No. 16-0834 – Camden-Clark Memorial Hospital Corporation v. Tuan Nguyen, M.D.
                                                                                 FILED
LOUGHRY, Chief Justice, dissenting:                                         November 13, 2017
                                                                                     released at 3:00 p.m.
                                                                                 EDYTHE NASH GAISER, CLERK
                                                                                 SUPREME COURT OF APPEALS
                                                                                      OF WEST VIRGINIA 
              With just a few strokes of the keyboard, the majority carelessly gutted a

long-standing and well-established holding of this Court that gave hospitals a wide berth

in granting or denying privileges or staff appointments. Nearly twenty-seven years ago,

this Court ruled without equivocation:

                      The decision of a private hospital to revoke, suspend,
              restrict or to refuse to renew the staff appointment or clinical
              privileges of a medical staff member is subject to limited
              judicial review to ensure that there was substantial
              compliance with the hospital’s medical staff bylaws
              governing such a decision, as well as to ensure that the
              medical staff bylaws afford basic notice and fair hearing
              procedures, including an impartial tribunal.

Syl. Pt. 1, Mahmoodian v. United Hosp.Ctr., Inc., 185 W.Va. 59, 404 S.E.2d 750 (1991)

(emphasis added). Based on scant allegations of patient safety (which are little more than

a belated counteroffensive to a suit initiated by the hospital), the majority has seemingly

eviscerated that holding. See W. Va. Code § 16-39-1 to -7 (2016) (Patient Safety Act of

2001). The majority reasons its way through the weighty issues of this case with the

delicacy of a charging rhinoceros, failing to clarify what vestiges remain of this well-

ensconced quasi-immunity or to consider that this unwelcome intrusion into hospital

staffing issues may actually jeopardize patient safety. Accordingly, I dissent.




                                              
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                             The facts in this matter are straightforward and largely undisputed. The

medical staff bylaws of Camden-Clark Memorial Hospital Corporation (“Hospital”)

require that physicians appointed to its staff be board certified in their area of practice

within five years of completing their residency training.                   It is undisputed that the

respondent (“Dr. Nguyen”), who was initially appointed to the Hospital’s staff in 2008 a

few months after he completed his residency, was not board certified when he applied for

re-appointment in 2013. That Dr. Nguyen fully understood the significance of this lack

of certification is clear from his letter to the Hospital, dated October 22, 2013, in which

he admitted, when requesting temporary privileges: “I take full responsibility for not

having obtained my board certification.” Given this acknowledged failure and consistent

with its by-laws, the Hospital refused to renew his staff appointment by letter dated

October 17, 2013.1 Notably, Dr. Nguyen’s employment contract with Camden-Clark

Physicians Corporation therefore terminated automatically under its own terms when his

privileges terminated at the Hospital on November 30, 2013.



                             Of no small moment is the fact that the denial of re-appointment and

resultant contractual termination yielded no action whatsoever on Dr. Nguyen’s part: he

                                                            
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       By letter dated October 17, 2013, the Hospital acknowledged receipt of Dr.
Nguyen’s re-appointment application and informed him:

                                    In accordance with the Medical Staff Bylaws and
                             Credentialing Policy, you are not eligible to apply for re-
                             appointment to the Medical Staff of Camden Clark Medical
                             Center due to your failure to obtain Board certification in
                             your primary area of practice at the Hospital.
                                                                
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neither appealed the decision nor initiated a civil action to assert a claim of retaliation.

Only when the Hospital filed suit against him seeking reimbursement for his tail coverage

premiums did he raise a claim of retaliation or otherwise take issue with the Hospital’s

staffing decision. While the dubious circumstances under which Dr. Nguyen finally

raised his claims of retaliation are scarcely dispositive of the issue, they demonstrate the

ease with which an aggrieved physician may circumvent the Mahmoodian ruling.



              More than fifty years ago, this Court recognized that “[t]he governing

authorities of a private hospital, in the exercise of their discretion, have the absolute right

to exclude licensed physicians from its medical staff and such action is not subject to

judicial review.” Syl. Pt. 3, State ex rel. Sams v. Ohio Valley Gen. Hosp. Ass’n, 149

W.Va. 229, 140 S.E.2d 457 (1965) (emphasis added); see Hurwitz v. AHS Hosp. Corp.,

103 A.3d 285, 301 (N.J. Super. Ct. App. Div. 2014) (“The judicial power to intervene in

disputes over a physician’s clinical privileges is circumscribed.”). Thirty years later, in

Mahomoodian, this Court again recognized that judicial interference in medical staffing

decisions must be limited, explaining that

              [t]he judicial reluctance to review the medical staffing
              decisions of private hospitals, by way of injunction,
              declaratory judgment or otherwise, reflects the general
              unwillingness of courts to substitute their judgment on the
              merits for the professional judgment of medical and hospital
              officials with superior qualifications to make such decisions.

185 W.Va. at 65, 404 S.E.2d at 756; see also Brinton v. IHC Hosps., Inc., 973 P.2d 956,

964 (Utah 1998) (“[H]ospitals are entitled to exercise good faith medical judgment,

                                                
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which courts should not lightly question in subsequent civil suits . . . [Accordingly,] we

give deference to a hospital’s decision to decide whether medical standards of practice

have been met.”). This essentially “hands off” approach to hospital staffing decisions is

widely-held and well-established. 2




                                                            
               2
                  In Mahmoodian, we cited the following cases to illustrate that a majority of
courts limit judicial review of a private hospital’s staffing decisions to a determination of
whether there was compliance with the hospital’s bylaws:

              Shulman v. Washington Hosp. Ctr., 222 F.Supp. 59, 63, 64
              (D.D.C.1963); Eidelson v. Archer, 645 P.2d 171, 175 n. 13
              (Alaska 1982) (citing cases from other jurisdictions);
              Gaenslen v. Bd. of Dirs., 185 Cal.App.3d 563, 568, 232
              Cal.Rptr. 239, 241-42 (1985); Gianetti v. Norwalk Hosp.,
              211 Conn. 51, 61-67, 557 A.2d 1249, 1254-56 (1989) (citing
              cases from other jurisdictions); Adkins v. Sarah Bush Lincoln
              Health Ctr., 129 Ill.2d 497, 506-07, 509-10, 514, 136 Ill.Dec.
              47, 51-52, 53, 55, 544 N.E.2d 733, 737-38, 739, 741 (1989);
              Pepple v. Parkview Mem’l Hosp., Inc., 536 N.E.2d 274, 276
              (Ind.1989); Porter Mem’l Hosp. v. Malak, 484 N.E.2d 54, 61
              (Ind.Ct.App.1985); State ex rel. Willman v. St. Joseph Hosp.,
              684 S.W.2d 408, 411, 412 (Mo.Ct.App.1984), application to
              transfer denied (Mo. Feb. 26, 1985); syl. pt. 2, Gotsis v.
              Lorain Cmty. Hosp., 46 Ohio App.2d 8, 345 N.E.2d 641
              (1974) (citing, in body of opinion, cases from other
              jurisdictions); Miller v. Indiana Hosp., 277 Pa.Super. 370,
              374-78, 380, 419 A.2d 1191, 1193-94, [185 W.Va. 65] 1196
              (1980), appeal denied (Pa. Oct. 1, 1980).

Mahmoodian, 185 W.Va. at 64-65, 404 S.E.2d at 755-56 (footnote omitted). More
recently, the Supreme Court of Missouri has observed that forty-six states adhere to the
rule that the staffing decisions of private hospitals are subject to limited judicial review
which is restricted to whether the hospital’s decision conformed to its own bylaws or
regulations. See Egan v. St. Anthony’s Med. Ctr., 244 S.W.2d 169, 172 (Mo. 2008).  
                                               
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              With little to no consideration of the critical need for hospitals to retain this

deferential autonomy regarding privileges and staffing, the majority has carelessly paved

a path for litigants, and the judiciary, to invade the decision-making process previously

reserved to those with expertise in matters of medical staffing and privileges. By simply

phrasing a challenge to a staff appointment as “retaliatory” or “discriminatory,” a

physician may now evade the construct established in Mahmoodian of limited judicial

review. To illustrate, as in this case, a physician denied re-appointment need only

articulate a suggestion rooted in patient safety or a health care-related complaint and then

allege that the privileges denial violates the Patient Safety Act of 2001. The ease with

which a physician can conjure such assertions, and thereby effectively circumvent the

limited review of staffing decisions, is troubling. Yet the majority, in its analysis, wholly

fails to address the need to strike a balance between purported policy concerns of patient

safety and this type of potential gamesmanship.



              These considerations aside, the majority’s errant holding also fails to

acknowledge that the existing judicial review available under Mahmoodian is more than

sufficient to guard against retaliation or discrimination. While maintaining that judicial

review of a hospital’s staffing decisions must be narrow in scope, this Court recognized

the appropriate framework in which to address improperly-motivated staff decisions. In

Mahmoodian, the Court held that “there are basic, common-law procedural protections

which must be accorded a medical staff member by a private hospital in a disciplinary

proceeding.” 185 W.Va. at 65, 404 S.E.2d at 756. More to the point, the Court held that
                                                
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“[t]he decision of a private hospital revoking or otherwise affecting adversely the staff

appointment or clinical privileges of a medical staff member will be sustained when, as

an element of fair hearing procedures, there is substantial evidence supporting that

decision.” Id. at 61, 404 S.E.2d at 752, syl. pt. 4 (emphasis added). Because principles

of fundamental fairness require “substantial evidence” in support of a hospital’s staffing

decision, a judicial avenue already exists for an aggrieved physician to demonstrate bias

or discrimination without opening up the decision-making process to the “scorched earth”

processes of civil litigation. See Hurwitz, 103 A.3d at 306 (finding that permitting

discovery to proceed in privileges cases “would needlessly entangle hospitals and review

participants in depositions and other litigation activities, thereby diluting the practical

benefit of the immunity protection conferred upon them[.]”).



              In short, the majority needlessly obliterates the Mahmoodian immunity in

the interest of avenging retaliation or discrimination. Where improper motivations exist,

the framework of Mahmoodian currently permits the unearthing of this type of prohibited

conduct. Cf. Pamintuan v. Nanticoke Mem’l Hosp., 192 F.3d 378, 386 (3d Cir. 1999)

(requiring   challenging   physician   to   demonstrate   “weaknesses,    implausibilities,

inconsistencies, incoherencies, or contradictions” in proffered reason for privileges

suspension); Kiracofe v. Reid Mem’l Hosp., 461 N.E.2d 1134, 1140-41 (Ind. Ct. App.

1984) (“The decision of a hospital concerning staff privileges is accorded great deference

and judicial intervention is limited to an assessment of whether the procedures employed


                                              
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by the hospital are fair, whether the standards set by the hospital are reasonable, and

whether they have been applied without arbitrariness and capriciousness.”); Hurwitz, 103

A.3d at 296 (rejecting physician’s challenge to clinical privilege denial where physician

provided “no evidence, nor even a plausible indication, that defendants failed to comport

with [] norms of fairness and reasonableness”). In this case, the undisputed facts amply

demonstrate the existence of “substantial evidence” supporting the Hospital’s decision;

the hospital by-laws mandate attainment of board certification within five years of

employment—a requirement that Dr. Nguyen admits he failed to obtain.



              Unlike this Court, when faced with similar attempts to camouflage staff

appointment challenges with a litany of tort claims, other courts have wisely rejected

such transparent maneuvers. “Prevailing under [a tort] theory would require judicial

review of the merits of a hospital’s staffing decisions which is strictly prohibited.” Ralph

v. St. Anthony’s Med. Ctr., 470 S.W.3d 783, 787 (2015) (internal quotations and citation

omitted); see also Pamintuan, 192 F.3d 378 (upholding dismissal of state law

discrimination claims in view of immunity); Bender v. Suburban Hosp., Inc., 758 A.2d

1090 (Md. Ct. Spec. App. 2000) (requiring hospital’s decision to be supported by only

objective reasonableness despite claims of sex discrimination); Brinton, 973 P.2d 956

(maintaining limited and deferential judicial review while addressing physician’s claims

of bias).




                                               
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              The majority casually disregards Mahmoodian with a talismanic reference

to “public policy” without citing so much as a single case where a court has extinguished

a hospital’s immunity for privileges or staff appointments simply because the physician

alleged a common law or statutory retaliation or discrimination claim. In fact, the Fahlen

case cited by the majority expressly refused to resolve that precise issue:          “The

substantive effect of [the immunity provided by the] H[ealth] C[are] Q[uality]

I[mprovement] A[ct] on section 1278.5’s whistleblower protection for hospital staff

physicians was not raised below, was not included in defendants’ petition for review, and

is beyond the scope of the issue on which we granted review.” Fahlen v. Sutter Cent.

Valley Hosps., 318 P.3d 833, 852 (Cal. 2014).



             To be clear, I wholeheartedly support the patient safety goals which the

Patient Safety Act of 2001 is designed to foster. Without question, the safety of patients

and quality of care rendered by health care professionals is of critical importance to the

citizens of this state. In fact, it is the paramount importance of those goals that compeIs

this dissent. In reaching its conclusion, the majority implicitly finds that the immunity

provided to hospitals for privileges and staff appointments is at odds with those goals and

must therefore give way. As expressly recognized by the majority of states having such

immunity, limited judicial review of such decisions exists such as to “vest[] [hospitals]

with wide managerial discretion, to be used to elevate hospital standards and to better

medical care.” Hurwitz, 103 A.3d at 296 (emphasis added). As such, both the Patient

Safety Act and Mahmoodian share a common, critically important goal: patient safety
                                              
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and quality assurance. By blithely dismissing the latter in favor of the former under the

dubious facts of this case and without fully considering the effect such holding may have

on these goals, the majority has seriously jeopardized patient safety. Sadly, the majority

does so for the negligible purpose of allowing a lone physician, who indisputably failed

to comply with the hospital by-laws, to leverage the hospital with a separation-induced

financial dispute. Accordingly, I respectfully dissent.



 

        

 




                                               
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