECOMMENDATION

Based on the foregoing findings of fact and conclusions of

Law, it is RECOMMENDED that Petitioner enter a final order

finding Respondent guilty of violating Section 459.015(1)(o) and

(x), Fl orida Statutes (1999), as set forth in this Recommended

Order. Respondent should be found not guilty of the other

alleged violations. It is further RECOMMENDED that Petitioner

issue Respondent a written reprimand for each violation.

DONE AND ENTERED this 1st day of October, 2003, in

Tallahassee, Leon County, Florida.

S

___________________________________

CLAUDE B. ARRINGTON

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3 060

(850) 488 - 9675 SUNCOM 278 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 1st day of October, 2003.

ENDNOTES

1 / E.S. is the widow of R.S. At the times pertinent to this

pr oceeding, E.S. and R.S. were engaged, but they had not

married.

2/ The testimony of Dr. Marcus should not be discredited

because he has known Respondent for a long period of time and

formerly practiced medicine with him.

3 / The reason Dr. Pevsner per formed this service for Respondent

was not clear. Respondent did not pay him for doing so, but he

did refer patients to him. Dr. Pevsner testified he began

reading x - rays for Respondent as part of a study he was

conducting. Since Dr. Pevsner did not kee p a record of the

x - rays he reviewed or a copy of any report he generated, the

study would be, at best anecdotal.

4 / The undersigned rejects Respondent's contention that he was

entitled to rely on the assumption that Dr. Pevsner had read an

x - ray and found it to be clear if Dr. Pevsner did not generate a

written report. The working relationship between Dr. Pevsner

and Respondent is called into question by the fact that

Dr. Pevsner did, on at least some occasions, generate a written

report when he found an x - ray to be normal. Moreover,

Dr. Pevsner testified that he sometimes made verbal reports to

Respondent and that he recalled discussing some of the x - rays at

issue in this proceeding with Respondent. Respondent's medical

records do not note any such conversations, nor do they reflect

that Dr. Pevsner was over - reading x - rays for which no report had

been generated.

5/ The testimony presented by Petitioner as to the issue of

x - rays (from Dr. Gatien and Dr. Siragusa) and the testimony

presented by Respondent as to that issue (from Respondent and

Dr. Pevsner) contain conflicts. That testimony has been

carefully considered by the undersigned. The findings of fact

pertaining to the x - rays reflect the resolution of those

conflicts.

6/ It should also be noted that there was no evidence that the

elevated serum calcium readings in February 1998 were related to

the melanoma discovered in October 2000.

7 / The fact that there was, in retrospect, no abnormality in

the area of the questionable density is not relevant to whether

Respondent breached the standard of care based on x - rays taken

between November 1999 and October 2000, because that

determination should be made prospectively, not retrospectively.

That fact, and the fact that Respondent’s care of R.S. did not

cause harm to the patient, can and should be considered in

determining the penalties to be imposed in this proceeding.

COPIES FURNISHED :

Kim M. Kluck, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 3 2399 - 3265

Roy R. Watson, II, Esquire

Adams, Coogler, Watson, Merkel,

Barry & Kellner, P.A.

NationsBank Tower, Suite 1600

1555 Palm Beach Lakes Boulevard

West Palm Beach, Florida 33402 - 2069

William H. Buckhalt, Executive Director

Board of Osteopathic M edicine

Department of Health

4052 Bald Cypress Way, Bin C06

Tallahassee, Florida 32399 - 1701

William W. Large, General Counsel

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1701

Dr. John O. Agwunobi, Secretary

Department of Health

4052 Bald Cypress Way, Bin A00

Tallahassee, Florida 32399 - 1701

R. S. Power, Agency Clerk

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1701

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order. Any exceptions

to this Recommended Order should be filed with the agency that

will issue the Final Order in this case.