Wyoming Association of Medical Staff Services
Mock "Peer Review" Hearing
Fact Pattern
I. Consulting MD and PCP are co-managing a patient's medical condition.
Consulting MD and Primary Care Physician (PCP) are both medical staff members at
hospital, and are managing a patient's course of treatment on an outpatient basis. The patient
was previously an inpatient of the Hospital for the condition, with PCP as the admitting
physician. PCP asked Consulting MD to consult on the patient during the inpatient admission.
The patient was discharged, and PCP is now following the patient in her office. Consulting MD
sees the patient in the hospital's outpatient specialty department on a periodic basis to make
sure a specific aspect of patient's condition does not worsen.
II. Consulting MD writes a comment in the patient's medical record that is highly critical
of PCP's treatment of patient.
After one periodic visit to the outpatient specialty department, the Consulting MD writes
a comment in the patient's medical record that is highly critical of the PCP's treatment of the
specific aspect of the condition for which Consulting MD is seeing the patient, but also of PCP's
overall treatment of the patient's condition. The Consulting MD's comment is that primary care
physician's treatment of this patient has been inadequate because of A, B, C, and that patient's
prognosis would be better if the primary care physician had done a better job by doing X, Y, Z.
Consulting MD's language in not specifically insulting, but is patronizing (Consulting MD states
that "perhaps they treated this condition like that at Eastern Walla Walla State University
Medical School, where resources were more scarce, but in Wyoming, we use more
sophisticated methods of treatment.") and highly critical of PCP's treatment. PCP brings the
comment to the Medical Executive Committee's attention and claims it violates the Code of
Conduct.
III.
The MEC conducts an investigation into the incident.
MEC conducts an investigation, finds that the Consulting MD wrote the comment in the
medical record. MEC finds that comment is similar to previous comment by Consulting MD
regarding another primary care physician's treatment of a patient with a similar problem. Chief
of Staff had previously counseled Consulting MD that comments like these were
inappropriate. Consulting MD disagreed at that time the comment was inappropriate, because
it did not use insulting language, though it was critical of the PCP.
MEC interviews PCP, who is angry that his choice of care has been criticized, and
specifically in the medical record where other people (including the patient) can see it. PCP's
medical malpractice insurance co., in a random chart audit, came across the comment, and
have informed him that they intend to raise his malpractice insurance premiums. The
malpractice insurance co. has not specified that Consulting MD's criticism was the reason, and
has cited "market conditions". But PCP believes it is directly related to the comments by
Conslting MD.
MEC interviews Consulting MD. Consulting MD disagrees that the comments were
inappropriate, because they were (A) accurate, and (B) intended to improve the PCP's quality of
care by pointing out how he could treat the patient better. The Consulting MD also states that
he believes the patient is entitled to know that his care could be better, and that any subsequent
physician's treating the patient are entitled to know that another, better treatment option was
available. Finally, Consulting MD states that he has tried to raise these issues with PCP inperson, but PCP (who has a very heavy practice load since she is the only MD in town that
treats Medicaid, low-income, and indigent patients) has never had time to meet with him.
MEC consults a third-party expert, who states that Consulting MD's criticism is valid, to
the extent that the course of treatment recommended by Consulting MD would lead likely to a
better result. However, the third-party expert also states that PCP's course of treatment is not
below the standard of care, and that it may be more effective with patients that cannot be
counted on to be compliant with the course of treatment Consulting MD recommended.
IV.
MEC finds that Consulting MD has violated the Code of Conduct.
MEC finds that Consulting MD has violated the Code of Conduct by writing the critical
comments about PCP and the treatment recommended in the patient's medical
record. Particularly, the MEC finds that the Consulting MD's comments were not the
appropriate place to record criticism of another medical staff member's care. The MEC has
recently been trying to reverse a trend of poor intra-medical staff relations, and wants to make a
point in dealing with Consultiong MD. The MEC therefore finds that the repeated instances of
this conduct, even after informal counseling, are cause to suspend Consulting MD's medical
staff membership and clinical privileges for 31 days, and makes that recommendation to the
Hospital's governing body.
[The Bylaws state that the physician must be provided with notice of the recommendation, which
must state specifically the grounds for the hearing]
MEC provides Consulting MD with notice of the recommendation, and provides him with
notice of his right to request a hearing within 30 days of the notice of the recommendation. The
notice of the MEC's recommendation simply states that the MEC has found that it has found
that Consulting MD's conduct in writing the critical comments in the patient's medical record
violates the Code of Conduct. The recommendation does not state the specific parts of the
Code of Conduct violated, or why the conduct violates the Code of Conduct.
V.
The Consulting MD requests a hearing and the parties go through the pre-hearing
process.
The Consulting MD requests a hearing within 30 days. The MEC sets a hearing to be
held within 90 days of the request for hearing. Both parties conduct discovery. The MEC
provides a detailed notice of charges within 15 days of the hearing, as required by the Bylaws,
in which it specifies the sections of the Code of Conduct violated, and how the Consulting MD's
conduct violated the Code of Conduct. The Consulting Physician asks the hearing officer to
dismiss the case, on the basis that the notice of the recommendation was inadequate under the
Bylaws, since it did not state specifically what sections of the Code of Conduct the Consulting
MD's conduct violated, or how the Consulting MD's conduct violated the Code of Conduct. The
Consulting MD claims that he could not effectively conduct discovery to defend himself at the
hearing because he didn't know until 2 weeks before the hearing why his conduct was alleged
to have violated the Code of Conduct. Consulting MD claims that his due process rights have
therefore been violated, and that proceeding with the hearing would also violate the Health Care
Quality Improvement Act. The hearing officer says that since the motion comes this late in the
process, she will have to hear the parties arguments on the motion to dismiss at the beginning
of the hearing.
VI.
The Hearing.
Consulting MD, the judicial review panel, the witnesses, the MEC's representative,
counsel for the Consutling MD and the MEC, and the hearing officer are present. The hearing
officer convenes the hearing, which begins with the hearing on Consulting MD's motion to
dismiss. The hearing officer states that if Consulting MD's motion is denied, the hearing will
proceed immediately afterward. The hearing will begin with any challenges to the judicial review
panel members (on the basis of bias or conflict of interest), any challenges to the hearing officer
(on the basis of bias or conflict of interest), opening statements by the MEC, then the Consulting
MD. The MEC will then put on its case, and the Consulting MD will put on his case. Each side
will get to make a 5 minute closing argument, and the judicial review committee will deliberate
for 10 minutes, then announce its decision (which will be followed by a written decision).