Fired Surgeon Takes On Hospital’s Elite : Medicine: Dr. Mark Anderson claims in an antitrust lawsuit that St. Joseph of Orange abused its peer review process.

The first skirmish in the war between neurosurgeon Mark Anderson and orthopedic surgeon Brian Ewald broke out one day in the operating room at St. Joseph Hospital, where their patient lay with a broken neck.

Anderson says that as he tried to mend the damaged vertebrae with prosthetic wire, Ewald suddenly refused to continue the surgery and threatened to get him kicked off the staff at St. Joseph, one of Orange County’s premier medical facilities.

To his amazement, Anderson recalls, Ewald stood there for several minutes, accusing him of performing an orthopedic procedure without hospital approval.

“It seemed like forever,” Anderson said in a recent interview. “Dr. Ewald thought I was encroaching on his turf, which I wasn’t under our pre-surgery agreement. If he had concerns, it should have been worked out before the patient was on the table. A very emotional outburst like this during a surgical procedure is totally improper.”

The patient survived the operation and the argument. Anderson’s tenure at St. Joseph did not. Almost 1 1/2 years after the operating room tiff, Anderson says he and four other doctors in the neurosurgery department were subject to dismissal from the staff in a purge that has become known to neurosurgeons across the nation as the “Orange County Massacre.”

Anderson, 40, an aggressive and confident physician with an unblemished record, is now pursuing an antitrust lawsuit in Orange County Superior Court against the hospital and some of its top doctors, including Ewald.

He alleges that his economic competitors--St. Joseph’s orthopedic surgeons--and physicians with whom he has had professional differences abused the hospital’s care review process to remove him and gut the neurosurgery department for reasons other than maintaining the quality of care.

In that effort, he contends in his lawsuit, the hospital fabricated evidence, enlisted physicians who were not neurosurgeons or had conflicts of interest with him to decide his fate, and filed a host of groundless allegations against him. Some of those charges involved the surgery in which Anderson and Ewald had argued.

“What happened at St. Joseph has not benefited patient care,” Anderson said. “The dissolution of the neurosurgery staff has resulted in partial or no coverage in the emergency room. You can’t practice medicine without neurosurgery, and you can’t assassinate neurosurgery to get money for your friends.”

Named as defendants in Anderson’s lawsuit are St. Joseph Hospital; Dr. James Grimes, the former chief of the medical staff; Ewald; and Dr. James Hodge, a neuro-radiologist.

None of the doctors could be reached for comment, and hospital officials referred all inquiries to the defense lawyer, Richard E. Madory. Madory contends in general that St. Joseph had legitimate concerns about its neurosurgery department and that Anderson went through a proper disciplinary process.

“The facts do not support what he is saying,” said Madory, who specializes in medical-related cases. “He was treated very fairly. He presented his side to the hospital and went through the same care review process as anyone else on staff. He is simply dissatisfied with the result.”

Physicians are subject to periodic reviews of their work by other doctors in their specialty--so-called “peer review.” The procedure can result in the suspension or revocation of hospital privileges.

In the end, St. Joseph sustained none of the charges that could have resulted in Anderson’s removal, according to his lawsuit. But it may have won at least for now. His practice in disarray from fighting the effort to remove him, Anderson has started over at Irvine Medical Center, where he is chief of the neurosurgery division.

Yet, he still wants his day in court, and his lawsuit has attracted the attention of neurosurgeons across the country who are concerned that the imbroglio at St. Joseph might be another symptom of the growing economic competition among doctors.

Dr. Clark Watts, a professor at the University of Maryland School of Medicine who heads a peer review committee for the American Assn. of Neurological Surgeons, says there have been a number of lawsuits involving hospitals around the country with allegations similar to the St. Joseph situation.

In one groundbreaking case, $2.2 million in damages were awarded to an Astoria, Ore., physician who claimed that a group of doctors used hospital peer review, among other things, to ruin his practice. The U.S. Supreme Court upheld the verdict in 1988.

The fear, Watts says, is that peer review and other disciplinary procedures are being initiated at some medical centers by physicians who stand to gain new patients if their competitors are removed from the staff.

“This type of thing will create more problems for doctors. You go through peer review and your practice is ruined,” Watts said. “Potentially, it could be devastating on health care and not result in improvements. What can drive it is competition expressed in another way. It’s a real problem.”

Locally, Dr. Ed Amyes, a neurosurgeon in Newport Beach, was asked to monitor the St. Joseph situation for the Society of Neurological Surgeons of Orange County and the California Assn. of Neurological Surgeons.

“What happened to Mark Anderson is that he was possibly subject to an unfair or an improper peer review process,” Amyes said. “In his case, he was reviewed by a radiologist, an orthopedist and a neurologist. They are not his peers.”

As a result of the lawsuit, Amyes said, neurosurgical associations have taken steps on the national and state level to ensure that the work of neurosurgeons is reviewed by other neurosurgeons, who have the expertise in the specialty.

At St. Joseph, Amyes said, the situation has hurt the neurosurgery service in the emergency room because the staff no longer has enough neurosurgeons on call for trauma cases. The specialty treats injuries to the nervous system, including the brain and spinal cord.

Madory, the attorney for the doctors and St. Joseph’s, said he did not know the status of care in the emergency room, but he noted that there has been a shortage of neurosurgeons countywide that might explain the problem if, in fact, it exists.

Anderson’s lawsuit, which was filed in 1988, seeks an unspecified amount in damages. It alleges violations of the federal Sherman Antitrust Act and the state Cartwright Act, laws designed to prevent monopolistic practices and unreasonable restraint of trade. A trial date has not been set.

According to the lawsuit, administrators at St. Joseph purportedly became concerned about one or two neurosurgeons in early 1987 who were involved in more medical malpractice cases compared to their colleagues. Anderson was not one of them.

The hospital formed an ad hoc committee of five or six physicians to review care in the neurosurgery department and make recommendations to the administration, including whether any of the neurosurgeons should be dismissed.

Anderson’s lawyers, Tim Stafford and Donald K. Hufstader, say that Ewald, Hodge and Dr. Donald Johnson, a neurologist, sat on the ad hoc committee, although none of them were neurosurgeons and all had had personal or professional disputes with Anderson. Johnson was named in Anderson’s lawsuit but has since died.

Unbeknown to the neurosurgeons, Stafford says, the hospital hired InterQual, a medical consulting firm in Massachusetts, to review the care received by a number of neurosurgery patients.

InterQual, which has not been sued, presented a report to the ad hoc committee, which then recommended to the hospital’s leadership that five neurosurgeons be removed from the staff.

On April 17, 1987, the hospital notified Anderson by mail that his privileges were to be revoked. It was the first time he learned of the action against him.

“This was a shocking, stunning event,” said Anderson, who, at 31, was one of the youngest neurosurgeons to be board certified in the nation. “There was no notice of this, no hearing. It just came out of the blue.”

Among other things, St. Joseph, based on the InterQual report, accused him of performing an unnecessary operation and using procedures in the realm of orthopedic surgery without hospital approval. Eleven accusations were leveled against him, Anderson’s lawyers say.

Over the next year, Anderson and his colleagues successfully contested virtually all of the hospital’s allegations during their appeals, calling into question the conduct of the ad hoc committee, which, they say, was riddled with conflict of interest.

Stafford and Hufstader contend that the panel violated protocols to use a random sample of patients by relying on some cases Ewald and Johnson had handpicked to use against Anderson. Those cases, Stafford said, had good results for the patients, but in each Ewald and Johnson had had personal disputes with Anderson and wanted to settle the score. According to the lawsuit, one case Ewald picked for review was the 1985 neck surgery in which he and Anderson had argued.

Because of their differences with Anderson, it is alleged that Ewald, Johnson and Hodge should have disqualified themselves from the ad hoc committee because they could not be impartial.

Anderson’s attorneys say that Ewald and the orthopedic surgery department also stood to gain a substantial number of patients if Anderson and other neurosurgeons were removed from the staff. Both orthopedic surgeons and neurosurgeons perform spinal surgeries, a potentially lucrative procedure.

Stafford alleges that in another case used by the hospital, X-rays were switched in an attempt to show that Anderson had performed an unnecessary surgery. Stafford says that post-operation X-rays, which showed that the injury had healed, were used as pre-operation X-rays.

Grimes, the former chief of staff, is accused in the lawsuit of orchestrating the conspiracy to clean out the neurosurgery division. Stafford and Hufstader say they have evidence indicating that Grimes played favorites by deciding not to target two veteran neurosurgeons on the staff.

In February, 1988, Anderson won his appeal. According to the lawsuit, a joint review committee at the hospital, which conducted a trial-like procedure, sustained none of the allegations against Anderson and found only that he had made minor errors in patient records.

Though the neurosurgeons successfully challenged the hospital, Anderson says, all decided to leave St. Joseph because of the bitter experience and the impact on their practices. Some of them are expected to testify on Anderson’s behalf if his case goes to trial. Anderson is the only one to sue, however.

In defense of the hospital, Madory said he did not know about Anderson’s allegations that X-rays were used fraudulently. However, he discounted the allegations about conflicts of interest involving Ewald, Johnson and Hodge.