Leal v. Secretary, U.S. Dep’t of Health & Human Serv.

[PUBL ISH ]

IN THE UN ITED STATES COURT O F A PPEALS
FILED
FOR THE ELEVENTH C IRCU IT
U.S. COURT OF APPEALS
________________________
ELEVENTH CIRCUIT
SEPT 22, 2010
JOHN LEY
CLERK

N o . 09 -15727
_______________________

D . C . D ocke t N o . 08 -01062 -CV -ORL -22 -G JK

JORGE J . LEAL ,
Jorge J . L ea l, M .D .,

versus

SECRETARY , U .S . DEPARTM ENT O F
HEALTH AND HUMAN SERV ICES ,
and h is Successo rs ,
UN ITED STATES DEPARTM ENT O F
HEALTH AND HUMAN SERV ICES ,
NAT IONAL PRACT IT IONER DATA BANK ,
an En tity o f and Run by the U .S .
D epar tm en t o f H ea lth and H um an
S erv ices ,

P la in tiff-A ppe llan t,

D efendan ts-A ppe llees .

________________________

A ppea l from the U n ited S ta tes D istr ic t Cou rt
fo r the M idd le D istr ic t o f F lorida
_________________________

(S ep tember 22 , 2010 )

*
B efo re EDMOND SON and CARNES , C ircu it Judges , and GOLDBERG , Judge .

CARNES , C ircu it Judge :

O ne day D r . Jo rge J . L ea l, a u ro log ica l c lin ic ian and surgeon , w as w a iting

for the opera ting room a t C ape C anavera l H osp ita l in Cocoa B each , F lo r ida to

becom e availab le . I t w as , as the doc to r w ou ld la ter descr ibe it, “a very long day .”

A nd no t a good one fo r h im . Instead , it appears that, like A lexander in the c lassic

ch ild ren ’s sto ry , D r . L ea l w as hav ing “a terr ib le , ho rr ib le , no good , very bad day .” 1

A nd at around 6 :30 p .m ., he w as to ld tha t h is use o f the opera ting room w as go ing

to be de layed (fo r 20 m inu tes as it tu rned ou t). A pparen tly , tha t w as the fina l

straw fo r h im .

W ha t D r . L eal d id af ter he w as to ld tha t he w ou ld have to w ait to use the

opera ting room led the H osp ita l to suspend h is c lin ica l p r iv ileges for a per iod o f

six ty days and to f ile a repo r t exp la in ing w hy . To summ ar ize , in co lloqu ia l term s ,

tha t repo r t’s descr ip tion o f D r. L ea l’s conduct: he p itched a f it. M o re spec if ica lly ,

the H osp ita l repor ted tha t D r . L ea l becam e so en raged tha t he b roke a te lephone , he

sha ttered the g lass on a copy m ach ine, he shoved a m e ta l cart in to the doo rs o f the

opera ting su ite so hard tha t it dam aged one o f them , he th rew jelly beans dow n the

Honorable Richard W. Goldberg, Judge, United States Court of International Trade,
*
sitting by designation.

Judith Viorst, Alexander and the Terrible, Horrible, No Good, Very Bad Day (1972).

ha llw ay in the su rg ica l su ite , he “f lung a m ed ical char t to the ground” w hen a nu rse

asked h im fo r w r itten au tho r iza tion to p roceed w ith su rgery , and he “verbally

abused a nu rse m anager” by ra ising h is vo ice , using p ro fan ity , and calling her a

liar . A cco rd ing to the repor t, D r . L ea l’s “v io len t and unpro fessiona l ac tions” on

tha t occasion “caused var ious m embers o f the nu rsing and techn ica l staff to

announce [ that] they w ere fearfu l o f w o rk ing w ith h im in the fu tu re .”

The H osp ita l f iled its repo r t o f the adverse ac tion taken against D r . L ea l w ith

the Secre tary o f the D epar tm en t o f H ea lth & H um an S erv ices , as it fe lt compe lled

to do under the H ea lth C are Q ua lity Imp rovemen t A c t, 42 U .S .C . § 11101 et. seq .

The S ecre tary inc luded the repor t in the N a tional P rac titioner D a ta B ank , w h ich

w as se t up under the A ct “to co llec t and re lease cer ta in in form a tion re la ting to the

p ro fessiona l compe tence and conduc t o f physic ians , den tists and o ther hea lth care

p ractitioners ,” 45 C .F .R . § 60 .1 (2010 ) .

D r . L eal w as unhappy enough abou t the suspension , and he certa in ly d id no t

w an t a repo r t of it in the N a tiona l P ractitioner D ata B ank w here o ther hosp ita ls

w ou ld have access to it. S ee 42 U .S .C . § 11135 (a) . H e sough t the S ecre tary’s

rev iew o f the repo r t, argu ing tha t it w as no t factua lly accu ra te, and he asked tha t

the repo r t be removed from the D a ta Bank because the H osp ita l’s ac tion against

h im w as no t o f the type tha t shou ld be repo r ted . The Secre tary re jec ted D r . L ea l’s

asser tion tha t the repo r t w as no t fac tua lly accu ra te . R e lying on docum en ts

subm itted by D r . Lea l as par t o f h is request fo r S ecre tar ia l rev iew , the S ecre tary

conc luded tha t the repo r t accu ra te ly descr ibed the H osp ita l’s ac tion and “reasons

for action as stated in the [H osp ita l’s] dec ision docum en ts .” The Secre tary a lso

refused D r . L ea l’s dem and to remove the repo r t, exp la in ing tha t “[t]here is no basis

on w h ich to conc lude tha t the repo r t shou ld no t have been f iled in the [D a ta

B ank ].” H e d id a llow D r . L ea l to f ile a response , a copy o f w h ich w ou ld be g iven

to anyone w ho ob ta ined the repo r t itse lf from the D a ta B ank . N o t happy w ith tha t

ou tcome , D r . L eal f iled an ac tion under the A dm in istra tive P rocedure A c t seek ing

a cour t o rder requ ir ing the S ecre tary to remove the repo rt from the D a ta B ank .

The d istr ic t cou r t en tered a judgm en t denying relief , and th is is D r . L ea l’s appea l.

I .

“In A PA ac tions , w e rev iew agency de term ina tions under the ‘arb itrary and

cap r ic ious’ standard , w h ich ‘p rov ides the rev iew ing cou r t w ith very lim ited

d iscre tion to reverse an agency dec ision .’” W arshauer v . So lis , 577 F .3d 1330 ,

1335 (11 th C ir . 2009) (quo ting C ity o f O x fo rd v . FAA , 428 F .3d 1346 , 1351 (11 th

C ir . 2005 )) . “The cour t’s ro le is to ensu re tha t the agency cam e to a rationa l

conc lusion , no t to conduc t its ow n investiga tion and substitu te its ow n judgm en t

for the adm in istra tive agency’s dec ision .” S ierra C lub v . V an A n tw erp , 526 F .3d

1353 , 1360 (11 th C ir . 2008 ) (quo ta tion m arks om itted ) ; see a lso M iccosukee T r ibe

o f Ind ians of F la . v . U n ited S ta tes , 566 F .3d 1257 , 1264 (11 th C ir . 2009 )

(exp la in ing tha t “[ t]he arb itrary and cap r ic ious standard is exceed ing ly deferen tia l”

and tha t th is Cou r t is “no t au thor ized to substitu te [ its] judgm en t fo r the agency’s

as long as [ the agency’s] conc lusions are ra tiona l” (quo tation m arks and c ita tions

om itted )) .

II .

In the H ea lth C are Q ua lity Imp rovem en t A c t, Cong ress d irec ted the

S ecre tary o f the D epar tm en t o f H ea lth & H um an S erv ices to p romu lga te

regu la tions estab lish ing “p rocedu res in the case o f d ispu ted accuracy o f the

info rm a tion” in the N a tiona l P rac titioner D a ta B ank . 42 U .S .C . § 11136 (2 ) . U nder

those regu la tions , a physic ian w ho d ispu tes the accu racy of a repo rt can seek

S ecre tar ia l rev iew , see 45 C .F .R . § 60 .16 (c)(2) , w h ich is lim ited to hav ing the

repor t rev iew ed “fo r accu racy o f fac tua l in fo rm a tion and to ensu re tha t the

info rm a tion w as requ ired to be repor ted .” U .S . D ep ’t o f H ea lth & H um an S ervs .,

N a tiona l P rac titioner D a ta B ank G u idebook F -3 (2001 ) ,

h ttp ://www .npdb -h ipdb .hrsa .gov /pubs/gb /N PDB_G u idebook .pd f (“G u idebook”) ;

see also Ch r istensen v . H arr is Cn ty., 529 U .S . 576 , 587 , 120 S .C t. 1655 , 1662–63

(2000 ) (exp lain ing tha t in terp re ta tions con tained in en fo rcem en t gu idelines ge t

Sk idmo re deference) .

U nder the regu lations , w hen a physic ian seeks S ecre tar ia l rev iew o f a repo r t

“the S ecre tary . . . rev iew [s] the w r itten in fo rmation subm itted by bo th par ties .” 45

C .F .R . § 60 .16 (c)(2 ) ; see a lso G u idebook , a t F -3 (exp lain ing tha t a physic ian

cha lleng ing a repo r t’s fac tua l accu racy must “[s]ubm it docum en ta tion

substan tia ting tha t the repo r ting en tity’s in fo rm a tion is inaccu ra te”). A nd tha t

happened in th is case . To show tha t the repo r t w as no t fac tua lly accu ra te , D r . L ea l

subm itted h is ow n aff idav its in w h ich he gave h is version o f the even ts tha t led the

H osp ita l to suspend h is c lin ica l p r iv ileges . A cco rd ing to those aff idav its , he

acc iden ta lly b roke a telephone w hen he tr ipped on its long cord ; he c losed the lid

o f a copy m ach ine w ith “som e fo rce” and the g lass cracked ; he moved a m e ta l car t

tha t w as b lock ing the doo rs o f the opera ting su ite ; he ate je lly beans , som e o f

w h ich m ay have fa llen on the f loo r w hen he tr ied to th row aw ay f lavo rs that he d id

no t like ; and w hen he w as handed a m ed ica l char t by a nu rse som e o f the char t’s

loose papers fe ll to the f loo r . In o ther w o rds , th is u ro log ical su rgeon , w ho earns

h is liv ing w ie ld ing a razo r-sharp sca lpe l on som e o f the most de lica te par ts o f the

body , does no t have a bad temper — he is just c lum sy. D r . L ea l d id adm it in h is

aff idav its , how ever , tha t he had on tha t occasion spoken “stern ly” to a nu rse w ho

incorrec tly to ld h im tha t h is pa tien t w as no t cleared fo r surgery . D r . L eal a lso

subm itted to the S ecre tary le tters from the H osp ita l’s adm in istrato rs to h im

form a lly stating tha t “in the best in terests o f pa tien t care” h is clin ica l p riv ileges

w ere suspended due to h is “v io len t, th reaten ing and physica lly destructive and

dam ag ing behav io r .” Based on tha t docum en ta tion , the S ecretary de term ined tha t

the H osp ita l’s repo r t w as fac tua lly accu ra te in the re levan t sense .

D r . L eal cha llenges the S ecre tary’s f ind ing . I t is h is position tha t a repo r t is

fac tua lly accu ra te on ly if the adm in istra tive reco rd includes sta temen ts from

eyew itnesses tha t substan tia te the in fo rm a tion in a hosp ita l’s repo r t abou t a

doc to r’s m isconduc t. W ithou t tha t requ irem en t, he con tends tha t a hosp ita l cou ld

un fa ir ly “b lack list” a physic ian by f iling a repo rt in the D a ta B ank based on

conduc t tha t never occu rred . B ecause the H osp ita l d id no t subm it sta tem en ts from

eyew itnesses to back up w ha t it sa id abou t h im , D r . L ea l argues that it w as

arb itrary and cap r ic ious fo r the S ecre tary to f ind tha t the repo r t w as accura te .

D r . L eal’s position m isunderstands the pu rpose of the D a ta B ank and the

scope of the S ecre tary’s rev iew . Cong ress enac ted the H ea lth C are Q ua lity

Imp rovem en t A c t, w h ich led to the crea tion o f the D a ta B ank , af ter f ind ing tha t

there w as “a nationa l need to restr ict the ab ility o f incompe ten t physic ians to move

from S ta te to S ta te w ithou t d isc losu re o r d iscovery of the physic ian ’s p rev ious

dam ag ing or incompe ten t perfo rm ance.” 42 U .S .C . § 11101 . The D a ta B ank

p reven ts a physician w ho app lies to becom e a member o f a hosp ita l’s m ed ica l staff

o r fo r clin ica l pr iv ileges from be ing ab le to h ide d isc ip linary ac tions tha t have been

taken aga inst h im . See id . § 11135 (a)(1 ) (requ ir ing a hosp ita l to request

info rm a tion from the D a ta B ank abou t a physic ian w hen the physic ian app lies to be

on the m ed ica l staff o r fo r c lin ica l p r iv ileges) . In fo rm a tion in the D a ta Bank is

in tended “on ly to a lert . . . hea lth care en tities tha t there m ay be a p rob lem w ith a

par ticu lar p rac titioner’s p ro fessiona l compe tence o r conduc t” because the

p ractitioner has been the sub jec t o f a d isc ip linary ac tion . G u idebook , a t A -3 ; see

a lso id . a t E -1 (exp la in ing tha t the “p r inc ipa l pu rpose [o f the D a ta B ank] is to

fac ilita te a comp rehensive rev iew o f p ro fessiona l creden tia ls” (emphasis added )) ;

id . at A -3 (no ting tha t the D ata B ank “p rov ides ano ther resou rce to assist . . .

hosp ita ls[ ] and o ther hea lth care en tities in conduc ting ex tensive , independen t

investigations of the qua lif ica tions o f the health care prac titioners they seek to . . .

h ire , o r to w hom they w ish to g ran t c lin ical priv ileges .”); id . at E -1 (exp la in ing tha t

the D a ta B ank serves as a “f lagg ing system ”) . The D ata Bank con ta ins no t on ly

the hosp ita l’s side o f the sto ry bu t a lso the physic ian ’s response. W ha t the

requesting hosp ita l does w ith the in form ation it ob tains from the D ata Bank is

en tire ly up to tha t hosp ita l. I t cou ld comp le te ly d iscoun t the in fo rma tion , o r it

cou ld back o ff from any p ro fessiona l re la tionsh ip w ith the physic ian , o r it cou ld

m ake fu r ther inqu ir ies to de term ine w ha t had actua lly happened .

B ecause in fo rm a tion in the D a ta B ank is in tended on ly to fu lly no tify the

requesting hosp ita l o f d isc ip linary ac tion aga inst a physician and the charges on

w h ich tha t action w as based , the S ecre tary’s rev iew o f in fo rm a tion in the D a ta

B ank is lim ited in scope. The rev iew process does no t p rov ide a physic ian w ith a

p rocedu re fo r cha lleng ing the repor ting hosp ita l’s adverse ac tion . S ee id . a t F -1

(“The d ispu te p rocess is no t an avenue . . . to appea l the under lying reasons o f an

adverse ac tion . . . .”) ; id . a t F -3 (“The S ecre tary does no t rev iew the . . .

app ropr ia teness o f , o r basis fo r , a health care en tity’s p ro fessiona l rev iew action . .

. .”) . N o r does it p rov ide a physic ian w ith a p rocedu re fo r chang ing the a llega tions

abou t the conduct tha t led to the ac tion tha t is repor ted . The S ecre tary rev iew s a

repor t for fac tua l accu racy dec id ing on ly if the repor t accu rate ly descr ibes the

adverse ac tion tha t w as taken aga inst the physic ian and the repo r ting hosp ita l’s

exp lana tion fo r the ac tion , w h ich is the hosp ita l’s sta tem en t o f w ha t the physic ian

d id w rong . S ee 42 U .S .C . § 11133 (a)(3 )(B ) (requ ir ing a hosp ita l to inc lude in the

repor t “a descr ip tion o f the ac ts o r om issions o r o ther reasons fo r the action”) ; see

a lso G u idebook , a t F -4 (g iv ing as examp les o f pertinen t docum en ta tion to p rove

tha t a repo r t is no t fac tually accu ra te : “[ t]he f ind ings o f fac t and recomm enda tions

o f the hea lth care en tity” and “[ t]he f ina l repo r t o f the hear ing pane l o r o ther

appe lla te body upon w h ich the descr ip tion o f ac ts o r om issions w as based”) . The

S ecre tary does no t ac t as a fac tf inder decid ing w he ther inc iden ts listed in the repo r t

ac tua lly occu rred o r as an appe lla te body decid ing w he ther there w as suff ic ien t

ev idence fo r the repo r ting hosp ita l to conc lude tha t those ac tions d id occu r. S ee

G u idebook , a t F -1 (exp lain ing tha t the “basis for” the adverse ac tion may no t be

d ispu ted by the physic ian).

D r . L eal’s aff idav its d ispu ted to som e ex ten t the H osp ital’s version o f h is

conduc t. Tha t d ispu te is ou tside the scope o f the S ecre tary’s rev iew . S ee id . The

letters to D r . L ea l from the H osp ita l’s adm in istra to rs , w h ich he subm itted to the

S ecre tary, conf irm ed tha t h is c lin ica l p r iv ileges w ere suspended , and they

con f irm ed tha t the reason fo r the suspension w as that the H osp ita l be lieved he had

engaged in “d isrup tive” and “v io len t, th rea ten ing and physica lly destruc tive and

dam ag ing behav io r .” The in form a tion in the repo r t w as consisten t w ith the charges

ou tlined in the H osp ita l’s le tters to D r . L ea l. The repo r t sta ted tha t h is c lin ica l

p r iv ileges w ere “summ arily suspended . . . due to h is v io len t and unp ro fessiona l

ac tions” and also sta ted in som e de ta il w ha t those ac tions w ere . The consistency

be tw een the H osp ita l’s le tters and its repor t to the D a ta B ank estab lishes the

repor t’s fac tua l accu racy in the on ly sense tha t m a tters under the A c t. The

S ecre tary reasonab ly de term ined tha t the repo r t w as fac tua lly accu ra te in tha t

sense .

A s fo r D r . L ea l’s concern abou t an unscrupu lous hosp ita l f iling a repo r t

based on conduc t tha t never occu rred and b lack listing a physic ian , w e have th ree

th ings to say . F irst, the requesting hosp ita l is free to igno re in fo rm a tion in the D a ta

B ank fo r purposes o f m ak ing its h ir ing dec ision or to investiga te it. S econd , a

physic ian w ho is the sub jec t of a repo r t can add a sta tem en t to the repo r t g iv ing h is

side o f the sto ry . G u idebook , at F -1 . O ther than a restr ic tion on inc lud ing “nam es ,

add resses , o r phone numbers ,” the con ten ts of a physic ian ’s sta tem en t are lef t

en tire ly up to the physician . Id . The sta tem en t is inc luded w ith the repo r t and is

sen t to every en tity tha t ge ts the repo r t. Id . Th ird , the D a ta B ank is no t designed to

p rov ide p ro tec tion to physic ians a t a ll costs , inc lud ing the cost o f no t p ro tec ting

fu tu re pa tien ts from p rob lem a tic physic ians .

III .

D r . L eal also challenges the S ecre tary’s de term ina tion tha t the H osp ita l’s 60 –

day suspension of h is c lin ical pr iv ileges w as a repo r tab le even t. U nder the A c t, a

hosp ita l tha t “takes a p rofessiona l rev iew ac tion tha t adverse ly affec ts the c lin ica l

p r iv ileges o f a physic ian for a per iod longer than 30 days” is requ ired to repo r t the

ac tion to the D a ta B ank . S ee 42 U .S .C . § 11133(a)(1)(A ) . A p ro fessiona l rev iew

ac tion is def ined as:

an ac tion o r recomm endation of a p ro fessional rev iew body w h ich is
taken o r m ade in the conduc t of pro fessiona l rev iew ac tiv ity , w h ich is
based on the compe tence o r p ro fessiona l conduc t o f an ind iv idua l
physic ian (w h ich conduc t affec ts o r cou ld affec t adverse ly the hea lth
o r w e lfare of a pa tien t or pa tien ts) , and w h ich affec ts (o r m ay affec t)
adverse ly the c lin ica l p r iv ileges . . . o f the physician .

Id . § 11151 (9) (emphasis added ) . D r . L ea l argues tha t he w as no t suspended fo r

conduc t “w h ich . . . affec ts o r cou ld affec t adverse ly the hea lth o r w e lfare o f a

pa tien t o r pa tien ts ,” id ., because no pa tien ts w ere invo lved in the inc iden ts

descr ibed in the adverse action repo r t. A cco rd ing ly , he asser ts tha t the H osp ita l

d id no t take a “p rofessiona l rev iew ac tion” aga inst h im tha t requ ired repo r ting to

the D a ta B ank .

In in terp re ting § 11151 (9 ) , “[o]u r star ting po in t is the language o f the sta tu te

itse lf .” H arr ison v . B enchmark E lecs . H un tsv ille , 593 F .3d 1206 , 1212 (11 th C ir .

2010 ) (quo ta tion m arks om itted ) . If the sta tu to ry tex t is unamb iguous , w e w ill

en force the sta tu te as w r itten and no fu r ther inqu iry is necessary . S ee U n ited S tates

v . D odge , 597 F .3d 1347 , 1352 (11 th C ir . 2010) (en banc) ; see also W arshauer ,

577 F .3d a t 1335 (“If the language a t issue has a p la in and unamb iguous m ean ing

w ith regard to the par ticu lar d ispu te in the case , and the sta tu to ry schem e is

coheren t and consisten t, the inqu iry is over .” (quo ta tion m arks om itted )) .

U nder § 11151 (9 ) , a d isc ip linary ac tion taken aga inst a physic ian qua lif ies as

a p ro fessiona l rev iew ac tion if the physic ian is d isc ip lined fo r conduc t that e ither

adverse ly affec ts pa tien t hea lth o r w e lfare , or cou ld do so . S ee 42 U .S .C . §

11151 (9 ) . The p la in language of § 11151 (9 ) m akes it c lear that ac tua l harm to a

pa tien t is no t a p rerequ isite fo r a d isc ip linary ac tion to qua lify as a pro fessiona l

rev iew action . I t is enough tha t a physic ian is d isc ip lined fo r conduc t tha t cou ld

resu lt in harm to a pa tien t. See M oo re v . W illiam sbu rg R eg ’l H osp ., 560 F .3d 166 ,

172 (4 th C ir . 2009 ) (“Th [e] paren the tica l c lear ly imp lies tha t the term ‘p ro fessiona l

conduc t’ is no t lim ited to past m ed ica l conduc t tha t has a lready affec ted patien t

w e lfare . . . . [N ]o th ing in the sta tu te requ ires peer rev iew comm ittees to w a it un til

m ed ica l d isaster str ikes.”) ; G o rdon v . L ew istow n H osp ., 423 F .3d 184 , 203 (3d C ir .

2005 ) (“The p la in language o f the sta tu te ind ica tes the b read th o f ‘conduc t’

encompassed w ith in the def in ition of ‘p ro fessiona l rev iew ac tion ’ by the inc lusion

o f conduc t tha t ‘cou ld affec t adverse ly the hea lth o r w e lfare o f a pa tien t.’” (quo ting

42 U .S .C . § 11151 (9))). The fac t tha t no pa tien ts w ere h it by p ieces o f the b roken

telephone , o r by the sha ttered copy m ach ine g lass , or by the careen ing m e ta l car t,

o r by the f lying je lly beans, o r by the a irbo rne m ed ica l char t, is no t d ispositive .

The H osp ita l w as requ ired to repo r t its d iscip linary ac tion to the D a ta B ank even

though its ha lls w ere no t littered w ith in jured pa tien ts as a resu lt o f D r . L ea l’s very

bad day .

D isrup tive and abusive behav io r by a physic ian , even if no t resu lting in

ac tua l or imm ed ia te harm to a pa tien t, poses a ser ious th rea t to pa tien t health o r

w e lfare . A physic ian must w o rk co llabo rative ly w ith o ther m embers of a m ed ica l

staff in o rder to p rov ide qua lity care to patien ts . A hosp ita l is one p lace w here no

one can do h is job a lone , w here be tter teamw o rk m eans better care, and w here

d isrup tive behav io r th rea tens lives . W hen a physic ian becom es enraged and lashes

ou t a t o ther m embers o f the m ed ica l staff, pa tien t w e lfare is endangered . Tha t k ind

o f behav io r in tim ida tes o ther hea lth care w o rkers , d iscou rag ing the k ind o f open

commun ica tion and c lose coopera tion tha t is essen tial to p rov id ing the best care to

pa tien ts . The H osp ital repo r ted tha t as a resu lt o f D r . Leal’s v io len t ou tbu rst som e

o f the nu rses and techn ica l staff w ere afraid to w o rk w ith h im in the fu tu re . Tha t

en tire ly p red ic tab le response is a ser ious p rob lem . S ee L au r ie T arkan , A rrogan t,

A busive , and D isrup tive— and a D oc to r , N .Y . T im es , D ec . 2 , 2008 , at D 1

(repo rting abou t a su rvey of hea lth care w orkers a t 102 nonp ro f it hosp itals

revea ling tha t 18 percen t o f the w o rkers sa id tha t “they knew o f a m istake tha t

occu rred because of an obnox ious doc to r”) ; D av id O . W eber , Fo r S afety’s S ake

D isrup tive B ehav io r M ust be T am ed , The Physic ian Execu tive, S ep t.-O c t. 2004 , a t

17 , h ttp ://ne t.acpe.org /M embersO n ly/pe jou rnal/2004 /S ep temberO c tober /

A r tic les/W eberD av id2 .pd f (no ting tha t in a su rvey o f nu rses, pharm ac ists , and

o ther hosp ita l w orkers , 7 percen t o f those su rveyed had been invo lved in a

m ed ica tion erro r du r ing the past year because o f the ir fa ilure to speak up to a

know n in tim idato r abou t d ispensing o r g iv ing a drug ) ; G reta Po r to & R ichard

L auve , D isrup tive C lin ic ian B ehav io r : A P ersisten t Th reat to P a tien t S afe ty , P a tien t

S afe ty & Q ua lity H ea lthcare , Ju ly-A ug . 2006 ,

h ttp ://www .psqh .com /ju laug06 /d isrup tive .h tm l (no ting tha t “stud ies have show n

tha t recip ien ts o f abusive behav io r learn to cope by avo id ing the abuser , even if

th is m eans fa iling to ca ll w hen w arran ted and avo id ing mak ing suggestions tha t

2
m igh t imp rove care”) . The S ecre tary reasonab ly de term ined tha t D r . L ea l’s

repor ted “v io len t and unp ro fessiona l ac tions ,” a lthough no t resu lting in any know n

harm to a pa tien t, is conduc t that “cou ld affec t adverse ly” pa tien t health o r w e lfare .

S ee 42 U .S .C . § 11151 (9 ) .

D r . L eal con tends tha t h is suspension w as no t a repo rtab le even t fo r ano ther

reason . The H osp ita l summ arily suspended h is c lin ica l p riv ileges the day af ter the

inc iden t, and he argues tha t under the A c t summ ary suspensions are to be trea ted

d ifferen tly from o ther p ro fessiona l rev iew ac tions . In o rder fo r a summ ary

suspension to be repo r tab le , he asser ts , it must have been imposed by the hosp ita l

“to p ro tect patien ts from imm inen t danger .” S ee G u idebook , a t E -20 (no ting tha t

In keeping with Eleventh Circuit Internal Operating Procedure 10, “Citation to Internet
2
Materials in an Opinion,” under Federal Rule of Appellate Procedure 36, copies of all of the
internet materials cited in this opinion are available at this Court’s Clerk’s Office.

the D epartm en t of H ea lth & H um an S erv ices “assum es tha t hosp ita ls use summ ary

suspensions . . . to p ro tec t patien ts from imm inen t danger, ra ther than fo r reasons

tha t w arran t rou tine p rofessiona l rev iew ac tions”) . H is suspension w as no t

imposed because of imm inen t danger to pa tien ts .

“Imm inen t danger” is no t requ ired before a summ ary suspension is

repor tab le . The term “imm inen t danger” on ly appears in § 11112 o f the A c t, w h ich

sets ou t standards tha t p ro fessiona l rev iew ac tions must comp ly w ith in o rder fo r

those w ho par tic ipa te in them to be immune from liab ility for money damages in

su its b rough t by d isc ip lined physic ians . S ee 42 U .S .C . §11112 ; B ryan v . H o lm es

R eg ’l M ed . C tr., 33 F .3d 1318 , 1321–22 (11 th C ir . 1994 ) (exp lain ing tha t if a

p ro fessiona l rev iew action m eets cer ta in due p rocess and fa irness requ irem en ts the

ac tion ’s partic ipan ts are immune from liab ility for money dam ages in su its b rough t

by the d isc ip lined physic ian ) . S ec tion 11112 does no t govern w hen a summ ary

suspension , w h ich is a type o f p ro fessiona l rev iew ac tion , is repo r tab le .

The p la in language of the A c t requ ires a hosp ita l to repo r t to the D a ta B ank

“a p ro fessiona l rev iew ac tion tha t adverse ly affec ts the c lin ica l p r iv ileges o f a

physic ian fo r a per iod longer than 30 days.” 42 U .S .C . § 11133 (a)(1 )(A ) . A

summ ary suspension is “a p rofessiona l rev iew ac tion .” See a lso G u idebook , E -19

(“A summ ary suspension is repo r tab le if it is: “(1 ) In effec t o r imposed fo r mo re

than 30 days; (2 ) B ased on the p ro fessiona l compe tence o r p ro fessiona l conduc t o f

the physician . . . tha t adverse ly affec ts , o r cou ld adverse ly affect, the hea lth o r

w e lfare o f a patien t; [and ] (3) The resu lt o f a p ro fessional rev iew ac tion taken by a

hosp ita l . . . .” (number ing added )) . B ecause D r. L ea l’s suspension p lain ly f its

w ith in § 11133 (a)(1 )(A ), the S ecre tary’s de term ina tion tha t it w as repo r tab le w as

no t arb itrary and cap r ic ious .

AFF IRMED .

Edmondson , C ircu it Judge , concu rs in the resu lt.