Oksanen v. Page Memorial Hosp.

• Decision Date: 12 September 1991
• Docket Number: No. 89-1768,89-1768
• Citation: 945 F.2d 696
• Parties: , 1991-2 Trade Cases P 69,562 Owen D. OKSANEN, M.D., Plaintiff-Appellant, v. PAGE MEMORIAL HOSPITAL; J.R. Holsinger, M.D.; Romulo Ancheta, M.D.; Fang S. Horng, M.D.; James G. Dale, M.D., Defendants-Appellees, American Hospital Association; The Virginia Hospital Association, Amici Curiae.
• Court: U.S. Court of Appeals — Fourth Circuit

Page 696

945 F.2d 696

60 USLW 2207, 1991-2 Trade Cases P 69,562

Owen D. OKSANEN, M.D., Plaintiff-Appellant, v. PAGE MEMORIAL HOSPITAL; J.R. Holsinger, M.D.; Romulo Ancheta, M.D.; Fang S. Horng, M.D.; James G Dale, M.D., Defendants-Appellees American Hospital Association; The Virginia Hospital Association, Amici Curiae.

No. 89-1768.

United States Court of Appeals Fourth Circuit.

Argued Feb. 5, 1991.

Decided Sept. 4, 1991.

As Amended Sept. 12, 1991.

Edward B. Lowry, Michie, Hamlett, Lowry, Rasmussen & Tweel, P.C., Charlottesville, Va., argued (Robert W. Jackson, Charlottesville, Va., Sheldon Braiterman, Baltimore, Md., on brief), for plaintiff-appellant.

Judith Bowles Henry, Crews & Hancock, Richmond, Va., argued (Lynn Fleming, Karen L. Gould, Richmond, Va., for defendant-appellee Dale; Stephen L. Altman, Vicki J. Hunt, Montedonico & Mason, Fairfax, Va., for defendant-appellee Horng; Norman F. Slenker, Slenker, Brandt, Jennings & Johnston, Fairfax, Va., Edward M. Burns, II, Poindexter, Burns & Marks, Waynesboro, Va., for defendant-appellee Holsinger; Phillip C. Stone, Gregory T. St. Ours, Wharton, Aldhizer & Weaver, Harrisonburg, Va., for defendant-appellee Page Memorial Hosp.; Mary S. Meade, Meade & Associates, P.C., Vienna, Va., for defendant-appellee Ancheta, on brief), for defendants-appellees.

Frederic J. Entine, Jeffrey M. Teske, Tracey L. Fletcher, American Hosp. Ass'n, Chicago, Ill., Heman A. Marshall, III, Woods, Rogers & Hazlegrove, Roanoke, Va., for amicus curiae American Hosp. Ass'n.

John J. Miles, Phillip A. Proger, Jones, Day, Reavis & Pogue, Washington, D.C., for amicus curiae Virginia Hosp. Ass'n.

Before ERVIN, Chief Judge, RUSSELL, WIDENER, HALL, PHILLIPS, MURNAGHAN, SPROUSE, WILKINSON, WILKINS, and NIEMEYER, Circuit Judges, and BUTZNER, Senior Circuit Judge, sitting in banc.

OPINION

WILKINSON, Circuit Judge:

Appellant Dr. Owen D. Oksanen contends that the Sherman Antitrust Act was violated when the medical staff of Page Memorial Hospital allegedly conspired amongst itself and with the hospital's Board of Trustees to revoke Oksanen's staff privileges. Whether such conspiracies are cognizable under federal antitrust law has significant implications for the nation's health care system because the peer review process that Oksanen challenges has become an important element of hospital governance.

In our view, the Board of Trustees and the medical staff of Page Memorial comprised a single entity during the peer review process. Because an entity cannot conspire with itself, the Board and the staff lacked the capacity to conspire. See Copperweld Corp. v. Independence Tube Corp., 467 U.S. 752, 104 S.Ct. 2731, 81 L.Ed.2d 628 (1984). While the members of a medical staff may have the capacity to conspire among themselves, such a conspiracy did not occur in this case. We likewise affirm the district court's dismissal of Oksanen's other claims and its refusal to cloak in federal antitrust law what is in essence a workplace dispute.

I.

Upon completing a residency program in 1978, Dr. Owen D. Oksanen began practicing family medicine in Luray, Virginia. Luray is located in Page County, a county of approximately 18,000 residents. In 1979, Oksanen received full medical staff privileges at the sole hospital in Page County, the fifty-four bed Page Memorial Hospital.

This hospital, like many others, has an organizational structure with three components. First, the Board of Trustees operates as the hospital's governing body with final decisionmaking authority on issues affecting the hospital. Second, day to day management of the hospital is vested in a hospital administrator. In this case, John S. Berry was the administrator responsible for supervising the hospital's staff of nurses, laboratory personnel, and other providers of services. Third, the physicians at the hospital are organized as a medical staff. Dr. Oksanen became a member of the staff by virtue of being granted staff privileges. Other members of the medical staff included Dr. Ancheta who primarily practiced general surgery, Dr. Horng who was also a surgeon, Dr. Holsinger a family practitioner, and Dr. Dale who was admitted to the staff in August of 1983 and practiced as an internist.

Page Memorial itself does not directly employ the physicians on the medical staff, but rather provides a facility for physicians to treat those of their patients who need hospital care. The hospital encourages physicians to seek staff privileges by providing staff members with office space and allowances for expenses. As part of the medical staff's relationship with the hospital, it engages in a process known as peer review. During peer review, the members of the medical staff make recommendations to the Board on whether physicians meet the standards for practicing medicine at the hospital in the first instance and on whether a physician will be able to continue practicing once he or she has been accorded staff privileges.

Almost immediately after the medical staff granted privileges to Oksanen the complaints about his conduct began. For example, in October 1979, administrator Berry wrote to Oksanen questioning his attitude toward the use of laboratory facilities and the treatment of laboratory personnel. The chronicle of complaints pertaining to Oksanen's abusive attitude mounted over time. Oksanen reportedly addressed or referred to hospital employees and third party professional reviewers with profanity. In another incident, this time in the emergency room, he termed the mother of a young patient a "red neck from Stanley." Many of Oksanen's outbursts were made publicly and disrupted hospital operations. One nurse who worked with him commented that he "has a volatile personality and you just don't know when it's going to erupt."

Oksanen contends that the friction which developed at the hospital could not be attributed to him alone. He responds that his actions simply reflected his concern with the quality of patient care at the hospital. For instance, he states that he questioned whether Drs. Horng and Ancheta recognized the appropriate limitations on their surgical abilities. As a result, he began referring his patients to other hospitals where he contended they would receive a better quality of care. Oksanen also claims that his poor relationship with Dr. Holsinger stemmed from his earlier refusal to accept a position in Dr. Holsinger's office.

Unfortunately, relations between Oksanen and other members of the hospital and medical staffs only worsened over time. In May of 1983, Oksanen publicly reprimanded a nurse and her supervisor for allegedly providing poor care to his patients. When the nurses attempted to respond, Oksanen refused to discuss the matter, threw down his charts, and left the area. Oksanen's actions spurred hospital administrator Berry to request that the medical staff, in accordance with Medical Staff Bylaws, investigate the incident. The medical staff declined, however, to take disciplinary action against Oksanen.

Oksanen's involvement in another incident, however, did motivate the hospital to take action against him. In response to a letter to all physicians from the President of the Board seeking a harmonious working environment, Oksanen wrote the Board that its letter was "demeaning [and] insulting." Oksanen further indicated that he would not cooperate with the Board's efforts unless the Board retracted its letter and a Trustee personally retrieved the letter from his office. The Board of Trustees discussed Oksanen's response at its July 12, 1983 meeting. Dr. Holsinger, the only physician who also served on the Board was absent from the meeting. Dr. Ancheta and administrator Berry both told the Board that they believed disciplinary actions against Oksanen were appropriate. The Board voted unanimously to request that the medical staff take corrective action against Oksanen. The Board, based on the staff's earlier refusal to take action against Oksanen, warned that if action was not taken against Oksanen, it would be forced to evaluate more thoroughly his hospital privileges during the annual credentialing process.

In response, the medical staff voted to revoke Oksanen's staff privileges. Oksanen then appealed this decision to a joint conference committee comprised of Dr. Ancheta and two members of the Board. This committee heard testimony from sixteen witnesses, including Oksanen. Some witnesses testified to Oksanen's competence, while other witnesses testified to the corrosive impact of Oksanen's behavior on staff morale and relations. For instance, the committee heard testimony that Dr. Oksanen initially rebuffed a suggestion by administrator Berry that they meet to discuss a concern about patient care raised by Oksanen. Then one night around 10:30 p.m. Oksanen called Berry at home demanding that they meet later that night to discuss the concern and stating that he would call back every twenty minutes until a meeting was arranged. Eventually Oksanen agreed to meet with Berry, two nursing supervisors, and the Chief of Staff the next morning at the hospital, but Oksanen failed to appear for the meeting even though he apparently was in the hospital and had been paged. After considering the body of evidence relating to Oksanen, the joint conference committee recommended to the Board that, at a minimum, his privileges be suspended.

The Board then in October of 1983 held a meeting at which Oksanen and his attorney argued against the committee's recommendation. The Board voted 9-2, with Dr. Holsinger abstaining, to suspend Oksanen's privileges for a two-month period, to be followed by a grant of privileges on a one-year probationary basis. The Board also stated that members of the medical and hospital staffs would be expected to cooperate with Oksanen during his probationary period.

Around the time of the suspension, public interest in Oksanen's relationship with the hospital began to increase, stimulated in part by...