Christhilf v. Annapolis Emergency Hospital Ass'n, Inc.

• Decision Date: 23 April 1974
• Docket Number: No. 73-1717.,73-1717.
• Citation: 496 F.2d 174
• Parties: Stuart M. CHRISTHILF, Jr., M.D., Appellant, v. The ANNAPOLIS EMERGENCY HOSPITAL ASSOCIATION, INC., et al., Appellees.
• Court: U.S. Court of Appeals — Fourth Circuit

496 F.2d 174 (1974)

Stuart M. CHRISTHILF, Jr., M.D., Appellant, v. The ANNAPOLIS EMERGENCY HOSPITAL ASSOCIATION, INC., et al., Appellees.

No. 73-1717.

United States Court of Appeals, Fourth Circuit.

Argued December 4, 1973.

Decided April 23, 1974.

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Norman R. Lilly, Annapolis, Md. (Merrill & Lilly, P. A., Annapolis, Md., on brief), for appellant.

John F. King, Baltimore, Md. (Frank C. Serio, Annapolis, Md., and Anderson, Coe & King, Baltimore, Md., on brief), for appellees.

Before BOREMAN, Senior Circuit Judge, and BUTZNER and FIELD, Circuit Judges.

BUTZNER, Circuit Judge:

Stuart M. Christhilf, Jr., a physician, appeals from an order of the district court denying his application for an injunction to restrain The Annapolis Emergency Hospital Association from interfering with the staff privileges previously extended to him by the Anne Arundel General Hospital, Annapolis, Maryland. Because we believe that Dr. Christhilf was denied procedural due process and that he had not waived this right, we reverse.

The Hospital Association, a nonprofit corporation governed by a board of managers, operates the Anne Arundel General Hospital. Though the hospital is a voluntary private institution, it has received funds for capital expenditures from Anne Arundel County and from the Hill-Burton program.

Dr. Christhilf has practiced his profession in Anne Arundel County, Maryland, since 1949. A past president of the Obstetrical and Gynecological Society of Maryland, he is board certified in obstetrics and gynecology but not in female urology. For many years, Dr. Christhilf had essentially unlimited privileges at the hospital in obstetrics, gynecology, and female urology. He was a member of the hospital's medical staff and served as chief of obstetrics from 1954 to 1956.

In an effort to upgrade its services, the hospital ruled that beginning January 1971 it would limit the urology privileges of doctors who were not board certified or eligible for certification in that specialty. Dr. Christhilf protested the change when it was announced, but to no avail. Under the new restrictions, doctors with limited urology privileges were permitted to continue to perform certain operative procedures, but they were specifically prohibited from undertaking others including retrograde pyelograms.

Dr. Christhilf's present difficulties arose when it came to the attention of the hospital's medical board that he had performed at least one unauthorized retrograde pyelogram after the rule limiting urology privileges had become effective. Dr. Christhilf appeared before the medical board in October 1971 and spoke in his own defense, claiming that the retrograde pyelogram, which he admitted performing, was done as a gynecological procedure and was, therefore, justifiable. The board, however, deemed that he had violated its rule, and after considering a summary of his past infractions of the rules and regulations of the hospital, it voted 10 to 4 not to renew his hospital privileges. The matter was then laid before the medical staff, which after hearing Dr. Christhilf, voted 38 to 28, with 5 abstentions, against renewing his privileges. The joint conference committee, meeting without Dr. Christhilf, accepted the staff's recommendation and transmitted it to the board of managers. The board, acting on the recommendation, but without affording Dr. Christhilf an opportunity to be heard, refused to renew his privileges at the hospital.

Dr. Christhilf then brought this action, seeking damages and an injunction requiring the board to reinstate him. The parties stipulated that the bylaws of the hospital provide that the board of managers has the sole and exclusive authority to grant or deny hospital privileges to physicians and that Dr. Christhilf had not been heard by the board. The district court, ruling that the doctor was entitled to be heard, granted an interlocutory injunction restraining the board from terminating his privileges until it afforded him a hearing.

The hospital president then wrote Dr. Christhilf a letter notifying him that he would have an opportunity to appear before the board for a hearing at which the board would decide what action to take with respect to his hospital privileges. The letter purportedly charged the following infractions of hospital rules and regulations:

· The performance of a retrograde pyelogram on October 1, 1971;

· Performance of one other urological retrograde procedure on an unspecified date;

· Failure to afford prompt attention to a patient on October 4, 1971;

· Thirty-two incidents occurring on specified dates between August 1957 and August 1971;¹

· Failure to properly care for a patient in December 1971.

Referring to the board's previous refusal to renew Dr. Christhilf's privileges, the letter stated that this action was not the result of any single violation "but rather was the result of your general pattern of behavior." The letter concluded by stating that each member of the board of managers had a copy and "will consider the information stated herein in its deliberations to determine whether or not your privileges should be renewed."

Correspondence between the attorneys for the parties and colloquy at the subsequent hearing before the board disclosed fundamental disagreements about the interpretation of the charges contained in the hospital's letter, the scope of the board's inquiry, and the comprehensiveness of the doctor's defense. Dr. Christhilf's attorney was denied discovery of additional documents in the hospital's possession, including those concerning the 32 incidents spanning the years from 1957 to 1971. The hospital's attorney took the position that the charges pertained only to the performance of a retrograde pyelogram in violation of the hospital's new rule. He stated that no further discovery was necessary with respect to the other infractions of the rules because they were before the board only as "historical background." Referring to the list of the 32 incidents, he emphasized, "This board isn't going to go back into those cases and determine whether or not they were proper or improper." Dr. Christhilf, he explained, could admit or deny that these charges had been the subject of former disciplinary proceedings, but in no event would the merits of the 32 allegations of wrongdoing be considered by the board.

On the other hand, Dr. Christhilf's attorney insisted that he had a right to contest the merits of these 32 charges since the board had never previously ruled whether they were well founded. To properly contest them, he asserted that he needed other documentary material the hospital was withholding. When it became apparent that this impasse could not be resolved, he advised Dr. Christhilf to withdraw from the hearing. Concerned that the preliminary injunction previously granted would expire at the conclusion of the hearing, he and the doctor then returned to the district court. There they obtained an ex parte temporary restraining order enjoining the hospital from terminating the doctor's privileges until the court could determine whether he had been denied due process of law at the board's hearing.

In the meantime, the board continued with the hearing after Dr. Christhilf and his attorney withdrew. The board heard three witnesses and then went into executive session where it voted to terminate Dr. Christhilf's privileges.

Subsequently, the court vacated the temporary restraining order and denied further injunctive relief. It held that Dr. Christhilf had failed to exercise self-help in obtaining documents which were available to him as a member of the hospital staff and that by leaving the meeting he waived his right to the specific procedural protections which the court had previously afforded him.

II

The district court properly held that the involvement of the federal and state governments through the Hill-Burton Program and the Anne Arundel County grant sufficiently implicated the state in the affairs of this otherwise private institution to subject the hospital to the restrictions which the fourteenth amendment places upon state action. Cf. Sams v. Ohio Valley General Hospital Ass'n, 413 F.2d 826 (4th Cir. 1969); Simkins v. Moses H. Cone Memorial Hospital, 323 F.2d 959 (4th Cir. 1963) cert. denied, 376 U.S. 938, 84 S.Ct. 793, 11 L.Ed.2d 659 (1964). The district court also correctly held that Dr. Christhilf's hospital privileges could not be terminated without affording him procedural due process. It premised this ruling on the finding that a denial of privileges might effectively foreclose Dr. Christhilf's practicing in the area because of the harm to his professional reputation and because of the lack of other facilities comparable to those of the hospital within 20 miles of Annapolis. Consequently, the court properly ruled that Dr. Christhilf's complaint stated a cause of action against the hospital under 42 U.S.C. § 1983. Jurisdiction, therefore, aptly rested on 28 U.S. C. § 1343(3); Suarez v. Weaver, 484 F. 2d 678 (7th Cir. 1973); Meredith v. Allen County War Memorial Hospital Com'n., 397 F.2d 33 (6th Cir. 1968); Birnbaum v. Trussell, 371 F.2d 672 (2d Cir. 1966).

While the parties have devoted a great deal of their argument to the dispute over the extent of discovery to which Dr. Christhilf was entitled, we believe that this question is only symptomatic of the basic issue. The fundamental question is whether the board denied Dr. Christhilf due process by ruling through its attorney that although it would consider the 32 infractions of the rules, "it would not go back into those cases and determine whether or not they were proper or improper." The 32 incidents are of crucial importance because, as the president explained in the letter notifying the doctor of the hearing, the board's earlier decision to refuse renewal of his privileges was not based on any single...