Silverstein v. Gwinnett Hosp. Authority

• Decision Date: 27 December 1988
• Docket Number: No. 87-8926,87-8926
• Citation: 861 F.2d 1560
• Parties: Gary M. SILVERSTEIN, D.O., David J. Conaway, D.O., and Richard L. Lieberman, D.O., Plaintiffs-Appellants, v. GWINNETT HOSPITAL AUTHORITY, Medical Staff of the Gwinnett Hospital System, Worth L. Thompson, Richard Sikes, Jeanine Gullett, Linda Burdine Price, Elwyn D. Carswell, Roy B. Payne, Sr., Ken O. Logue, B. Doug Etheridge and Lillian Webb, Defendants-Appellees.
• Court: U.S. Court of Appeals — Eleventh Circuit

Page 1560

861 F.2d 1560

Gary M. SILVERSTEIN, D.O., David J. Conaway, D.O., and Richard L. Lieberman, D.O., Plaintiffs-Appellants, v. GWINNETT HOSPITAL AUTHORITY, Medical Staff of the Gwinnett Hospital System, Worth L. Thompson, Richard Sikes, Jeanine Gullett, Linda Burdine Price, Elwyn D. Carswell, Roy B Payne, Sr., Ken O. Logue, B. Doug Etheridge and Lillian Webb, Defendants-Appellees.

No. 87-8926.

United States Court of Appeals Eleventh Circuit.

Dec. 27, 1988.

Matthew J. Mitten, Kilpatrick & Cody, Susan A. Cahoon, Atlanta, Ga., for plaintiffs-appellants.

James N. Gorsline, King & Spalding, Michael Eric Ross, J.M. Hudgins, IV, Sidney F. Wheeler, Long, Weinberg, Ansley & Wheeler, Atlanta, Ga., for defendants-appellees.

Appeal from the United States District Court for the Northern District of Georgia.

Before TJOFLAT and FAY, Circuit Judges, and SHARP ^*, District Judge.

SHARP, District Judge:

This case challenges the constitutionality of the Hospital Authority of Gwinnett County, Georgia (GHA) bylaw provision, which requires specific postgraduate specialty training or residency in order for physicians to be eligible for admission to the Medical Staff of the Gwinnett Hospital System (Medical Staff). Plaintiffs-appellants, doctors of osteopathy (D.O.s) as opposed to allopathic physicians (M.D.s), do not meet the postgraduate training requirements of the subject bylaw. These osteopaths contend that their inability to be admitted to the Medical Staff, despite comparable osteopathic postgraduate training, violates equal protection and due process under the United States and Georgia Constitutions as well as a Georgia statute prohibiting discrimination in the review of applications for public hospital staff privileges.

On cross motions for summary judgment, the district court granted the motion of defendants-appellees and denied the motion of plaintiffs-appellants. Silverstein v. Gwinnett Hospital Authority, 672 F.Supp. 1444 (N.D.Ga.1987). The district court determined that the bylaw provision in question was rationally related to the legitimate government interest of quality health care because of the differences in the postgraduate specialty training of osteopaths and allopaths. The bylaws, therefore, were held valid under the equal protection and due process clauses of the Fourteenth Amendment and the Georgia Constitution. The district court also concluded that the Georgia antidiscrimination statute, regarding review of public hospital staff applications, was not violated and that an apposite Georgia case was dispositive of this issue.

The pertinent facts are uncontroverted. Each appellant graduated from a four-year osteopathic medical school and completed specialized postgraduate training in a program accredited by the American Osteopathic Association (AOA). Appellants have been certified by the appropriate American Osteopathic Boards for their respective specialities. Dr. Silverstein is an ophthalmologist, Dr. Conaway is an orthopedic surgeon, and Dr. Lieberman is an otolaryngologist. Appellants are licensed to practice medicine in Georgia as D.O.s.

Appellee GHA is a public corporation created pursuant to Georgia Hospital Authorities Law. O.C.G.A. Secs. 31-7-70-96 (1985). The Medical Staff is an unincorporated association of physicians and dentists admitted to staff privileges in the Gwinnett Hospital System. The individual appellees are current or former GHA members, who approved and/or enforced the subject bylaw provision.

As adopted by GHA, the bylaw in question provides in relevant part the following qualifications for members of the Medical Staff:

Membership

Section 1. Basic Qualifications

Subsection 1. Effective March 24, 1981, applicants for membership on the Medical Staff shall be physicians or dentists licensed by the Composite State Board of Medical Examiners for the State of Georgia.

Subsection 2. Physicians shall have completed training requirements for certification by their respective American Specialty Board and shall have completed a post-graduate training program approved by the Accreditation Council for Graduate Medical Education (formerly known as Liaison Committee for Graduate Medical Education) ... This qualification does not apply to practitioners who have already been granted privileges as of the date of enactment (September 28, 1983).

Bylaws, Rules and Regulations of the Medical Staff of the Gwinnett Hospital System, art. III, Sec. 1. Appellants assert that Subsection 2 of this bylaw (hereinafter Subsection 2) discriminates against D.O.s as to Medical Staff privileges because the American Specialty Boards and the Accreditation Council for Graduate Medical Education (ACGME) are allopathic organizations. They argue that D.O.s are excluded categorically from the Medical Staff because their postgraduate specialty training and accreditation is by osteopathic organizations.

Generally, osteopathy assists the body's remedial capabilities by focusing on the interaction of the biological systems and stressing musculoskeletal manipulative therapy, while allopathy treats disease by producing effects incompatible with the condition to be alleviated. Appellants and appellees acknowledge the recognized differences in the philosophies and training of osteopathy and allopathy. Although Georgia licenses both D.O.s and M.D.s to practice medicine, the state distinguishes between the two medical educations, referencing them separately in the licensing statutes. O.C.G.A. Secs. 43-34-20(3), 43-34-26 (1984). No nonmilitary osteopathic postgraduate specialty program has sought review by ACGME, an accreditation body which establishes standards and evaluates allopathic postgraduate specialty programs in the United States. Consequently, ACGME has not had the opportunity to evaluate osteopathic postgraduate specialty programs such as those undertaken by appellants.

Individuals with basic osteopathic medical education, accredited by AOA, may obtain postgraduate training in ACGME-accredited programs and certification by an American Specialty Board. In contrast, graduates of allopathic medical schools, accredited by the American Medical Association (AMA), are ineligible to participate in AOA-accredited postgraduate programs or to be certified by an American Osteopathic Board. Significantly, four of the five D.O.s, who presently serve on the active Medical Staff, complied with Subsection 2 by completing ACGME-accredited postgraduate programs and receiving American Specialty Board certification, while one was admitted under the grandfather provision.

Appellants recognize that Subsection 2 was enacted in an effort to upgrade the standards of the Gwinnett Hospital System. Although they complain that the bylaw provision precludes them from admission to the Medical Staff, appellants are not restricted from the practice of their respective specialties in Georgia, and they have staff privileges in other hospitals in the proximate, metropolitan Atlanta area. Each appellant was denied admission to the Medical Staff because of his failure to meet the postgraduate specialty training criteria of Subsection 2. Thereafter, appellants exhausted their procedural appellate rights within the Gwinnett Hospital System. On appeal, appellants pursue their arguments that Subsection 2 violates equal protection and due process under the United States and Georgia Constitutions as well as their state statutory claim, regarding antidiscrimination in the review of medical staff applications in a public hospital.

Since there was no genuine issue as to material facts and a declaratory judgment as a matter of law was sought, the parties and the district court agreed that summary judgment was appropriate. Fed.R.Civ.P. 56(c). Corresponding to directed-verdict analysis, the district court should grant summary judgment if there is but one reasonable conclusion under the substantive law governing the case. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250-52, 106 S.Ct. 2505, 2511-12, 91 L.Ed.2d 202, 213-14 (1986); see Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 106 S.Ct. 2548, 2552-53, 91 L.Ed.2d 265, 273-74 (1986); Everett v. Napper, 833 F.2d 1507, 1510 (11th Cir.1987); Dominick v. Dixie National Life Insurance Co., 809 F.2d 1559, 1572 (11th Cir.1987). In its plenary review of a grant of summary judgment, the appellate court must apply the same legal standards used by the district court. Livernois v. Medical Disposables, Inc., 837 F.2d 1018, 1021-22 (11th Cir.1988); Carlin Communication, Inc. v. Southern Bell Telephone & Telegraph Co., 802 F.2d 1352, 1356 (11th Cir.1986). This court has concluded that the agreed facts as well as reasonable inferences drawn therefrom do not create a genuine issue of material fact warranting trial. See Augusta Iron & Steel Works, Inc. v. Employers Insurance of Wausau, 835 F.2d 855, 856 (11th Cir.1988) (per curiam); Carlin Communication, 802 F.2d at 1356; Warrior Tombigbee Transportation Co. v. M/V Nan Fung, 695 F.2d 1294, 1296-97 (11th Cir.1983). Therefore, the federal and state equal protection and due process arguments as well as the state statutory claim must be analyzed under the controlling substantive law in order to determine if the decision by the district court was correct as a matter of law. Everett, 833 F.2d at 1510; see Fed.R.Civ.P. 56(c).

I. Equal Protection

A. Fourteenth Amendment

The inception of equal protection analysis is the disparate treatment of similarly situated individuals by a governmental unit. Johnson v. Smith, 696 F.2d 1334, 1336 (11th Cir.1983); see New York City Transit Authority v. Beazer, 440 U.S. 568, 587-88, 99 S.Ct. 1355, 1367, 59 L.Ed.2d 587, 604 (1979). Absent the implication of a fundamental right or suspect classification, a local economic regulation is presumed constitutional under equal protection if it is rationally related to a legitimate state interest. City of New Orleans v. Dukes, 427 U.S. 297, 303, 96 S.Ct. 2513, 2516-17, 49 L.Ed.2d 511, 516-17 ...