190 F.3d 905 (8th Cir. 1999), 98-274298-2743, Sugarbaker v. SSM Health Care

Docket Nº:98-274298-2743
Citation:190 F.3d 905
Party Name:Sugarbaker v. SSM Health Care
Case Date:August 19, 1999
Court:United States Courts of Appeals, Court of Appeals for the Eighth Circuit

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190 F.3d 905 (8th Cir. 1999)

Stephen P. Sugarbaker, M.D.,Appellant/Cross-Appellee,


SSM Health Care, d/b/a St. Marys Health Center,Cross-Appellant/Appellee.

Nos. 98-2742,98-2743

United States Court of Appeals, Eighth Circuit

August 19, 1999

Submitted: April 19, 1999

Appeals from the United States District Court for theWestern District of Missouri.

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[Copyrighted Material Omitted]

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[Copyrighted Material Omitted]

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Before BEAM and HANSEN, Circuit Judges, and KOPF,1 District Judge.

HANSEN, Circuit Judge.

St. Marys Health Center (St. Marys) restricted and then terminated the staff privileges of Dr. Stephen P. Sugarbaker. In response, Dr. Sugarbaker filed suit alleging that St. Marys' actions violated federal antitrust laws, as well as various Missouri state laws. The district court 2 granted summary judgment in favor of St. Marys on the basis of immunity under the Health Care Quality Improvement Act of 1986 (HCQIA). See 42 U.S.C. §§ 11111(a)(1), 11112(a) (1994). Dr. Sugarbaker appeals, and we affirm. Because we affirm the district court's judgment regarding immunity under the HCQIA, we do not reach St. Marys' cross-appeal challenging the district court's denial of St. Marys' motions to dismiss Dr. Sugarbaker's suit.

I. Background

Dr. Stephen Sugarbaker is a general surgeon who practiced in Jefferson City, Missouri. SSM Health Care (SSM) owns and operates St. Marys Health Center in Jefferson City. In 1994, Dr. Sugarbaker obtained provisional medical staff privileges at St. Marys. St. Marys suspended Dr. Sugarbaker's privileges in 1995, and it eventually terminated his privileges in 1997. Dr. Sugarbaker contends that he was the victim of a conspiracy to control the market for medical services in the Jefferson City area. Specifically, Dr. Sugarbaker contends that because he refused to join the Jefferson City Medical Group (JCMG), members of that group conspired with persons at St. Marys to terminate Dr. Sugarbaker's medical staff privileges.

The dispute between Dr. Sugarbaker and St. Marys began in early 1995. At that time, Mike Wilfawn, St. Marys' Department Manager for Surgical Services, and Gay Cunningham, the Vice President of Patient Services, notified Dr. John Koonce, the Surgery Department Chairman, of staff concerns regarding Dr. Sugarbaker. Dr. Koonce forwarded the concerns to St. Marys' Medical Executive Committee (Executive Committee) and requested a full review of Dr. Sugarbaker's cases. The Executive Committee is responsible for providing recommendations to the SSM Board of Directors regarding medical staff privileges. On May 1, 1995, St. Marys informed Dr. Sugarbaker. of its concerns. Dr. Sugarbaker agreed to a full retrospective review and concurrent monitoring of his cases.

On June 19, 1995, after four surgeons had reviewed some 24 of Dr. Sugarbaker's cases, St. Marys' Surgery Review Committee met to discuss Dr. Sugarbaker's situation. The reviewing surgeons found evidence of the following: (1) delay in initiating an operation; (2) excessive surgery times in some cases; (3) excessive blood loss; (4) questionable use of antibiotics; and (5) excessive tissue removal in breast biopsies. In view of these health care quality concerns, the Surgery Review Committee recommended a precautionary summary suspension of Dr. Sugarbaker's clinical privileges. After Dr. Sugarbaker

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refused to request a voluntary leave of absence, the Executive Committee imposed the precautionary suspension, and on August 3, 1995, the Executive Committee voted to continue the precautionary suspension. On August 7, St. Marys provided Dr. Sugarbaker with a detailed listing of the Surgery Review Committee's case review findings. St. Marys also informed Dr. Sugarbaker of his right to request a hearing.

Dr. Sugarbaker requested a hearing, and the Executive Committee appointed an Ad Hoc Committee of independent physicians, including two general surgeons, to review the Executive Committee's concerns. The Ad Hoc Committee held a hearing on November 6, 1995, and permitted Dr. Sugarbaker to present evidence and expert testimony, and to cross-examine the Executive Committee's representative. Thereafter, the Ad Hoc Committee unanimously voted to remove the precautionary suspension due to a lack of information. The Ad Hoc Committee indicated that it had only received information concerning the procedures followed, not the factual basis for the conclusions reached by the Surgery Department.

Notwithstanding the Ad Hoc Committee's recommendation to remove the suspension due to a lack of information, the Executive Committee determined that four areas of concern remained, and it decided to send these issues back to an Ad Hoc. Committee for further consideration. Dr. Sugarbaker, however, requested that the additional hearing be directly before the Executive Committee, rather than before an Ad Hoc Committee.3 On January 24, 1996, the Executive Committee held a six-hour fact-finding hearing. Dr. Sugarbaker was again permitted to present evidence on his own behalf, to respond to questions, and to cross-examine adverse witnesses. After this hearing, the Executive Committee voted to permanently terminate Dr. Sugarbaker's privileges. In a letter dated February 1, 1996, St. Marys notified Dr. Sugarbaker of the Executive Committee's decision. The letter stated that the Executive Committee based its decision on Dr. Sugarbaker's "lack of clinical judgment, technical ability, and ethical perspective in performance of clinical privileges." (J.A. at 760.) The letter also informed Dr. Sugarbaker of his right to an appeal and enclosed copies of the relevant sections of the Medical Staff Bylaws.

Dr. Sugarbaker appealed the Executive Committee's decision. The SSM Board appointed an Appellate Review Committee comprised of two SSM Board members and one SSM administrator. According to the Medical Staff Bylaws, the Appellate Review Committee reviews "the hearing record and any statements submitted . . . to determine whether the adverse Recommendation or decision was justified and was not arbitrary or capricious." (Id. at 240.) Contrary to the Executive Committee's views, the Appellate Review Committee recommended that Dr. Sugarbaker be provisionally reinstated for one year, that Dr. Sugarbaker be prohibited from performing emergency/trauma surgery, that he be supervised during certain types of surgery, and that all of his cases be subject to review and monitoring. (See id. at 982-83.) The Appellate Review Committee also found that "the Executive Committee did not act in an arbitrary or capricious manner," and that there was no "conspiracy" to oust Dr. Sugarbaker. (Id. at 984.) The Appellate Review Committee expressed a concern that the Executive Committee had not sufficiently articulated what it believed to be the standard of care in each case, but it concluded that the

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Executive Committee had "identified some very clear deficiencies on Dr. Sugarbaker's part," and that "sufficient evidence exists to raise concerns about Dr. Sugarbaker's practice." (Id. at 984-85.)

The Appellate Review Committee enumerated four specific deficiencies with regard to Dr. Sugarbaker's practice. First, the committee expressed concern for the amount of time Dr. Sugarbaker required to perform laparoscopic cholecystectomies.4 The committee noted that despite Dr. Sugarbaker's inexperience in performing such operations independently, he failed to request assistance in the performance of these procedures. The Appellate Review Committee's second concern related to a neck trauma case in which the patient experienced an airway obstruction. The committee concluded that irrespective of the various possible reasons why the patient experienced the obstruction, "Dr. Sugarbaker's delay in securing the patient's airway, and, by the accounts of all witnesses present, the further delay in responding to a life and death crisis, exhibits an inability to respond appropriately in crisis situations." (J.A. at 985.) Third, the Appellate Review Committee noted that it was "unconvinced by Dr. Sugarbaker's varying explanations as to why [a patient] experienced [a] mid-procedure crisis and why Dr. Sugarbaker failed to document the event." (Id.) Finally, the committee expressed concerns for Dr. Sugarbaker's apparent lack of "self-awareness." (Id.) According to the Appellate Review Committee:

[Dr. Sugarbaker's] lack of self-awareness precludes him from being self-critical about his surgical skills, which interferes with his abilities to improve in certain areas, seek appropriate assistance, or decline to perform some procedures or in some contexts, such as trauma. This perceived lack of self-awareness is consistent with the Executive Committee's concerns about Dr. Sugarbaker's judgement [sic].


In view of the Appellate Review Committee's decision to provisionally reinstate Dr. Sugarbaker for one year, the SSM Board voted to modify in part, and to reverse in part, the Executive Committee's recommendation to permanently suspend Dr. Sugarbaker's privileges. According to the Bylaws, when the Board's decision is contrary to the Executive Committee's recommendation, the Executive Committee may request a Joint Conference Committee to review the matter. The Joint Conference Committee is comprised of three members of the SSM Board and three members of the Executive Committee. In this case, the Joint Conference Committee essentially followed the Appellate Review Committee's decision and recommended that Dr. Sugarbaker be reappointed to the provisional staff for one year, subject to a host of substantial restrictions and conditions. The SSM Board followed the recommendations of the Appellate Review Committee and the Joint Conference Committee. Dr. Sugarbaker was eventually terminated for failing...

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