Title: CHRISTIAN GUIER, M.D. v. TETON COUNTY HOSPTIAL DISTRICT, d/b/a ST. JOHN'S MEDICAL CENTER

State: wyoming

Issuer: Wyoming Supreme Court

Document:

CHRISTIAN GUIER, M.D. v. TETON COUNTY HOSPTIAL DISTRICT, d/b/a ST. JOHN'S MEDICAL CENTER2011 WY 31Case Number: No. S-09-0259Decided: 02/24/2011NOTICE: This opinion is subject to formal revision before publication in Pacific Reporter Third. Readers are requested to notify the Clerk of the Supreme Court, Supreme Court Building, Cheyenne, Wyoming 82002, of any typographical or other formal errors so correction may be made before final publication in the permanent volume.
OCTOBER 
TERM, A.D. 2010

 
 
CHRISTIAN GUIER, 
M.D.,

Appellant 
(Petitioner),

 
 
v.

 
 
TETON COUNTY HOSPITAL 
DISTRICT, d/b/a ST. JOHN'S MEDICAL CENTER,

Appellee 
(Respondent).

 
 
Appeal from the 
District Court of Teton County

The Honorable Nancy 
J. Guthrie, Judge

 
Representing 
Appellant:

Anna M. Reeves Olson 
and Weston W. Reeves, Park Street Law Offices, Casper, Wyoming.  Argument by Mr. 
Reeves.

 
 
Representing 
Appellee:

Mark A. Kadzielski, 
Fulbright & Jaworski, LLP, Los Angeles, California; Janet Lewis, Janet 
Lewis, PC, Jackson, Wyoming; Thomas E. Lubnau, II, Lubnau Law Office, PC, 
Gillette, Wyoming.  Argument by Mr. 
Lubnau.

 
 
Before KITE, C.J., 
and GOLDEN, HILL, VOIGT*, and BURKE, JJ.

 
 
*Chief Justice at 
time of oral argument.

 
 
BURKE, 
Justice.

 
 

[¶1]        
Dr. 
Christian Guier appeals from an order of the district court affirming a decision 
by St. John's Medical Center Board of Trustees to revoke his medical staff 
privileges.  After reviewing the 
entire record, we conclude the Board's decision is supported by substantial 
evidence, is not arbitrary or capricious, and is otherwise in accordance with 
law.  We affirm. 

 
 
ISSUES

 
 

[¶2]      
Dr. 
Guier presents the following issues for review: 

 
 

1.    
Whether 
Dr. Guier was denied his constitutional and statutory right to a contested case 
hearing when the Agency reversed the burden of proof.

 
 

2.    
Whether 
the Agency's breach of the Medical Staff Reappointment Agreement, by refusing to 
notify Dr. Guier of complaints that had been made against him, its 
disregard for its own policies, and its persistent concealment of evidence, 
renders its decision arbitrary and capricious.

 
 
St. 
John's styles the issues as follows:

 
 

1.    
Was 
the burden of proof applied appropriately in Dr. Guier's fair hearing? In 
any event was there substantial evidence to support the Board's final 
decision?

 
 

2.    
Did 
St. John's Medical Center provide Dr. Guier procedural due 
process?

 
 

3.    
Did 
St. John's Medical Center act arbitrarily and 
capriciously?

 
 
FACTS

 
 

[¶3]        
Teton 
County Hospital District, doing business as St. John's Medical Center, is a 
Wyoming Governmental Agency organized pursuant to Wyo. Stat. Ann. §§ 35-2-401 
through 35-2-404.  St. John's Board 
of Trustees (Board of Trustees or Board) is an "agency" as defined by Wyo. Stat. 
Ann. § 16-3-101(b)(i).  Medical 
Staff Bylaws govern the management of the Hospital and were adopted pursuant to 
Wyo. Stat. Ann. § 35-2-113.  As a 
requirement of continuing medical staff membership, all physicians must 
periodically submit an application for reappointment.  The application for reappointment 
requires physicians to abide by all of the Bylaws, including those governing 
standards of professional conduct, and to sign a Code of Conduct resolution. 

 
 

[¶4]        
Dr. 
Guier, an orthopedic surgeon, joined the medical staff in 1990.  During his tenure, Dr. Guier exhibited 
disruptive behavior in the operating room on multiple occasions.  Prior to the events leading to this 
litigation, the operating room staff at St. John's had refused to work with Dr. 
Guier on two occasions due to his disruptive behavior.  The first of these incidents occurred in 
1992 and the second occurred sometime between 1994 and 1996.  A focused review of Dr. Guier's 
performance at the hospital was conducted from December 1, 2005 through May 31, 
2006.1  The summary report from that review 
stated that "[r]epeated instances of behavioral issues with Dr. Guier have 
created a strain in the working relationships between Dr. Guier and some members 
of the staff."  

 
 

[¶5]        
In 
May of 2006, Dr. Guier completed an application for reappointment to the medical 
staff.  As part of its consideration 
of Dr. Guier's application, the Medical Executive Committee (MEC), the 
professional review body at the Hospital, reviewed the focused report.  In a June 21, 2006 letter, the 
Chief-of-Staff of the Hospital advised Dr. Guier that "the MEC is concerned 
about your professional conduct.  
Your inappropriate interactions with staff on several occasions, as noted 
in the focused review report, raise questions about your ability to work 
reasonably with others in the hospital."  
In July, the MEC recommended a six-month reappointment of Dr. Guier's 
privileges, on the conditions that Dr. Guier would sign a Medical Staff 
Reappointment Agreement and that the MEC would continue the focused review of 
his professional conduct and clinical performance for the entire term of the 
reappointment.  The Reappointment 
Agreement identified several specific behavioral concerns and set forth the 
following conditions of reappointment:

 
 

a.    
Dr. 
Guier shall not, under any circumstances, shout or otherwise raise his voice 
with any individual at St. John's, including but not limited to, nurses, 
administrative staff or other employees, Medical Staff members, patients or 
visitors.  This includes responding 
to any individual who calls to discuss concerns or issues regarding Dr. Guier or 
his patients.

 
 

b.    
Dr. 
Guier shall not, under any circumstances, make discourteous comments, including 
but not limited to, name calling, or give discourteous orders or demands to any 
individual at St. John's, including but not limited to, nurses, administrative 
staff or other employees, Medical Staff members, patients or visitors.  This includes responding to any 
individual who calls to discuss concerns or issues regarding Dr. Guier or his 
patients.

 
 

c.    
Dr. 
Guier shall not, under any circumstances, criticize any individual at St. John's 
in front of or within earshot of any other individual at St. John's, including 
but not limited to, nurses, administrative staff or other employees, Medical 
Staff members, patients or visitors.  
Dr. Guier will address any criticisms of or concerns about employees or 
staff members to the appropriate supervisor in a courteous manner and in 
private.

 
 

d.    
Dr. 
Guier shall not threaten, physically or otherwise, any person at St. John's, 
including but not limited to, nurses, administrative staff or other employees, 
Medical Staff members, patients or visitors.

 
 

e.    
Dr. 
Guier shall not exhibit any other inappropriate, unprofessional or disruptive 
behavior while on St. John's premises.

 
 
Dr. 
Guier signed the Reappointment Agreement on July 10, 2006, after writing his own 
"addendum," which he testified was "an avenue in which we could try and 
institute some reasonable process to try and deal with some of the issues that 
were at hand."  The typewritten 
addendum appeared at the bottom of the last page of the Agreement and was signed 
by Dr. Guier. It provided:

 
 
This 
agreement is signed with the understanding, that certain terms need to be 
defined, some facts or conclusions are in need of verification, and that the 
agreement is subject to acceptable amendments to be agreed upon in the near 
future.  As a beginning we agree to 
due process in the event of any complaint brought against Dr. Guier and vice 
versa, by Dr. Guier against the Hospital Staff or Medical Staff.  Due process is defined as (1) 
notification of a complaint (2) the nature of the complaint (3) an opportunity 
to respond and (4) call for witnesses (including the accusers with some 
exceptions)[.]  Due process needs to 
be granted to all individuals from the beginning.

 
 
The 
Board of Trustees approved the six-month reappointment. 

 
 

[¶6]        
In 
the ensuing months, several employees reported incidents of Dr. Guier's 
inappropriate behavior.  Some of 
these incidents were verbally relayed to supervisors and others were also 
documented in written reports.  The 
supervisors did not discuss the verbal reports with Dr. Guier at the time they 
were made.  The workplace discord 
reached a crisis level on October 16, 2006 when the MEC was presented with a 
"Work Refusal Petition" signed by the entire operating room staff.  The Petition 
stated:

 
 
This 
petition represents repeated documented occurrences in the operating room as 
well as psychological abuse in a hostile work environment.  This petition also represents the 
concerns of the current operating room staff at St. John[']s Medical 
Center.  These concerns are in 
reference to Dr. Chris Guier and his 
repeated abuse to the operating room staff.  We have exhausted our pleas for change 
and have finally resorted to this method of resolution.  As of this 16th day of October 2006, the Operating Room staff at 
St. John[']s Medical Center refuses to continue performing any 
cases with Dr. Chris Guier.  
The signatures below support this letter, as a much anticipated 
resolution is needed. 

 
 
(Emphasis 
in original.)  The MEC discussed the 
Petition with Dr. Guier at a meeting held the following day.  At that meeting, the doctor in charge of 
the focused review shared the findings from the latest focused review report 
with Dr. Guier.  The doctor 
explained that the most significant part of the report involved Dr. Guier's 
interaction with operating room personnel, and noted that all of the incident 
reports generated regarding Dr. Guier had been discussed with him by human 
resources.  Dr. Guier acknowledged 
that he had reviewed the incident reports, but stated that no one had brought up 
to him that there were behavioral issues.  
He stated that the Petition came as a surprise to him because he made an 
attempt to address problems in the operating room as they 
arose.

 
 

[¶7]        
At the conclusion of 
the meeting, the Medical Executive Committee summarily suspended Dr. Guier's 
privileges for 29 days pending investigations by the Hospital's CEO and by an ad 
hoc committee created by the MEC.  
Dr. Guier was notified in writing of the suspension and of the fact that 
there was a request for an investigation pursuant to the Bylaws.  The MEC informed Dr. Guier that 

 
 
it was the unanimous 
consensus of the MEC that there are reasonable grounds to believe your conduct 
and activities pose a threat to the life, health, or safety of any patient, 
employee, or other person present at the Hospital and that the failure to take 
prompt action may result in imminent danger to the life, health or safety of any 
such person.  Thus, the MEC decided 
to impose this temporary precautionary suspension.  

 
 

[¶8]        
Dr. Guier was given 
the opportunity to provide information to the ad hoc committee at two meetings 
held on October 30th and 31st, 2006.  The 
ad hoc committee presented its findings to the MEC on November 9, 2006.  The committee reported six incidents 
between July and October of 2006 that it considered disruptive and abusive. 
 The CEO presented a report with 
substantially similar findings.  The 
MEC determined that the incidents sufficiently supported a recommendation that 
Dr. Guier's medical staff membership and clinical privileges be terminated.  Dr. Guier was notified of the MEC's 
decision and his right to a contested case hearing on the matter.  He subsequently requested a contested 
case hearing.

 
 

[¶9]        
The 
contested case hearing was held over several evenings before a Judicial Review 
Committee (JRC) comprised of four physicians from the medical staff.  The JRC was assisted by a hearing 
officer.  The parties agreed that 
the Bylaws would apply to the contested case hearing unless they conflicted with 
the Wyoming Administrative Procedure Act (WAPA) or other applicable law.  The parties also agreed that only 
Dr. Guier's behavior, not the quality of care provided to patients, was at 
issue.  Dr. Guier took the pretrial 
depositions of several nurses, technicians, and operating room staff involved in 
the incidents.  He was represented 
by counsel during the hearing, evidence was presented on his behalf, and he was 
provided the opportunity to cross-examine each witness.  

 
 

[¶10]     
The JRC issued its 
Findings and Conclusions following the contested case hearing.  It concluded that the application for 
reappointment and the terms of the Reappointment Agreement placed Dr. Guier on 
notice of expected standards of conduct.  The JRC also concluded that Dr. Guier 
violated those standards during six separate incidents when he displayed anger 
or responded inappropriately 1) to the opening of an extra set of sponges; 2) to 
the suction not working properly during a procedure; 3) when a surgical supply 
item was unavailable; 4) to the loss of a bone fragment after surgery; 5) to the 
postponement of a surgical procedure and, during that procedure, to surgical 
items that were available but not opened; and 6) to the potential contamination 
of a gown.  The JRC concluded that 
Dr. Guier had failed to prove that the MEC's decision to permanently suspend his 
privileges should be reversed or modified.  
Dr. Guier appealed the decision of the JRC to the Board of Trustees, as 
provided for in the Bylaws.  The 
Board reviewed the entire record and found substantial evidence to support the 
MEC's action and recommendation.

 
 

[¶11]     
Dr. 
Guier appealed the Board's final decision to the district court.  The district court found that some of 
the procedures used during the investigation and contested case hearing were 
flawed, but concluded that Dr. Guier's right to due process was not impacted. 
 The district court determined that 
the Board's decision was supported by substantial evidence and affirmed the 
JRC's decision.  Dr. Guier timely 
appealed to this Court.  

 
 
STANDARD 
OF REVIEW

 
 

[¶12]     
We 
review the Board's action as we would review any other agency's decision.  Reynolds v. West Park Hospital District, 
2010 WY 69, ¶ 6, 231 P.3d 1275, 
1277 (Wyo. 2010).  When we consider 
an appeal from a district court's review of an administrative agency's 
decision, we review the case as 
though it had come directly from the administrative agency. 
 Id.  
Our review of an agency decision is limited to those 
considerations specified in Wyo. Stat. Ann. § 16-3-114(c) (LexisNexis 2009) 
which provides, in pertinent part:

 
 

(c) 
To the extent necessary to make a decision and when presented, the reviewing 
court shall decide all relevant questions of law, interpret constitutional and 
statutory provisions, and determine the meaning or applicability of the terms of 
an agency action. In making the following determinations, the court shall review 
the whole record or those parts of it cited by a party and due account shall be 
taken of the rule of prejudicial error. The reviewing court 
shall:

 
 
(i)  Compel agency action unlawfully withheld 
or unreasonably delayed; and

 
 
(ii) 
Hold unlawful and set aside agency action, findings and conclusions found to 
be:

 
 

(A) Arbitrary, 
capricious, an abuse of discretion or otherwise not in accordance with law;      (B) Contrary to constitutional 
right, power, privilege or immunity;            
(C) In 
excess of statutory jurisdiction, authority or limitations or lacking statutory 
right;         
(D) Without 
observance of procedure required by law; or        
(E) Unsupported by substantial 
evidence in a case reviewed on the record of an agency hearing provided by 
statute.   

 
 

[¶13]     
We 
affirm an agency's findings of fact if they are supported by substantial 
evidence.  Dale v. S & S Builders, 
LLC, 
2008 WY 84, ¶ 22, 188 P.3d 554, 561 (Wyo. 
2008).  An 
administrative agency's conclusions of law are not entitled to the same 
deference as its factual findings.  We review an agency's conclusions of 
law de novo, and "[w]e will affirm an agency's legal conclusion 
only if it is in accordance with the law."  DC Production Service v. 
Wyo. Dep't of Employment, 2002 WY 142, ¶ 7, 54 P.3d 768, 771 (Wyo. 2002).  We employ the arbitrary and capricious standard 
as a safety net against administrative agency action that 
is contrary to law but not readily correctible under the other applicable standards of review.  Reynolds, ¶ 6, 231 P.3d  at 
1277.

 
 
DISCUSSION

 
 

[¶14]     
It is 
well-established that a hospital board may prescribe reasonable rules and 
regulations to be followed by physicians using the hospital facilities.  Board of Trustees of Memorial Hospital of 
Sheridan County v. Pratt, 262 P.2d 682, 688-89 (Wyo. 1953); see 
also 41 C.J.S., Hospitals, § 5, 
p. 336; 28 A.L.R.5th 107; Green v. City 
of St. Petersburg, 154 Fla. 339, 17 So. 2d 517 (Fla. 1944); Selden v. City of Sterling, 316 Ill. 
App. 455, 45 N.E.2d 329 (Ill. App. Ct. 1942); Bryant v. City of Lakeland, 158 Fla. 
151, 28 So. 2d 106 (Fla. 1946); Jacobs v. 
Martin, 20 N.J. Super. 531, 90 A.2d 151 (Ch. Div. 1952).  The 
Wyoming statute that governs hospital privileges provides individual hospitals 
broad discretion in the management of their staffs:  

 
 
Any 
hospital owned by the state, or any hospital district, county or city thereof, 
and any hospital whose support, either in whole or in part, is derived from 
public funds, shall be open for practice to doctors of medicine, doctors of 
osteopathy, doctors of chiropractic, doctors of dentistry and podiatrists, who 
are licensed to practice medicine or surgery, chiropractic, dentistry or 
podiatry in this state.  Provided, however, that these hospitals by 
appropriate bylaws shall promulgate reasonable and uniform rules and regulations 
covering staff admissions and staff privileges.  Admission shall not be predicated solely 
upon the type of degree of the applicant and the governing body shall consider 
the competency and character of each applicant. 

 
 
Wyo. Stat. Ann. § 
35-2-113 (LexisNexis 2009) (emphasis added).  We have said that it is improper for any 
court to substitute its judgment for that of a hospital concerning the 
management and operation of a health care facility.  Gonzales v. Personal Collection Service, 
494 P.2d 201, 206 (Wyo. 
1972).  However, a physician may not be excluded by rules, 
regulations, or acts of the hospital's governing authorities which are 
unreasonable, arbitrary, capricious, or discriminatory.  Pratt, 262 P.2d  at 689.  We have stated:

 

In 
reviewing a decision of a public hospital to refuse to grant or to terminate 
staff privileges of a physician, whether the review is conducted in the district 
court or in this court, the applicable standard of review is one which accords 
great deference to a hospital's decision.  That review is limited to a determination 
of whether the exclusion was made on a rational basis, supported by substantial 
evidence, in accordance with reasonable hospital bylaws, and was not 
discriminatory, arbitrary, or capricious.

 
 

Garrison 
v. Board of Trustees of Memorial Hospital, 795 P.2d 190, 193 (Wyo. 1990).  

 
 
Standard 
& Burden of Proof

 
 

[¶15]     
In 
his first issue, Dr. Guier asserts that the burden of proof in his contested 
case hearing is controlled by the Wyoming Administrative Procedure Act, and that 
the hearing examiner erred by applying the burden of proof identified in the 
Medical Staff Bylaws.  We note 
initially that the proper allocation of the burden of proof is a matter of law 
and is reviewed de novo.  Penny v. State ex rel. Wyo. Mental Health 
Prof. Licensing Bd., 2005 WY 
117, ¶ 13, 120 P.3d 152, 160 
(Wyo. 2005).  

 
 

[¶16]     
Prior 
to the contested case hearing, the parties stipulated that "[t]he Medical Staff 
Bylaws of St. John's Medical Staff shall remain in full force and effect, and 
shall apply to the Contested Case Hearing except where they are in conflict with 
the WAPA, or other applicable law and this Stipulation, in which case the WAPA, 
or other applicable law and this Stipulation, shall control."  The hearing examiner determined that the 
burden of proof in the Bylaws did not conflict with the WAPA and instructed the 
JRC to apply the burden of proof provided for in the Bylaws.  The Bylaw governing the burden of proof 
at hearings provides, in pertinent part:

 
 
VIII.D.7.  BURDENS OF PRESENTING EVIDENCE AND 
PROOF

 
 
. 
. . [T]he professional review body that proposed the adverse recommendation or 
action shall present supporting evidence, but the 
Medical Staff appointee shall have the burden of proving, by a preponderance of 
the evidence, that the proposed adverse recommendation or action should 
be rejected and/or modified. 

 
 
(Emphasis 
added.)  The hearing examiner 
instructed the JRC as follows:

 

According 
to Section VIII.D.7 of the Bylaws, the MEC must first present evidence "in 
support of" its action and recommendation.  
To satisfy this initial obligation, the MEC does not have to prove that 
its action was the best or only action to take, or to establish that its 
decision was the "correct" one.  
Rather, to satisfy this initial obligation, the MEC only must show that 
its action and recommendation are supported by evidence or, in other words, that 
its action and recommendation are not arbitrary or capricious and are based on 
evidence that a reasonable mind might accept in support of the actions and 
recommendation.

 
 

If 
you decide that the MEC has presented evidence "in support of" its action and 
recommendation, then, according to Section VIII.D.7 of the Bylaws, Dr. Guier has 
the burden of proving, "by a preponderance of the evidence" that the MEC's 
action and recommendation must be rejected or modified. 

 
 

(Emphasis 
added.)  Dr Guier asserts that the 
WAPA requires the MEC to prove its allegations by "clear and convincing 
evidence."  He contends that this 
burden of proof conflicts with the burden identified in the Bylaws and therefore 
supersedes the provision in the Bylaws pursuant to the parties' 
stipulation.  

 
 

[¶17]     
The 
language of the WAPA does not expressly provide a standard of proof in contested 
case hearings.  See Wyo. Stat. Ann. § 16-3-114(c). We 
have previously recognized that the standard applicable to 
an adjudicatory hearing before an agency, unless otherwise 
stated, is the "preponderance of the evidence" standard 
customarily used in civil cases.  Willadsen v. Christopulos, 731 P.2d 1181, 1184 (Wyo. 
1987).  A "preponderance of the evidence" is 
defined as "proof which leads the trier of fact to find that the existence of 
the contested fact is more probable than its non-existence."  Judd v. State ex rel. Wyo. Workers' Safety 
& Comp. Div., 2010 WY 85, ¶ 31, 233 P.3d 956, 968 
(Wyo. 2010).  We have also 
recognized that the preponderance of the evidence standard generally does not 
adequately protect the property interest one has in a professional license, and 
have instead required a licensing board to prove its disciplinary cases by clear 
and convincing evidence.  Painter v. Abels, 998 P.2d 931, 940 (Wyo. 2000).  Dr. Guier contends that our 
cases 
applying the WAPA to the revocation of professional licenses required the 
Hospital to prove the allegations supporting revocation of his privileges by 
"clear and convincing evidence."  See, e.g., In re Greene, 2009 WY 42, ¶ 10, 204 P.3d 285, 290 (Wyo. 2009) 
(suspension of chiropractor's license); Dorr 
v. Wyo. Bd. of Cert. Pub. Accountants, 
2006 
WY 144, ¶ 13, 146 P.3d 943, 949 (Wyo. 2006) (suspension of certificate to 
practice public accounting); Devous v. 
Wyoming State Bd. of Med. Examiners, 845 P.2d 408, 416 (Wyo. 1993) 
(suspension of medical license).  
The Hospital asserts that the clear and convincing standard does not 
apply because Dr. Guier faced the revocation of his medical staff privileges, 
not the revocation of his medical license.  

 
 

[¶18]     
A "license" is 
defined in the WAPA as "any agency permit, certificate, approval, registration, 
charter or similar form of permission required by law."  Wyo. Stat. Ann. § 16-3-101(a)(iii).  The Hospital argues that staff 
privileges are not a medical license.  
It points out that Dr. Guier still has his license to practice medicine 
in the State of Wyoming, and is able to practice his profession at other 
facilities in the state.  Dr. Guier 
asserts that staff privileges are required by law in order for him to perform 
operations, admit patients to a hospital, and treat patients, and that 
privileges therefore meet the definition of a "license."  He supports this position by citing to 
Bylaw § V.A.1 which prohibits any person from admitting a patient or providing 
medical treatment unless they have been granted privileges.  That Bylaw also states that medical 
staff privileges are "in the nature of a license."

 
 

[¶19]     
Although 
medical staff privileges may be "in the nature of" a license, we find there is a 
clear and important distinction between hospital privileges and a medical 
license.  Medical staff privileges 
allow a physician to use hospital facilities and be assisted by hospital 
staff.  As Dr. Guier points out, 
this includes the authority to admit and treat patients.  A medical license, however, confers a 
general right to practice medicine within the boundaries of a particular 
jurisdiction.  The distinction 
between a medical license and staff privileges is acknowledged in Wyoming, as 
indicated by the fact that licensing and privileging decisions are granted to 
different administrative bodies.

 

[¶20]     
Pursuant 
to statute, the Wyoming Board of Medicine, not the Judicial Review Committee or 
the Boards of Trustees of individual hospitals, oversees physician licensing 
matters.  Title 33, Chapter 26 of 
the Wyoming statutes, known as the "Medical Practice Act," provides rules 
relating to licensing of physicians.  
The Medical Practice Act empowers the Wyoming Board of Medicine to 
"[g]rant, refuse to grant, suspend, restrict, revoke, reinstate or renew 
licenses to practice medicine," and lists more than thirty specific reasons 
justifying revocation, restriction, or suspension of a medical license. Wyo. 
Stat. Ann. §§ 33-26-202(b)(i), 
33-26-402(a)(i)-(xxxiv).  The Act 
provides a clear and convincing burden of proof and allocates the burden to the 
Wyoming Board of Medicine.  Wyo. 
Stat. Ann. § 33-26-407.  The Act 
defines a "license" as "a license to practice medicine in this state issued by 
the board pursuant to this chapter" and clearly distinguishes between a license 
and medical staff privileges. Wyo. Stat. Ann. § 33-26-102(a)(ix); see Wyo. Stat. Ann. §§ 33-26-202, 
303-409. 

 
 

[¶21]     
Medical 
staff privileges, on the other hand, are addressed in the Wyoming Public Health 
and Safety statutes relating to hospitals and other care facilities.  The statute governing hospital 
privileges expressly entrusts matters of staff admissions and privileges to 
hospital administration.  As stated 
above, that statute provides that "hospitals by appropriate bylaws 
shall promulgate reasonable and uniform rules and regulations covering staff 
admissions and staff privileges."  
Wyo. Stat. Ann. § 
35-2-113.  Staff privileges, in 
contrast to medical licenses, are specific to individual hospitals, and 
decisions regarding staff privileges are within the discretion of hospital 
management.  The cases that Dr. 
Guier cites involving license suspensions are inapposite. 
 In this case, Dr. Guier faced the 
revocation of his medical staff privileges.  The Hospital, pursuant to its 
prerogative, decided that privileging decisions would be subject to a burden of 
proof expressly identified in the Bylaws, and the burden of proof set forth in 
those Bylaws was applied at the contested case hearing.  Dr. Guier agreed to be bound by the 
Bylaws when he initially sought hospital privileges and in his subsequent 
application for reappointment.  The 
Bylaws do not require a clear and convincing burden of proof and do not require 
the burden of proof to be carried by the Hospital.

 
 

[¶22]     
Dr. 
Guier also asserts that his loss of privileges is similar to the loss of his 
medical license because it has impacted his ability to earn a living by 
practicing medicine.  He stated that 
the termination of his privileges was reported to the National Practitioner 
Database as required by federal law.  
42 U.S.C. § 11133(a)(1)(A).  
As a result of the reporting and subsequent notification to other 
hospitals, Dr. Guier stated that he had lost privileges at a nearby hospital, 
and was called to hearings before the Wyoming and Montana Boards of 
Medicine.  We 
note that Dr. Guier did not provide details of those hearings and did not 
testify that revocation of his hospital privileges resulted in revocation of his 
license to practice medicine in Montana or Wyoming.  We do not dispute that the loss of 
privileges at a particular hospital or health care facility may seriously impact 
a physician's ability to maintain a medical practice.  

 
 

[¶23]     
Under 
Wyo. Stat. Ann. § 33-26-303(d), the Board of Medicine may deny licensure to a 
person whose privileges have been revoked at a particular health care facility 
on that basis alone.  Also, under 
Wyo. Stat. Ann. § 33-26-402(a)(xxvi)(A), a license may be revoked based on any 
action by a health care entity that adversely affects clinical privileges for a 
period of thirty or more days.  The 
fact that there may be additional consequences to a physician who loses staff 
privileges, however, does not impair the ability of a hospital to establish 
reasonable bylaws and requirements for physicians seeking hospital privileges at 
its facility, and does not transform a privilege to practice at a particular 
hospital into a medical license.  In 
this case, Dr. Guier was aware that his professional behavior was under intense 
scrutiny, as indicated by the focused review of his performance, the 
Reappointment Agreement, and correspondence during the reappointment application 
process.  He was aware that failure 
to abide by the Reappointment Agreement could result in the loss of privileges 
and consequently damage his career.  
In spite of the terms of his Reappointment Agreement, however, Dr. Guier 
continued to act in a manner that jeopardized his ability to practice at St. 
John's and other facilities where he had privileges.

 
 

[¶24]     
The 
WAPA does not mandate a clear and convincing burden of proof for suspension of 
hospital privileges.  Wyo. Stat. 
Ann. § 35-2-113 provides broad discretion to a hospital in determining 
requirements for the ability to practice at a particular hospital.  We have previously recognized that a 
hospital is entitled to great deference in the management of its facility and we 
afford great deference to the hospital's determination of standards relating to 
hospital privileges.  Garrison, 795 P.2d  at 193.  In sum, 
the Hospital was entitled to establish the burden of proof to be applied.  While it is not the level of proof that 
every hospital might adopt, we cannot find that it is unreasonable or that it 
conflicts with the WAPA.

 
 

[¶25]     
Dr. Guier also argues 
that, even if a clear and convincing standard of proof does not apply, Bylaw § 
VIII.D.7 is not reasonable because it places the burden on the physician facing 
charges to show that the adverse recommendation should be rejected or 
modified.  Pursuant to the Bylaws, 
the Medical Executive Committee has the burden of producing evidence supporting 
its recommendation.  Once that 
evidence is produced, the burden shifts to the medical staff appointee to 
persuade the JRC that the action should not be taken.  Dr. Guier asserts that the 
burden-shifting under the Bylaws logically requires him to carry both the burden 
of production and the burden of persuasion, and that the practical effect of 
requiring the MEC to produce "some evidence" supporting its decision does not in 
any way assuage his burden.  
However, our conclusion that the Hospital has discretion to enact 
reasonable and uniform rules and regulations, based on an express statutory 
grant of that power, obviates the need for a discussion regarding the effect of 
burden-shifting under the Bylaws.  
As indicated above, we do not find that the Hospital's decision to place 
the burden of proof on the medical staff appointee, and to require that the 
burden be met by a preponderance of the evidence, is 
unreasonable.

 
 
Substantial 
Evidence

 
 

[¶26]     
Although 
somewhat entangled in his standard of proof argument, Dr. Guier also appears to 
contend that the Board's decision was not supported by substantial 
evidence.  Substantial evidence is 
relevant evidence which a reasonable mind might accept in support of the 
agency's conclusions.  
Dale, ¶ 11, 188 P.3d  at 
558.

 
 

[¶27]     
Dr. 
Guier asserts that the record lacks substantial evidence to support each of the 
six incidents of his misbehavior.  
He contends that several incidents were not documented by written 
reports.  Of the written reports 
that were made, Dr. Guier claims they did not contain the level of detail 
required to determine he violated the application for reappointment or the 
Reappointment Agreement.  He also 
maintains that the ad hoc committee learned of several of the incidents from 
individuals who did not actually witness the outbursts. 

 

[¶28]     
The 
Medical Staff Bylaws require a medical staff member to "agree to work 
harmoniously with others;" to "work[] cooperatively with members, nurses, 
Hospital Administration and others so as to promote high quality patient care;" 
and to adhere to a professional code of conduct, which includes "the ability to 
relate to others in a civil, collegial, and courteous manner." Bylaws §§ 
II.B.1.e; II.E.7; II.E.14. 
The 
Code of Conduct provides:

 
 
The 
policy of St. John's Medical Center & Living Center is that all individuals 
within its facilities be treated courteously, respectfully and with 
dignity.  To that end, while in St. 
John's facilities, individuals who are granted medical privileges agree to 
conduct themselves in a professional and cooperative manner.  All such individuals shall refrain from 
disruptive, abusive, rude, hostile or otherwise inappropriate 
conduct.

 
 

[¶29]     
The record contains 
ample evidence of Dr. Guier's inability to work cooperatively with others, to 
relate to others in a civil, collegial, and courteous manner, and to refrain 
from disruptive conduct.  Six 
members of the operating room staff who worked directly with Dr. Guier testified 
at the contested case hearing, as did the Chief-of-Staff, Chief-of-Surgery, and 
Operating Room Supervisor.  The 
written reports of the ad hoc committee and the CEO investigation were submitted 
as evidence.  The head of the ad hoc 
committee and the CEO also testified during the contested case hearing regarding 
those reports. 

 
 

[¶30]     
The 
decision to permanently suspend Dr. Guier's privileges was based on six separate 
incidents of misconduct.  Dr. Guier 
does not dispute that these incidents occurred.  He either could not remember the 
incidents or contends the incidents were not as serious as reported.  All incidents involved anger, 
mistreatment of staff, and disruptive behavior, and all incidents demonstrated 
an inability to relate to others in a civil, collegial, and courteous 
manner.  The evidence supporting 
those incidents can be summarized as follows:

 
 
July 18, 2006:  Two nurses testified that Dr. Guier 
became angry during a procedure when the operating room staff used unauthorized 
materials.  One nurse stated that 
when Dr. Guier realized an extra set of surgical sponges had been opened he 
stopped what he was doing, became angry and red in the face, was shaking, and 
yelling, "like level 10 yelling."  This incident occurred eight days after 
Dr. Guier signed the Reappointment Agreement.

 
 
July 20, 2006: Two 
nurses testified that Dr. Guier yelled and was intimidating toward operating 
room personnel during a procedure in which an instrument's suction was not 
working properly.

 
 
July 21, 2006: Two 
nurses testified that Dr. Guier became upset when a surgical supply item was 
unavailable.  Both nurses testified 
that Dr. Guier forcefully tore the drapes off the patient and threw a pair of 
scissors during this incident.  The 
incident was also documented in an incident report.

 
 
October 2, 2006: An 
incident report stated that Dr. Guier became angry with the operating room staff 
when he learned of the mishandling of a bone fragment.  A nurse involved in the incident 
testified that Dr. Guier "was so angry.  
He started coming at me."  Dr. Guier accused the nurse of sabotage 
when he learned the fragment had been discarded.

 
 
October 9, 2006: A 
nurse testified that Dr. Guier became angry when surgery was postponed because 
of a room conflict.  Another member 
of the operating room staff testified that, after a room was arranged, Dr. Guier 
yelled at operating room personnel during the procedure for not unwrapping items 
that would be needed, though they were available in the room.  

 
 
October 11, 2006: The 
investigation by the ad hoc committee revealed that Dr. Guier reacted 
angrily to the possible contamination of his surgical gown. According to the 
committee's report, Dr. Guier grabbed the gown from one of the operating 
room staff members, threw the gown to the floor, and made a demeaning comment to 
the staff member.  Dr. Guier 
defended his behavior by stating that he prefers to take his own gown to 
decrease the possibility of infection.  
According to the committee's report, Dr. Guier stated that he discussed 
the incident with another doctor, who agreed that Dr. Guier's reaction could be 
interpreted as demeaning.

 
 

[¶31]     
The Judicial Review 
Committee and the Board of Trustees found that all of these incidents were 
supported by substantial evidence. We agree with this conclusion.  The incident where Dr. Guier was alleged 
to have angrily thrown a contaminated gown on the floor was based on 
hearsay.  Nonetheless, hearsay is 
admissible in administrative proceedings if it is probative, trustworthy, and 
credible, and otherwise satisfies the requirements of Wyo. Stat. Ann. § 
16-3-108.  Story v. Wyoming State 
Board of Medical Examiners, 721 P.2d 1013, 1018 (Wyo. 1986).  
Further, Dr. Guier did not deny that this incident occurred.  The other incidents were testified to by 
eye-witnesses and several were corroborated by more than one witness.  The six members of the operating room 
staff who testified at the contested case hearing provided evidence of Dr. 
Guier's disruptive behavior.  All 
six members of the staff testified that they would continue to refuse to operate 
with Dr. Guier if his privileges were reinstated.  We are satisfied that there is 
substantial evidence supporting the JRC's decision to revoke Dr. Guier's medical 
staff privileges.

 
 

[¶32]     
We also cannot find 
error in the Board's conclusion that Dr. Guier did not carry his burden of 
proving, by a preponderance of the evidence, that the recommendation should be 
set aside or modified.  Dr. Guier 
presented some conflicting evidence regarding his conduct in the operating 
room.  One physician's assistant who 
frequently worked with Dr. Guier testified in support of Dr. Guier.  In reference to Dr. Guier's professional 
behavior, the physician's assistant stated: "I've never heard Dr. Guier raise 
his voice. . . . I've never heard him call people names," and "I've never heard 
him use profanity in any form, even when we're outyou know, outside of the 
OR.  It's just not in his nature." 
 He testified that the OR is a very 
loud and sometimes stressful place and that Dr. Guier's voice may have taken on 
a stressor during several of the incidents, but that he did not witness Dr. 
Guier lose his temper during any of the incidents.  Dr. Guier also called one other doctor 
on his behalf, who testified that Dr. Guier did not have any behavioral problems 
at any of the other hospitals at which he had privileges to 
practice.

 
 

[¶33]     
Dr. 
Guier also testified at the contested case hearing.  He did not recall several of the 
incidents.  He admitted to being 
angry when he found out about the mishandling of the bone fragment.  However, he denied yelling, approaching 
anyone in a threatening manner, or losing his focus on the patient. 

 
 

[¶34]     
The JRC, as the trier 
of fact, was in the best position to determine the credibility of the witnesses 
and to weigh the evidence.  Upon 
weighing the evidence, the JRC found that "Dr. Guier failed to meet his burden 
of proving, by a preponderance of the evidence, that the decision of the Medical 
Executive Committee to permanently suspend his privileges should be reversed or 
modified."  The JRC found that the 
documentary and testimonial evidence demonstrated that Dr. Guier engaged in 
unacceptable personal conduct.  
Given the extensive testimony regarding Dr. Guier's conduct in the 
operating room, and the ample documentation produced by the investigations of 
the ad hoc committee and the Hospital's CEO, we cannot conclude the JRC erred in 
determining that Dr. Guier had not met his burden of 
proof.

 
 
Arbitrary & 
Capricious

 
 

[¶35]     
In 
his last issue, Dr. Guier asserts that the Board's decision was arbitrary and 
capricious.  The arbitrary and 
capricious standard remains as a "safety net" to catch agency action that 
prejudices a party's substantial rights or that may be contrary to the other 
WAPA review standards yet is not easily categorized or fit to any one particular 
standard.  Dale, ¶ 23, 188 P.3d  at 561. 

 

Underlying 
our often repeated statement that "in determining whether the action of an 
agency is arbitrary, capricious, or an abuse of discretion, the court ascertains 
whether the decision is supported by the record," is the assumption that an 
agency will abide by the rules it promulgates.  The failure of an agency to abide by its 
rules is per se arbitrary and capricious. 

 
 

Bowen v. Wyoming Real 
Estate Comm'n, 900 P.2d 1140, 1142 (Wyo. 1995) 
(citation omitted).

 
 

[¶36]     
Dr. 
Guier contends that the Board's decision was per se arbitrary and capricious 
because the Medical Executive Committee did not follow the notice procedures 
provided for in the Reappointment Agreement or the Hospital's internal 
Disruptive Practitioner Policy.  The 
Disruptive Practitioner Policy provides that if disruptive behavior is reported, 
the Chief-of-Staff and CEO shall meet with the practitioner, discuss the 
incident, and document all meetings and conversations concerning the 
behavior.  However, the last 
paragraph of the policy also provides:

 
 
Notwithstanding 
the foregoing, at any time an issue pertaining to a practitioner's disruptive 
conduct may be referred to the Medical Executive Committee.  Such referral may lead to a formal 
investigation and corrective action as set forth in the Medical Staff 
bylaws.  Nothing in this policy 
shall be interpreted to prevent the Medical Executive Committee from exercising 
its prerogatives in these matters.  
This policy presents an informal approach to dealing with a disruptive 
practitioner, which does not replace the right of the Medical Executive 
Committee to exercise its powers as set forth in the Medical Staff 
bylaws.

 
 
The 
MEC chose to bypass the Hospital's Disruptive Practitioner Policy, and opted to 
address the disruptive conduct under the Bylaws, which was its right under the 
policy.  The Disruptive Practitioner 
Policy is not a rule promulgated by the Hospital.  It is designated a "policy" and does not 
carry the authority of the Medical Staff Bylaws.  Likewise, the Reappointment Agreement is 
not a hospital rule or regulation.  
We note that the MEC failed to adhere to the "critical" documentation 
standards of the Disruptive Practitioner Policy, and that none of the suggested 
steps were taken by the Hospital's CEO or Chief-of-Staff to resolve the problems 
informally.  Nonetheless, the 
Disruptive Practitioner Policy does not replace the right of the MEC to exercise 
its powers under the Medical Staff Bylaws.  
The MEC was entitled to proceed under the Bylaws and its decision to do 
so was not arbitrary or capricious.

 
 

[¶37]     
The 
Medical Executive Committee was required to follow the formal procedures 
provided for in its Bylaws, which were promulgated pursuant to statute.  The record reflects that it did 
that.  The MEC, finding that the 
Work Refusal Petition prevented the Hospital from properly staffing the OR, 
creating a threat to the life, health and safety of its patients, summarily 
suspended Dr. Guier's privileges for 29 days according to Bylaw § VII.C.1.  Following the summary suspension, the 
MEC appointed an ad hoc committee to investigate the incidents as required by 
Bylaw § VII.B.3.  The MEC determined 
that the ad hoc committee's investigation supported a recommendation that Dr. 
Guier's medical staff membership and clinical privileges be terminated pursuant 
to Bylaw § VII.B.4.  Dr. Guier was 
immediately notified of the decision and his right to a contested case hearing 
on the matter in accord with Bylaw § VII.B.5.  A contested case hearing was held by the 
JRC and Dr. Guier was afforded an appeal to the Board of Trustees according to 
Bylaws §§ VIII.D and VIII.E.  We 
cannot conclude that the MEC did not follow its rules and 
regulations.

 
 

[¶38]     
Although 
he does not expressly argue that the Medical Executive Committee violated his 
due process rights, Dr. Guier makes much of the fact that the MEC did not notify 
him immediately of each incident of inappropriate behavior.  We note initially that Dr. Guier does not actually contend 
that he lacked notice of the issues that were considered at the contested case 
hearing.  Rather, he asserts that 
had the MEC discussed and documented complaints regarding his professional 
conduct prior to the Workforce Refusal Petition, he could have apologized and 
been admonished if necessary.  He 
claims "[t]he controlling question is whether good faith work with Dr. Guier of 
the kind pledged would have saved his career."  Dr. Guier received 
notice of the charges 
against him, a hearing before an impartial tribunal, representation by counsel, 
the opportunity to cross-examine witnesses and to present evidence, and the 
opportunity to inspect documentary evidence against him.  In light of 
the ample process that was provided to contest the decision of the MEC, we 
cannot conclude that the Board's decision was arbitrary or capricious.  While it may have been possible 
to resolve informally under the methods of conflict resolution identified in the 
Disruptive Practitioner Policy, the fact that the MEC did not follow its 
recommended procedures does not violate Dr. Guier's due process rights.  

 
 

[¶39]     
"Parties to administrative 
proceedings are entitled to due process of law.  Procedural due process principles 
require reasonable notice and a meaningful opportunity to be heard."  Amoco Production Co. v. Wyoming State Bd. of 
Equalization, 7 P.3d 900, 
905 (Wyo. 2000) (internal citations and quotation marks 
omitted).  Dr. 
Guier signed an application for reappointment and a Reappointment Agreement, 
both of which specifically articulated the professional behavior expected of 
those with medical staff privileges.  We find no error in the Board's 
conclusion that the "Reappointment 
Agreement placed Dr. Guier on unequivocal notice that his personal 
conduct had been an issue and would be closely scrutinized during the period of 
his reappointment to the medical staff."  Dr. Guier's testimony indicated his 
awareness of issues relating to his interactions with operating room personnel 
and he was clearly aware of the type of behavior which would be considered 
unacceptable under the Medical Staff Bylaws and the Reappointment 
Agreement.

 
 

[¶40]     
Having reviewed the 
record we cannot conclude that the Board's decision was arbitrary, capricious, 
or otherwise not in accordance with law.  
We affirm the Board's decision for reasons articulated by the Oregon 
Supreme Court when faced with a similar situation:

 
 
Most other courts 
have found that the factor of ability to work smoothly with others is reasonably 
related to the hospital's object of ensuring patient welfare. This conclusion 
seems justified for, in the modern hospital, staff members are frequently 
required to work together or in teams, and a member who, because of personality 
or otherwise, is incapable of getting along, could severely hinder the effective 
treatment of patients. . . . Hospitals uniformly consider cooperativeness an 
important factor, and in these circumstances it seems questionable whether this 
court should gainsay the hospitals' experience and judgment in this 
matter.

 
 

Huffaker v. 
Bailey, 540 P.2d 1398, 
1400-01 (Or. 1975) (footnotes omitted).

 
 

[¶41]     
Affirmed.

 
 

FOOTNOTES

 
 

1A focused review is 
authorized under the Medical Staff Bylaws as part of a "program (1) to monitor 
and assess the quality of professional practice in the Hospital and (2) to 
promote quality and efficiency of clinical and Hospital services by (a) 
providing education and counseling, (b) issuing letters of admonition, warning 
or censure, as necessary, and (c) requiring routine monitoring when deemed 
appropriate by the Medical Executive Committee."