Doctor’s Lawsuit Alleges Abuse of Peer Reviews

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

Anderson says that as he tried to mend the damaged vertebrae with prosthetic wire, Ewald refused to continue and threatened to get Anderson 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.

“Dr. Ewald thought I was encroaching on his turf, which I wasn’t under our pre-surgery agreement,” Anderson said in a recent interview. “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 said, he and four other doctors in the neurosurgery department were dismissed 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 pursuing an antitrust lawsuit against the hospital and some of its top doctors, including Ewald. Although Anderson was reinstated, he left the staff and later filed the suit.

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

In that effort, he contends in his lawsuit, the hospital fabricated evidence, enlisted physicians who were not neurosurgeons or who had conflicts of interest with him to judge his work, and filed a host of groundless allegations against him. Some of those charges involved the operation during which Anderson and Ewald 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 are St. Joseph Hospital, Dr. James Grimes, former chief of the medical staff; Ewald and Dr. James Hodge, a neuroradiologist.

None of the doctors could be reached for comment, and the hospital referred inquiries to Richard E. Madory, its lawyer. Madory contends 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,” Madory said. “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 by other doctors in their specialty--so-called peer reviews. The process can result in the suspension or revocation of hospital privileges.

Anderson claims in his lawsuit that St. Joseph sustained none of the charges that could have resulted in his removal. But Anderson, who at 31 became one of the nation’s youngest board-certified neurosurgeons, said his practice is in disarray from fighting the effort to remove him. He 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 nationwide who are concerned that the St. Joseph imbroglio might be another symptom of growing economic competition among doctors.

Dr. Clark Watts, a professor at the University of Maryland School of Medicine, heads a peer review committee for the American Assn. of Neurological Surgeons. He knows of many similar lawsuits nationwide.

In one groundbreaking case, $2.2 million in damages was 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 said, is that peer review and other disciplinary procedures are being initiated by physicians who stand to gain new patients if their competitors are removed.

“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.”

Dr. Ed Amyes, a Newport Beach neurosurgeon, was asked by neurosurgery groups to monitor the St. Joseph situation. “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.”

Because of the lawsuit, Amyes said, neurosurgical associations have taken steps to ensure that the work of neurosurgeons is reviewed by other neurosurgeons.

At St. Joseph, Amyes said, the situation has hurt neurosurgery service in the emergency room because the staff no longer has enough neurosurgeons on call for trauma cases.

Madory, the attorney for St. Joseph and its doctors, said he did not know the status of care in the emergency room, but he noted that the county has a shortage of neurosurgeons, which might explain the situation.

Anderson’s lawyers, Tim Stafford and Donald K. Hufstader, said that Ewald, Hodge and Dr. Donald Johnson, a neurologist, sat on an ad hoc committee that was formed to review neurosurgery care because of a high number of malpractice cases against one or two neurosurgeons. Anderson was not one of the surgeons. None on the committee were neurosurgeons and all had had personal or professional disputes with Anderson, they said. Johnson was named in the lawsuit but has since died.

Unbeknown to the neurosurgeons, Stafford said, the hospital hired InterQual, a medical consulting firm, to review the care received by some neurosurgery patients.

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

On April 17, 1987, the hospital notified Anderson that his privileges were to be revoked. “This was a shocking, stunning event,” Anderson said. “There was no notice of this, no hearing. It just came out of the blue.”

Among other things, St. Joseph, using 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 Anderson, his lawyers said.

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

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

Anderson’s attorneys said that Ewald and the orthopedic surgery department also stood to gain many patients if neurosurgeons were removed from the staff. Orthopedic surgeons and neurosurgeons perform spinal surgeries, a potentially lucrative procedure.

Stafford alleges that in one case cited by the hospital, X-rays were switched to show that Anderson had performed an unnecessary surgery. Stafford said that post-operation X-rays, which showed that the injury had healed, were passed off as preoperative X-rays.

Grimes is accused in the lawsuit of orchestrating the conspiracy to clean out the neurosurgery division.

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

Still, the neurosurgeons all decided to leave St. Joseph because of the bitter experience and the impact on their practices, Anderson said. He is the only one to sue.

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

“They are fair, objective people as far as I am concerned,” Madory said. “There is nothing there. It is easier to make a contention than defend against it. . . . We will meet the issues he is raising head-on.”