Question of the Week

Question:  Our Medical Executive Committee recently made a recommendation to revoke the privileges of a physician appointed to our medical staff.  This has come at the end of a long process – extending for years – with medical staff officers, department chairs, and the peer review committee trying to get the physician to change her clinical practice habits.  Immediately after requesting a medical staff hearing, the physician demanded copies of every document in the hospital’s files that has her name on it, as well as peer review information involving other physicians in her specialty area.  Do we have to provide all of this information to her?

Answer:  No.  A medical staff hearing is not a trial.  Formal “discovery” that seeks every possible relevant document does not apply in this context.  That said, fairness – as well as the federal Health Care Quality Improvement Act – requires that the individual under review be given a statement of the specific reasons for the recommendation.  Consistent with this, the physician should also be given copies of those documents actually considered in support of the recommendation, such as the medical records, incident reports, reports of outside consultants or other documents which formed the basis for the recommendation made by the Medical Executive Committee.  This information should also be made available sufficiently in advance of the hearing to allow the physician adequate time to prepare a response.

It is becoming increasingly common for physicians under review or subject to a medical staff hearing to request the peer review records of other physicians.  The argument is generally that these other records are needed to show that he or she was treated differently than other physicians on the medical staff.  This specific issue has been considered by several courts, all of which have said that there is no requirement to provide information about other physicians in the context of a medical hearing.  The subject of a medical staff hearing is the fitness of the physician under review.  Files of other physicians are simply irrelevant to this assessment.  In order to prevent a lot of time spent arguing over this issue, we recommend that your medical staff bylaws or credentials policy include a specific statement to this effect.