Title: Goodwich v. Sinai Hosp. of Baltimore

State: maryland

Issuer: Maryland Supreme Court

Document:

KENNETH GOODWICH v. SINAI HOSPITAL OF BALTIMORE, INC. 
NO. 66, SEPTEMBER TERM, 1995
HEADNOTE:
HEALTH CARE QUALITY IMPROVEMENT ACT -- SUMMARY JUDGMENT --
PHYSICIAN FAILED TO PRODUCE SUFFICIENT EVIDENCE OF THE EXISTENCE OF
A GENUINE DISPUTE AS TO THE MATERIAL FACT OF WHETHER THE DEFENDANT
HOSPITAL WAS ENTITLED TO THE QUALIFIED IMMUNITY PRESCRIBED BY THE
HCQIA.
IN THE COURT OF APPEALS OF MARYLAND
NO. 66
SEPTEMBER TERM, 1995
___________________________________
   
    KENNETH GOODWICH
V.
SINAI HOSPITAL OF BALTIMORE, INC. 
___________________________________
Murphy, C. J.
Eldridge
Rodowsky
Chasanow
Karwacki
Bell
Raker
     
    
JJ.
___________________________________
  OPINION BY BELL, J.
___________________________________
        FILED:  August 6, 1996
     The first letter from Dr. Goldstein addressing patient care
1
issues in Dr. Goodwich's credentialing file is dated July 15,
This case presents for our review the issue of whether summary
judgment was properly granted in favor of the respondent, Sinai
Hospital of Baltimore, Inc. ("Sinai"), based upon the immunity
provided by the Health Care Quality Improvement Act of 1986
("HCQIA" or "the Act"), 42 U.S.C. §§11101-11152 (1994). The
petitioner, Kenneth Goodwich ("Dr. Goodwich"), sued Sinai in the
Circuit Court for Baltimore City because it restricted his
privileges to practice medicine in the hospital. The court granted
Sinai's motion for summary judgment on the ground that it was
statutorily immune from suit. On appeal, the Court of Special
Appeals affirmed the judgment of the circuit court. Goodwich v.
Sinai Hospital, 103 Md. App. 341, 653 A.2d 541 (1995). At the
petitioner's request, we issued the writ of certiorari. We shall
affirm the judgment of the Court of Special Appeals.
I.
The professional relationship between Dr. Goodwich and Sinai,
which is at the heart of this appeal, began in 1974, when Dr.
Goodwich interned at the hospital. From 1975 to 1978, he served as
a resident in the Obstetrics and Gynecology Department. Upon
completion of his residency, Dr. Goodwich joined the hospital staff
as an assistant attending physician. 
On June 29, 1988, after several years of discussion and
correspondence with Dr. Goodwich regarding patient care issues,1
2
1980. In that letter, Dr. Goldstein expressed concern about a
cesarean section delivery Dr. Goodwich performed on a 14-year-old
girl, whose labor pattern appeared to be normal. In a letter
dated September 29, 1980, Dr. Goldstein raised concern over Dr.
Goodwich's refusal to see a patient because he had terminated his
contract with her referral center.   The patient suffered a
seizure and therefore "essentially had no attending supervision
in her immediate post convulsive state." Dr. Goodwich's
administration of the drug Pitocin to a patient to stimulate
labor without using an electronic monitor to evaluate her
contractions and their effect on the fetal heart rate was
questioned in a letter dated October 26, 1982.  In that letter,
Dr. Goldstein stated, "[t]he use of a dangerous drug in the
absence of adequate surveillance suggests a degree of negligence
not acceptable to me or to this institution."  Dr. Goldstein's
letter dated August 8, 1984 concerned a patient admitted for a
second trimester abortion in which Dr. Goodwich performed a
laparoscopy for a possible ectopic pregnancy, without having
performed a sonogram.  Stating that he considered such behavior
"a profound violation of the standard of care," in a letter dated
June 19, 1987, Dr. Goldstein addressed the issue of a discharged
patient who had to be readmitted for an infection after Dr.
Goodwich failed to give her prophylactic antibiotics despite her
history of rheumatic fever.
     The June 29, 1988 letter stated, in relevant part:
2
A recent survey of the physician activities here
at Sinai Hospital identified the fact that you have 
not as yet passed your boards. As you know it isn't man-
datory to pass your boards for membership in the Sinai
Medical Staff. On the other hand, I also recently 
noticed a pre-eclamptic* admitted to the obstetrical
service, with no senior consultation. It would seem
prudent that for any of the high-risk patients, in 
the litigious atmosphere of 1988, that such a con-
Dr. Phillip Goldstein, the Chairman of the Obstetrics and
Gynecology Department, sent Dr. Goodwich a letter, noting yet
another patient care issue and suggesting that "in the litigious
atmosphere of 1988" it would be prudent for him to obtain second
opinions from board certified obstetricians and gynecologists ("OB-
GYNs") for all "high risk [obstetrical] patients."  Dr. Goodwich
2
3
sult note would be useful. I am not suggesting that
I be the individual to act as a consultant in such
high-risk obstetrical patients. On the other 
hand, it makes sense for you to select a board 
certified obstetrician and gynecologist to support
your therapeutic goal in the management of such 
patients.
*Preeclampsia is a serious disease of late pregnancy. The
symptoms include hypertension, protein in the urine, and fluid
retention that causes the face and hands to become puffy. David
E. Larson, Mayo Clinic Family Health Book, 1990.
     Dr. Calvin J. Hobel, along with other medical researchers,
3
developed a methodology to predict poor neonatal outcomes during
the prenatal period based on an analysis of various prenatal and
intrapartum factors. See Calvin J. Hobel et al., Prenatal and
Intrapartum High-risk Screening, 117 Am. J. Obstetrics &
Gynecology 1 (1973).
agreed with Dr. Goldstein's recommendation and so informed him by
a letter dated August 12, 1988.  
Over time, however, Dr. Goodwich failed to obtain second
opinions as he had agreed to do. Thus, in a letter dated January
22, 1990, Dr. Goldstein wrote to Dr. Goodwich advising him of his
failure to abide by his second opinion agreement. He also addressed
three issues involving patient care. The letter concluded by
advising Dr. Goodwich that a written second opinion by a board
certified OB-GYN for all patients who were "high risk by the
criteria of Calvin Hobel"  was required to be obtained and that,
3
unless Dr. Goodwich complied voluntarily, Dr Goldstein would
"present [a] recommendation for abridgement of [Dr. Goodwich's]
privileges to the Medical Executive Committee on May 1, 1990." This
prompted a February 1990 meeting between Dr. Goldstein and Dr.
4
     In a letter from the Quality Assurance Department dated
4
November 5, 1990, Dr. Goldstein was advised that for the third
quarter of 1990, "Dr. Goodwich performed nine C-sections. A
second opinion was absent in each case." In a letter to Dr.
Goodwich, dated March 15, 1991, Dr. Goldstein raised concern over
an emergency cesarean section Dr. Goodwich performed in which he
first attempted to induce a vaginal delivery by "push[ing] the
cervix over the [baby's] head."  Dr. Goldstein characterized this
maneuver as "a remarkable deviation from the standard of
care...."
     According to Sinai, in the report by the Quality, Risk &
5
Utilization Management staff on Dr. Goodwich, there were "56
cases, of which 25 did not contain second opinions, six involved
delivery complications, eleven involved maternal infectious
complications, and two involved failure to obtain required
consents from patients."
Goodwich's attorney. In that meeting it was agreed that Dr.
Goldstein would not seek abridgement of Dr. Goodwich's privileges,
provided that Dr. Goodwich obtained second opinions on all of his
high risk patients. This agreement was memorialized in a letter
dated February 26, 1990 from Dr. Goodwich's attorney to Dr.
Goldstein.
Nevertheless, Dr. Goodwich's violation of the second opinion
agreement continued, as did the instances in which his patient care
was questioned.  Consequently, Dr. Goldstein asked the Director of
4
Quality, Risk & Utilization Management at Sinai to examine Dr.
Goodwich's compliance with the second opinion requirement. That
information, provided to Dr. Goldstein on December 2, 1991,
revealed Dr. Goodwich's failure to obtain second opinions for
several high risk patients. It also revealed additional problems
with Dr. Goodwich's patient management methods.  Dr. Goldstein,
5
5
     Dr. Taylor expressed concern about a delivery Dr. Goodwich
6
performed, in which he was absent from the labor and delivery
suite during the time, purportedly an hour before the delivery,
when the fetal monitor depicted fetal distress. Dr. Taylor also
addressed, in the letter, a second incident involving an
emergency cesarean section in which Dr. Goodwich apparently was
not in the labor and delivery suite after being notified of fetal
distress.
therefore, met with Dr. Goodwich to discuss these issues. Once
again, Dr. Goodwich agreed to obtain second opinions in high risk
obstetrical cases. Dr. Goldstein confirmed the agreement in an
April 23, 1992 letter to Dr. Goodwich. In the letter, Dr. Goldstein
also reemphasized that the required second opinion  had to be in
writing and posted in the patient's chart prior to surgery. 
  In June 1992, Dr. W. Scott Taylor, who was then acting Chief
of the Obstetrics and Gynecology Department, Dr. Goldstein having
left Sinai to accept a position at another hospital, wrote to Dr.
Goodwich concerning two patient care issues.  In December 1992, Dr.
6
Taylor asked Sinai's Director of Quality, Risk & Utilization
Management, once again, to review Dr. Goodwich's compliance with
the second opinion requirement.  
  Responding to Dr. Taylor's request, the Quality Assurance
Committee, on January 27, 1993, reported to Dr. John L. Currie, who
had earlier been appointed Chief of the Obstetrics and Gynecology
Department, that since April 1992, the date when the second opinion
agreement was reaffirmed for the third time, Dr. Goodwich had not
obtained second opinions in 8 obstetrical cases. On January 28, Dr.
Currie met with Dr. Goodwich to discuss this matter. At that time,
6
     The letter enumerated the OB-GYN procedures for which Dr.
7
Goodwich was required to obtain second opinions:
Obstetrical: Operative vaginal deliveries (i.e.
forceps, 
   vacuum extraction)
   Management of fetal distress
   Cesarean deliveries
   Breech deliveries
   Disorders of pregnancy such as pre-
   eclampsia, etc.
Gynecological: All major abdominal procedures
Vaginal hysterectomy
Laparoscopy (i.e., when any surgical 
procedure other than visual diagnosis 
occurs)
Dr. Goodwich again agreed to obtain second opinions in high risk
obstetrical cases. On that same date, Dr. Currie sent Dr. Goodwich
a letter confirming the latest agreement and advising him that his
privileges had been extended to March 31, 1993, but that renewal
was dependent upon his obtaining written second opinions and direct
supervision by board certified OB-GYNs for certain obstetrical and
gynecological procedures.  Dr. Currie also advised Dr. Goodwich
7
that his failure to obtain the second opinions for those specified
procedures would result in further action against his privileges.
Although he was requested to acknowledge his agreement with its
contents by signing the letter, Dr. Goodwich declined to do so. On
February 2, however, Dr. Goodwich and his attorney met with Dr.
Currie, at which time Dr. Goodwich verbally agreed to the second
opinion requirement. 
When subsequently faced with yet another failure by Dr.
Goodwich to obtain a second opinion, as well as further patient
7
     In a letter dated February 18, 1993, Dr. Taylor wrote to
8
Dr. Goodwich regarding two patients that developed
hyperstimulation syndrome after the use of prostaglandin gel.
Also, according to Dr. Currie's testimony, given at the hearing
held on April 30, 1993, Dr. Goodwich performed an abdominal
hysterectomy on February 17, 1993 without obtaining a second
opinion.
     Article IV, §7C provides, in pertinent part:
9
6. In instances where, in the opinion of the Chief,
the Chairman of the Medical Executive Committee, and
the Chief Executive Officer of the Hospital, the wel-
fare of a patient may be seriously affected absent
abridgement of a member's privileges, the privileges
of a member may be temporarily abridged until per-
manent procedures can be concluded. Before temporary
abridgement may be imposed, the member must be ad-
vised in writing of the reasons therefor, and that
permanent abridgement of his privileges will be con-
sidered by the Medical Executive Committee at a 
meeting to be held within fourteen (14) days after
the notice.
care concerns,  Sinai, consistent with the January 28 letter,
8
responded by temporarily abridging his privileges.  This
abridgement was memorialized in a letter from Dr. Currie to Dr.
Goodwich dated February 26, 1993. In the letter, Dr. Currie
informed Dr. Goodwich that this action was taken pursuant to
Article IV, §7C of the By-Laws, Rules and Regulations of the
Medical Staff of Sinai Hospital.  The letter also informed Dr.
9
Goodwich that the Medical Executive Committee ("MEC") would
consider permanent abridgement of his privileges on March 8. It
also provided him with the time and location of the meeting and
advised him of his right to attend. 
Prior to the MEC meeting, Dr. Goodwich's counsel was provided
8
     The record reflects that before rendering its decision,
10
the MEC deliberated for approximately one hour and a half.
     See Maryland Code (1981, 1994 Repl. Vol., 1995 Cum.
11
Supp.), Health Occ. Art. §14-413(e); 45 C.F.R. §60 (1995).
     Dr. Goodwich did not sue any of the physicians involved in
12
this case in their individual capacities.
with a list of the specific cases under consideration and, in
addition, the hospital's medical records for each patient were made
available for his inspection. During the meeting, at which Dr.
Goodwich, represented by counsel, was present, Dr. Currie discussed
the proposed abridgement with the Committee members and the reasons
for it. After allowing Dr. Goodwich to make a statement and to
respond to questions from its members, the MEC voted to abridge Dr.
Goodwich's privileges for a period of three months, beginning March
8, 1993, on the same terms and conditions as the prior temporary
abridgement.  The change in Dr. Goodwich's privileges was reported
10
to the Maryland State Board of Physician Quality Assurance and the
National Practitioner Data Bank.11
After the meeting, Dr. Goodwich requested, and received,
before a panel of three physicians, an evidentiary hearing to
consider the reasonableness of the MEC's decision. He subsequently
requested, and received, an administrative hearing before another
three-physician panel. Both panels affirmed the decision of the
MEC, as did Sinai's Board of Trustees at a subsequent meeting.   
Within four days after and based upon the March 8 abridgement,
Dr. Goodwich filed suit against Sinai and the MEC  in the Circuit
12
9
     In ruling on the motion, the trial judge stated:
13
Counsel, I'm prepared to rule on this issue....
I will tell you, I have serious doubt as to whether or
not summary judgment should not be granted for
Sinai Hospital in this case because I don't believe
that the standard is subjective. The case law that
I've read, Maryland or federal, I do believe that
the standard is objective and that you have not
presented, even in the doctor's affidavit, anything
that, any facts that go beyond innuendo, allegation
or conspiracy, so to speak, as to bad faith in apply-
ing an objective standard to the actions of Sinai
Hospital, which are documented by the record, as
exists at this point.   
 
I find as follows: I find that applying either
the federal statute or the Maryland applicable statutes
as to the subjective test, as to whether or not the con-
duct of the defendant, Sinai Hospital in this case, was
unreasonable and/or as to whether or not the plaintiff,
Dr. Goodwich, was denied procedural due process, that 
the answer to those questions is no.
And the record, as far as this Court is concerned,
Court for Baltimore City, alleging civil conspiracy, denial of
procedural 
due 
process, 
breach 
of 
contract, 
intentional
interference with contractual relations, and tortious interference
with prospective economic benefit. On May 12, 1993, by stipulation
of dismissal, the MEC was dismissed from the suit as were the civil
conspiracy and due process counts. On January 17, 1994, Sinai filed
a motion for summary judgment as to all remaining counts, claiming
immunity under the HCQIA and state law. The hospital attached to
the motion its correspondence with Dr. Goodwich over the years,
hearing transcripts, as well as various other exhibits, including
Supplemental Exhibit 25, which it identified as his credentialing
file. After a hearing on the matter, the motion was granted.13
10
does not read as a genuine dispute as to a material
fact on those issues, including immunity. The Court 
will sign an order this date that will grant de-
fendant, Sinai Hospital, Incorporated's motion for
summary judgment.
Dr. Goodwich appealed to the Court of Special Appeals. That
court, as previously noted, affirmed the judgment of the circuit
court. Goodwich v. Sinai Hospital, supra, 103 Md. App. at 355, 653
A.2d at 548. The intermediate appellate court concluded that the
hospital acted reasonably as the HCQIA requires and, therefore, was
entitled to the immunity it provides. It further held that, because
Sinai was immune from damages under federal law, it was unnecessary
to reach the question of state law immunity. As we have also
already noted, we granted Dr. Goodwich's petition for the writ of
certiorari.
II.
A.
Congress enacted the HCQIA in 1986 for the express purpose of
"`improv[ing] the quality of medical care by encouraging physicians
to identify and discipline other physicians who are incompetent or
who engage in unprofessional behavior.'" Bryan v. Holmes Regional
Medical Center, 33 F.3d 1318, 1321 (11th Cir. 1994), cert. denied
___ U.S. ___, 115 S.Ct. 1363, 131 L.Ed.2d 220 (1995) (quoting H.R.
Rep. No. 903, 99th Cong., 2d Sess. 2, reprinted in 1986
U.S.C.C.A.N. 6287, 6384). Moreover, Congress stated, in the text of
the statute, that "[t]he increasing occurrence of medical
11
     In accordance with 42 U.S.C. §11111(a)(1), the immunity
14
provided by the Act specifically applies to:
(A) the professional review body,
(B) any person acting as a member or staff to the
    body,
(C) any person under a contract or other formal
    agreement with the body, and
(D) any person who participates with or assists
    the body with respect to the action
malpractice and the need to improve the quality of medical care
have become nationwide problems that warrant greater efforts than
those that can be undertaken by any individual State." 42 U.S.C.
§11101(1) (1994). It further stated that such problems "can be
remedied 
through 
effective 
professional 
peer 
review." Id.
§11101(3).
Thus, in keeping with its stated objective, the HCQIA provides
participants in peer review activities with qualified immunity from
liability for monetary damages in suits brought by the physicians
who were the subjects of these review activities.  The Act provides
14
immunity for medical peer review actions if four statutory elements
exist:
For purposes of the protection set forth
in section 11111(a) of this title, a profess-
ional review action must be taken --
(1) in the reasonable belief that the action
was in the furtherance of quality health care,
(2) after a reasonable effort to obtain the
facts of the matter,
(3) after adequate notice and hearing pro-
cedures are afforded to the physician in-
volved or after such other procedures as
12
     Subsection (11) defines a "professional review body" as
15
[A] health care entity and the governing body
or any committee of a health care entity which
conducts professional review activity, and in-
cludes any committee of the medical staff of
such an entity when assisting the governing
body in a professional review activity.
are fair to the physician under the circum-
stances, and
(4) in the reasonable belief that the action
was warranted by the facts known after such
reasonable effort to obtain facts and after
meeting the requirement of paragraph (3). 
42 U.S.C. §11112(a) (1994). Section 11112(a) further states:
A professional review action shall be 
presumed to have met the preceding standards
necessary for the protection set out in section
11111(a) of this title unless the presumption
is rebutted by a preponderance of the evidence.
The term "professional review action" is defined in §11151(9),
which provides, in pertinent part:
[A] `professional review action' means an
action or recommendation of a professional
review body[ ] which is taken or made in the
15
conduct of professional review activity, 
which is based on the competence or profess-
ional conduct of an individual physician
(which conduct affects or could affect ad-
versely the health or welfare of a patient
or patients), and which affects (or may
affect) adversely the clinical privileges,
or membership in a professional society, of
the physician. 
The legislative history of §11112(a) reveals that Congress
intended that the test of the statute's reasonableness requirements
be an objective one, rather than a subjective good faith standard.
13
The House Report on that section states, in relevant part:
Initially, the Committee considered a `good
faith' standard for professional review 
actions. In response to concerns that `good
faith' might be misinterpreted as requiring
only a test of the subjective state of mind
of the physicians conducting the profession-
al review action, the Committee changed to
a more objective `reasonable belief' standard.
The Committee intends that this test will be
satisfied if the reviewers, with the infor-
mation available to them at the time of the
professional review action, would reasonably
have concluded that their actions would re-
strict incompetent behavior or would pro-
tect patients.   
Austin v. McNamara, 979 F.2d 728, 734 (9th Cir. 1992) (quoting H.R.
Rep. No. 903, 99th Cong., 2d Sess. 10, reprinted in 1986 Code Cong.
& Admin. News 6287, 6392-93) (emphasis added); Bryan, supra, 33
F.3d at 1323.  It is also evident from the legislative history that
Congress intended that defendants in suits involving peer review
immunity issues be allowed to file motions to resolve those issues
"as early as possible in the litigation process." Id. at 1332
(footnote omitted); "[The Committee intends that] `these provisions
allow defendants to file motions to resolve the issue of immunity
in as expeditious a manner  as possible.'" Id. (quoting H.R. Rep.
No. 903, 99th Cong., 2d Sess. 12, reprinted in 1986 U.S.C.C.A.N.
6394).
B.
Dr. Goodwich contends that Sinai failed to satisfy the
standards in §11112(a) of the HCQIA, relating to the reasonableness
14
     Dr. Goodwich does not dispute Sinai's position that the
16
March 8 abridgement was a "professional review action" as that
term is statutorily defined.
     Specifically, Dr. Goodwich challenges §11112(a)(1), (a)(2)
17
and (a)(4) of the HCQIA. He does not contend that Sinai failed to
conform to the third element, §11112(a)(3), the requirement of
fair and adequate hearing procedures. Indeed, he could not in
good faith do so.  Section 11112(b) provides that a health care
entity is considered to have met the adequate notice and hearing
requirement of subsection (a)(3), with respect to a physician, if
certain enumerated criteria are met. Those criteria include, in
pertinent part:
(1) Notice of proposed action
    
The physician has been given notice stating --
(A)(i) that a professional review action has 
  
 been proposed to be taken against the 
 physician,
   (ii) reasons for the proposed action,
(B)(i) that the physician has the right to
     request a hearing on the proposed action,
   (ii) any time limit (of not less than
        30 days) within which to request such a
hearing, and
(C) a summary of the rights in the hearing under
paragraph (3).
(2) Notice of hearing
  
  
If a hearing is requested on a timely basis under
     paragraph (1)(B), the physician involved must be
    given notice stating --
 (A) the place, time, and date, of the hearing, 
      which date shall not be less than 30 days after
 the date of the notice, and
 (B) a list of the witnesses (if any) expected
 to testify at the hearing on behalf of the profess-
 ional review body.
§11112(b)(1) and (b)(2).
of its belief that the March 8, 1993 professional review action16
was taken in furtherance of quality health care and was warranted
by the facts known to it.  He submits further that §11112(a)'s
17
15
Section 11112(b)(3) further states that if a hearing is
requested pursuant to §11112(b)(1)(B), the hearing must be held,
inter alia, before a panel of individuals appointed by the health
care entity, who are not in direct economic competition with the
physician involved. In addition, in the hearing, the physician
has the right to representation by an attorney or other
individual of the physician's choosing, the right to call,
examine, and cross-examine witnesses, and to present relevant
evidence.
placement of the burden of proof on the physician to "rebut[] by a
preponderance of the evidence" that the review action was
unreasonable based on one of the four statutory elements, in the
summary judgment context, imposes on him an improper burden. As he
sees it, a motion for summary judgment predicated on the immunity
established by the HCQIA should be reviewed in accordance with
Maryland summary judgment procedure.
Simply put, Dr. Goodwich maintains that the burden he has to
overcome on summary judgment is one of production, not one of
persuasion. He thus concludes that, at the summary judgment stage
of the trial, he must present sufficient evidence to allow an issue
material to his case to go the jury, rather than meet the ultimate
burden of proving that issue by a preponderance of the evidence.
Indeed, Dr. Goodwich asserts that the trial judge needed only to 
determine whether, when viewed in the light most favorable to him,
there was sufficient evidence on the basis of which reasonable
jurors could differ regarding whether he satisfied his burden of
persuasion. Moreover, he claims that the Court of Special Appeals
erroneously viewed the evidence he presented based on the
16
preponderance standard. Goodwich, supra, 103 Md. App. at 353, 653
A.2d at 546-47.
In Dr. Goodwich's view, he met his burden of production by
providing sufficient evidence to support the factual inference that
Sinai's purpose in abridging his privileges was to avoid
litigation, not "in the reasonable belief that the action was in
the furtherance of quality health care." Specifically, Dr. Goodwich
notes two letters sent to him by Dr. Goldstein which, in the
context of discussing second opinions for high risk patients,
reference 
a 
concern 
about 
Dr. 
Goodwich's 
lack 
of 
board
certification creating a potential liability exposure for the
hospital.
He further maintains that he met his burden of production by
providing sufficient evidence to support the factual inference that
Sinai made no "reasonable effort to obtain the facts of the
matter." In this regard, Dr. Goodwich submits that there was
sufficient probative evidence that Drs. Taylor and Currie continued
the second opinion requirement started by Dr. Goldstein "without
any meaningful evaluation of his ability to provide patient
care[,]" and, indeed, "deliberately refused to investigate the
underlying facts."
In similar fashion, Dr. Goodwich contends that there was
probative and admissible evidence that the MEC took action against
him without any meaningful review of the patient care he provided
and that the Hearing Committee simply "rubberstamped" the MEC's
17
     In this regard, Dr. Goodwich contends that Sinai's
18
Supplemental Summary Judgment Exhibit 25, which chronicles the
events leading up to the March 8 abridgement, is inadmissible
hearsay.  Moreover, he maintains that both the trial court and
the Court of Special Appeals improperly relied on this exhibit.
See Goodwich, supra, 103 Md. App. at 352, 653 A.2d at 546.
Sinai offers several responses to Dr. Goodwich's charge that
Supplemental Exhibit 25 is inadmissible hearsay. First, it
asserts that this file is not hearsay because it was not offered
for the truth of the matter asserted, but rather to show that
there was a reasonable basis for the abridgement of his
privileges. Second, it asserts that, assuming arguendo, it is
decision. He concludes that Dr. Currie, the MEC, and the Hearing
Committee could not have decided to abridge his privileges for
reasons of "patient welfare" without having reviewed any patient
charts. He also points to the testimony his expert witness, Dr.
Theodore M. King, former Chief of the Obstetrics and Gynecology
Department at The Johns Hopkins Hospital, gave at the April 
hearing, as evidence that he was not a threat to patient welfare.
  
Finally, Dr. Goodwich asserts that he met his burden of
production by providing sufficient evidence to support the factual
inference that Sinai's action was not taken "in the reasonable
belief that [it] was warranted by the facts known." In this regard,
he argues that there were material factual issues relative to
whether there was "any reasonable concern for patient welfare on
the part of the hospital administration and the successive chiefs
of the OB-GYN department at Sinai when Dr. Goodwich's privileges
were abridged." He concludes that "there was no admissible evidence
that the second opinions were necessary or that there was any
patient mismanagement."  
18
18
hearsay, Exhibit 25 falls under the business records exception.
See Maryland Evidence Rule 5-803(b)(6).  Sinai also argues that
the full contents of the exhibit were discussed with Dr. Goodwich
when it examined him under oath at the administrative hearing. 
Finally, it points out that, when transcripts of the hearing were
offered as summary judgment exhibits at trial, Dr. Goodwich did
not object to them.
We need not address this issue. As we noted at oral
argument, Dr. Goodwich failed to raise this issue in his
certiorari petition.
See Maryland Rule 8-131(b).
     Section 14-501(f) of the Health Occupations Article
19
provides:
A person shall have the immunity from liability de-
scribed under §5-393 of the Courts and Judicial Proceed-
ings Article for any action as a member of the medical
review committee or for giving information to, partici-
pating in, or contributing to the function of the med-
Dr. Goodwich claims that "[i]n many of the patient cases
identified by Sinai as supporting the abridgement of privileges,
second opinions were in fact part of the file." He further
maintains that the hospital made no effort to discover the facts
underlying the absence of a written second opinion in the remaining
patient cases to determine if patient welfare was jeopardized, and
that the Hearing Committee neither asked for nor heard evidence to
establish that he had deviated from accepted standards of care in
any specific case.  
     As his last contention, Dr. Goodwich asserts that Sinai, in
addition to lack of entitlement to federal immunity, also is not
entitled to immunity under the provisions of Health Occupations
Article of the Maryland Code (1981, 1994 Repl. Vol., 1995 Cum.
Supp.), §§14-501(f) and 14-504(c).  This is so, he maintains,
19
19
ical review committee.
Section 14-504(c) of the Health Occupations Article
provides:
A person described in subsection (b) of this
section shall have the immunity from liability described
under §5-394 of the Courts and Judicial Proceedings
Article for giving information to any hospital,
hospital medical staff, related institution, or other
health care facility, alternative health system,
 
professional society, medical school, or professional 
licensing board.
Section 5-393(b) of the Courts and Judicial Proceedings
Article provides:
A person who acts in good faith and within the 
scope of the jurisdiction of a medical review committee
is not civilly liable for any action as a member of the
medical review committee or for giving information to,
participating in, or contributing to the function of the
medical review committee.
     According to Dr. Goodwich, his relationship with Dr.
20
Goldstein had long been fraught with animosity, which ultimately
contributed to Dr. Goldstein's institution of the second opinion
requirement. Thus, in his brief submitted to this Court, Dr.
Goodwich asserts that Dr. Goldstein instituted the second opinion
requirement, in part, because of "personal feelings toward Dr.
Goodwich."   We find it interesting, however, that in the
February 26, 1990 letter to Dr. Goldstein, Dr. Goodwich's
attorney commented that Dr. Goldstein had "no ... personal
adverse interest to Dr. Goodwich."
because his evidence regarding bad faith on Sinai's part,
specifically that of Dr. Goldstein, would be relevant to state
immunity, thereby preventing the entry of summary judgment.20
C.
Not unexpectedly, Sinai views matters quite differently. It
contends that, as a defendant seeking HCQIA immunity in a summary
20
     The Maryland Hospital Association, Inc. filed a brief, as
21
amicus curiae, in which it also argues that it is Dr. Goodwich
who has the burden, on summary judgment, to rebut the statutory
presumption and to do so by a preponderance of the evidence.
judgment context, it need only show that its actions fall within
the statutory definition of a "professional review action" under 42
U.S.C. §11151(9). Having made the requisite showing, Sinai claims
that it qualifies for the presumptive immunity afforded by the
HCQIA. Therefore, it disputes Dr. Goodwich's contention that it has
the burden, at the summary judgment stage, of producing evidence
demonstrating the reasonableness of its actions. On the contrary,
it claims that upon showing that the March 8 abridgement was a peer
review action, the four immunity elements in §11112(a) are presumed
to exist, and it is Dr. Goodwich who, in order to survive summary
judgment, must rebut the statutory presumption by a preponderance
of the evidence.    
21
Sinai maintains that it temporarily abridged Dr. Goodwich's
privileges because he repeatedly failed to obtain second opinions
that were reasonably necessary for it to insure quality patient
care. It further maintains that the abridgement process represented
a reasonable effort to consider all relevant facts, complied with
all applicable hospital Medical Staff By-Laws, and afforded Dr.
Goodwich an opportunity to participate and present any information
he desired.
It also claims that, given the presumptive immunity it enjoys,
the proper measure of the reasonableness of its actions is whether
21
     Federal courts, in applying the HCQIA, have concluded that
22
the appropriate standard for a non-movant on summary judgment is
"[m]ight a reasonable jury, viewing the facts in the best light
for [the non-movant], conclude that [it] has shown, by a
preponderance of the evidence, that the defendant[']s[] actions
are outside the scope of §11112(a)?" Austin v. McNamara, 979 F.2d
728, 734 (9th Cir. 1992). See also Bryan v. Holmes Regional
Medical Center, 33 F.3d 1318, 1323 (11th Cir. 1994), cert.
denied, ___ U.S. ___, 115 S.Ct. 1363, 131 L.Ed.2d 220 (1995);
Quartermont v. St. Joseph Hospital and Health Center, No. H-94-
Dr. Goodwich "submitted any admissible evidence that would permit
a reasonable jury to conclude that other reasonable hospitals would
not have acted to abridge a physician's privileges under similar
circumstances." It concludes that he failed to submit such
evidence, as both the trial court and the Court of Special Appeals
determined. Goodwich, supra, 103 Md. App. at 352, 653 A.2d at 546.
III.
The standard of review for a grant of summary judgment is
whether the trial court was legally correct. Hartford Insurance Co.
v. Manor Inn, 335 Md. 135, 144, 642 A.2d 219, 224 (1994); Gross v.
Sussex, 332 Md. 247, 255, 630 A.2d 1156, 1160 (1993); Beatty v.
Trailmaster, 330 Md. 726, 737, 625 A.2d 1005, 1011 (1993); Brewer
v. Mele, 267 Md. 437, 441, 298 A.2d 156, 159 (1972). Toward this
end, we must, in this case of first impression, decide the
appropriate burden of production for a non-movant in a HCQIA
summary judgment proceeding -- that is to say, determine how  one
rebuts the statutory presumption that a professional review action
was objectively reasonable.22
22
1787, 1995 U.S. Dist. LEXIS 14160 (S.D. Tex., Aug. 14, 1995).
This is the standard that Sinai submits is proper and it is the 
one which appears to have influenced the Court of Special
Appeals. See Goodwich, supra, 103 Md. App. at 353, 653 A.2d at
546-47 ("Dr. Goodwich has not offered sufficient evidence to
permit a trier of fact reasonably to conclude, by a preponderance
of the evidence, that Sinai's actions were outside the scope of
§11112(a).").
This approach to summary judgment -- as articulated by the
Austin court and its progeny, namely that the non-movant must
rebut the statutory presumption by a preponderance of the
evidence, -- entails a kind of weighing of the evidence. The
trial judge must consider the evidence the non-movant has
proffered to determine whether the preponderance standard has
been met, thereby effectively creating a paper trial. Indeed,
such a transformation of the summary judgment process was warned
against by Justice Brennan in dissent in Anderson v. Liberty
Lobby, 477 U.S. 242, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). He
stated, "I am fearful that this new rule ... will transform what
is meant to provide an expedited `summary' procedure into a full-
blown paper trial on the merits." Id. at 266, 106 S.Ct. at 2519,
91 L.Ed.2d at 223 (Brennan, J. dissenting).
To be sure, placing the non-movant in the position of
rebutting the statutory presumption by a preponderance of the
evidence, as Austin teaches, in effect, takes the burden of
persuasion applicable at trial and engrafts it onto summary
judgment procedure.
While it is well-settled that we must apply the substantive
federal law governing a case such as this, it is equally well-
settled that "[t]he law of the forum governs procedural matters."
Rein v. Koons Ford, 318 Md. 130, 147, 567 A.2d 101, 109 (1989);
Vernon v. Aubinoe, 259 Md. 159, 162, 269 A.2d 620, 621 (1970)
("Maryland law ... controls as to the inferences to be drawn from
the evidence, the sufficiency of the evidence, the inferences from
it to go to the jury and other procedural matters.").  Summary
judgment practice in this state is governed by Maryland Rule 2-501.
It states, in relevant part, "[t]he court shall enter judgment in
23
     Interestingly, Maryland Rule 2-501 is derived from Federal
23
Rule of Civil Procedure 56. Metropolitan Mortgage Fund v.
Basiliko, 288 Md. 25, 27, 415 A.2d 582, 583 (1980); Berkey v.
Delia, 287 Md. 302, 306, 413 A.2d 170, 172 (1980). That rule
provides, in pertinent part:
The adverse party prior to the day of hearing may
serve opposing affidavits. The judgment sought shall be
rendered forthwith if the pleadings, depositions, answers
to interrogatories, and admissions on file, together with
the affidavits, if any, show that there is no genuine 
issue as to any material fact and that the moving party
is entitled to a judgment as a matter of law.
Rule 56(c).
favor of or against the moving party if the motion and response
show that there is no genuine dispute as to any material fact and
that the party in whose favor judgment is entered is entitled to
summary judgment as a matter of law." Rule 2-501(e).23
Summary judgment is not a substitute for trial. Stated
differently, its purpose is not to try the case or resolve factual
disputes. Hartford Insurance Co., supra, 335 Md. at 144, 642 A.2d
at 224; Coffey v. Derby Steel Co., 291 Md. 241, 247, 434 A.2d 564,
567-68 (1981); Berkey v. Delia, 287 Md. 302, 304, 413 A.2d 170, 171
(1980); Salisbury Beauty Schools v. State Board of Cosmetologists,
268 Md. 32, 40, 300 A.2d 367, 373 (1973). Rather, the procedure is
designed to determine whether a factual controversy exists
requiring a trial. Hartford Insurance Co., supra, 335 Md. at 144,
642 A.2d at 224; Beatty, supra, 330 Md. at 737, 625 A.2d at 1011;
Foy v. Prudential Insurance Co., 316 Md. 418, 422, 559 A.2d 371,
373 (1989); Metropolitan Mortgage Fund v. Basiliko, 288 Md. 25, 28,
24
415 A.2d 582, 584 (1980); Lynx, Inc. v. Ordnance Products, 273 Md.
1, 7, 327 A.2d 502, 508 (1974); Brewer v. Mele, 267 Md. 437, 442,
298 A.2d 156, 160 (1972) (quoting Lipscomb v. Hess, 255 Md. 109,
118, 257 A.2d 178, 182-83 (1969)); see also Bond v. Nibco, 96 Md.
App. 127, 134-35, 623 A.2d 731, 735 (1993). Thus, in keeping with
Maryland law, the trial judge is not allowed to weigh evidence.
This principle is also expressed in federal case law. See, e.g.,
Anderson v. Liberty Lobby, 477 U.S. 242, 249, 106 S.Ct. 2505, 2511,
91 L.Ed.2d 202, 212 (1986) ("[A]t the summary judgment stage the
judge's function is not himself to weigh the evidence and determine
the truth of the matter but to determine whether there is a genuine
issue for trial."). 
It is also true that, under Maryland law, the non-movant bears
no burden of proof at the summary judgment stage. Rather, after the
moving party has produced sufficient evidence in support of summary
judgment, the non-movant "must demonstrate that there is a genuine
dispute of material fact by presenting facts that would be
admissible in evidence." Gross, supra, 332 Md. at 255, 630 A.2d at
1160; see also Beatty, supra, 330 Md. at 737, 625 A.2d at 1011. "A
material fact is a fact the resolution of which will somehow affect
the outcome of the case." King v. Bankerd, 303 Md. 98, 111, 492
A.2d 608, 614 (1985) (citing Lynx, supra, 273 Md. at 7-8, 327 A.2d
at 509).        
  
In addition, those facts must be presented "in detail and with
precision," general allegations are insufficient. Gross, supra, 332
25
Md. at 255, 630 A.2d at 1160; Beatty, supra, 330 Md. at 738, 625
A.2d at 1011; see also Lynx, supra, 273 Md. at 7-8, 327 A.2d at
509. Finally, in determining whether there is a genuine dispute of
material fact, the court must resolve all inferences against the
moving party. Hartford, supra, 335 Md. at 145, 642 A.2d at 224;
Gross, supra, 332 Md. at 256, 630 A.2d at 1160; King, supra, 303
Md. at 111, 492 A.2d at 614; Coffey, supra, 291 Md. at 246, 434
A.2d at 567; Berkey, supra, 287 Md. at 304-05, 413 A.2d at 171;
Leonhart v. Atkinson, 265 Md. 219, 220, 289 A.2d 1, 2 (1972). 
In Maryland, when there is a genuine issue of material fact,
the evidence, or the inferences deducible therefrom, is sufficient
to permit the trier of fact to arrive at more than one conclusion;
consequently, the moving party is not entitled to judgment as a
matter of law. Because the applicable standard in civil cases is
preponderance of the evidence, see Beatty, supra, 330 Md. at 738-
39, 625 A.2d at 1011; Bond, supra, 96 Md. App. at 135, 623 A.2d at
735; Seaboard Surety v. Kline, Inc., 91 Md. App. 236, 244, 603 A.2d
1357, 1360 (1992), when the evidence the non-movant presents, or
the inferences from that evidence, demonstrate that there is a
genuine issue of material fact, it is at least arguable that he or
she has met that burden. In other words, the generation of a
genuine dispute of material fact is, in this context, the
equivalent of meeting a preponderance of the evidence standard at
trial. We thus conclude that the proper summary judgment standard
in this case is whether Dr. Goodwich produced sufficient evidence
26
of the existence of a genuine dispute as to the material fact of
whether Sinai was entitled to the qualified immunity prescribed by
the HCQIA.  
IV.
We shall now review seriatim Dr. Goodwich's claims that he has
produced sufficient evidence to support the factual inference that
Sinai failed to satisfy the standards of §11112(a). In this regard,
we are mindful that, in accordance with the Act, "the defendants'
[professional review] action is immune if the process was
undertaken in the reasonable belief that quality health care was
being furthered." Imperial v. Suburban Hospital Association, Inc.,
37 F.3d 1026, 1030 (4th Cir. 1994). We are also mindful that "[t]he
standard is an objective one which looks to the totality of the
circumstances." Id.
Dr. Goodwich first contends that Sinai's purpose in abridging
his privileges was to insulate it from lawsuits, not to further
patient welfare as §11112(a)(1) requires. He points to language in
the June 29, 1988 and March 15, 1991 letters, in which Dr.
Goldstein referred not only to obtaining second opinions but also
to the potential for litigation against Sinai, as evidence that the
second opinion requirement was implemented out of Dr. Goldstein's
fear of litigation, rather than any legitimate concern for patient
welfare. To Dr. Goodwich it is extremely relevant that, in these
letters, "[n]ot one word was mentioned about his actions
27
potentially jeopardizing patients."
This argument is specious. Even if the second opinion
requirement was initiated out of fear of litigation, rather than
patient care concerns, neither evidence of that fact nor the
inferences 
from 
such 
evidence 
rebuts 
the 
presumption 
of
reasonableness the MEC's abridgement action enjoys. This evidence
may support an inference of bad faith on Sinai's part; however, as
we have already pointed out, what is relevant here is the objective
reasonableness of the hospital's actions, not its subjective intent
or motivation. In sum, Dr. Goodwich's reliance on these two letters
improperly focuses on what is more accurately characterized as the
hospital's preliminary conduct, while failing to address the basis
for Sinai taking the professional review action that it did; this
focus does not address, not to mention rebut, the evidence that was
before the MEC when it abridged Dr. Goodwich's hospital privileges.
Moreover, while it is true that these letters reference
concern about litigation, it is equally true that these same
letters address patient care issues. In fact, the March 15 letter
characterizes Dr. Goodwich's conduct in caring for a patient as "a
remarkable deviation from the standard of care...." Also, and as we
have seen, the letters were preceded by years of discussion and
correspondence on patient care issues. In addition, as Sinai quite
correctly points out, "concern about litigation and concern about
patient welfare are not mutually exclusive -- lawsuits are
28
     During the period 1985 to 1993, Dr. Goodwich was sued for
24
medical malpractice five times. At the time of the abridgement,
however, these cases remained unresolved.
typically not filed unless an injury results ...."24
Not only is his contention concerning the letters unavailing,
but Dr. Goodwich offers nothing else; he does not even direct our
attention to anything, in the way of evidence or inference, that
would demonstrate a genuine dispute of material fact with respect
to Sinai's compliance with §11112(a)(1). To be sure, he does rely
on his testimony before the Hearing Committee and his amended
affidavit in opposition to Sinai's summary judgment motion for the
proposition that the institution of the second opinion requirement
was undertaken for reasons related to litigation, rather than
patient care. Yet, this evidence suffers from the same defect. It
simply does not rebut the reasonableness of the hospital's March 8
action. In any event, it is well settled that "general allegations
that do not show facts in detail and with precision" are
insufficient to survive summary judgment. Gross, supra, 332 Md. at
255, 630 A.2d at 1160; see also Lynx, supra, 273 Md. at 7-8, 327
A.2d at 509. Upon examination, the evidence amounts to no more than
general, imprecise allegations that cannot survive summary
judgment. Thus, however viewed, it is clear that Dr. Goodwich has
not produced facts, admissible in evidence, sufficient to
demonstrate a genuine dispute as to the material fact of whether
the restrictions Sinai imposed on his privileges were based on the
29
reasonable belief that doing so would further quality health care.
Nor do the inferences deducible from those facts he has produced
generate such a dispute.
 
Dr. Goodwich's second contention is that Sinai failed to
satisfy §11112(a)(2) because it abridged his privileges without
making any reasonable effort to obtain the facts of the matter. 
He asserts that Drs. Taylor and Currie both failed to make inquiry
into the validity of Dr. Goldstein's concerns about his practice.
As he sees it, this behavior occurred because they were driven
"purely by fear of litigation" rather than the quality of his
patient care. As we have made clear, assuming that these
allegations are accurate, the fact remains that such evidence fails
to address the relevant inquiry in this case, namely the objective
reasonableness 
of 
the 
MEC's 
action 
once 
the 
abridgement
recommendation was made.
Clearly, as long as the MEC had enough information before it
to justify the abridgement, it simply is irrelevant to the outcome
of this case whether Drs. Taylor and Currie investigated the entire
history of Dr. Goldstein's concerns about Dr. Goodwich's patient
management skills or, subjectively, were driven by fear of
litigation.  With that said, however, we note that this record
contains evidence that Dr. Goodwich does not even attempt to rebut,
specifically documentation evidencing both the hospital's concerns
about Dr. Goodwich's practice and that those concerns continued to
be raised long after Dr. Goldstein left Sinai. Indeed, Drs. Taylor
30
and Currie had direct involvement in these concerns. Moreover, the
record reflects that not only did they independently monitor Dr.
Goodwich's clinical practices during their respective tenures as
Chief of the OB-GYN Department, but they also met with members of
the Quality, Risk & Utilization Management staff to discuss Dr.
Goodwich's compliance with the second opinion requirement.
Dr. Goodwich also asserts that the abridgement took place
without any meaningful review of the cases at issue and that the
Hearing Committee "rubberstamped" the MEC's decision. As evidence
of the MEC's failure to investigate, he refers to Dr. Currie's
Hearing Committee testimony to the effect that "the MEC in essence
voted to uphold the department chairman's decision. The MEC did not
go into all the garbage. The MEC in my opinion looked at the fact
that the chief quality assurance officer for the department, the
chairman, had made recommendations and restrictions and voted to
uphold them [,]" (emphasis added). Dr. Currie's statement, however,
is precisely as he characterized it -- an opinion. His testimony
does not constitute evidence in the sense that he is an expert
witness qualified to testify as to the MEC's decisionmaking
process. Stated differently, such testimony does not constitute
evidence demonstrating the existence of a genuine dispute as to the
material fact of Sinai's entitlement to immunity.     
Thus, we note again that the proper focus in this case is not
on such unsubstantiated opinions, but rather the information the
MEC had before it regarding patient care issues and violations of
31
the second opinion requirement, when it voted to restrict Dr.
Goodwich's privileges. In that regard, and without contradiction
from Dr. Goodwich, the record reflects that, when the MEC met to
consider permanent abridgement of his privileges, it heard from
both Dr. Currie and Dr. Goodwich. Dr. Currie presented information
to the MEC concerning Dr. Goodwich's failure to comply with the
several and various second opinion agreements, as well as the many
cases, over the years, in which his patient care practices had been
questioned. Dr. Goodwich, in turn, responded to Dr. Currie's
allegations and was permitted to present any information he so
chose.
As for Dr. Goodwich's contention that the Hearing Committee
rubberstamped the MEC's decision, the record reflects, again
without contradiction by Dr. Goodwich, that the Committee consisted
of a panel of three physicians selected as neutral arbiters to
consider the reasonableness of the MEC's decision. It further
reflects that in addition to hearing from Dr. Goodwich and his
expert witness, Dr. King, all participants were provided with the
opportunity to review his departmental and medical staff files,
which included documentation of cases in which patient care
concerns were raised as well as documentation of the successive
violations of the second opinion agreements.
 Dr. Goodwich's final assertion concerning Sinai's compliance
with the requirements of §11112(a)(2), is that Dr. King's testimony
demonstrates that he was "in no way a threat to patient welfare."
32
     Dr. Goodwich also contends that Dr. King provided evidence
25
of a genuine dispute of material fact when he testified, in
effect, "that a reasonable hospital (i.e. one with a basic
understanding of the insurance industry) would not have imposed
this specific [second opinion] requirement upon Dr. Goodwich or
abridged his privileges for non-compliance without further
inquiry."   This contention was not raised in his summary
judgment affidavit and, thus, was not considered by the trial
judge in ruling on the motion. Therefore, we do not consider it
now.
Indeed, according to Dr. Goodwich, Dr. King testified that some of
the cases the MEC reviewed were not breaches of the standard of
care, at all, "once adequate inquiry was made," but that the MEC
made no such inquiry.25
Unfortunately, Dr. Goodwich's proffer of Dr. King's expert
testimony misses the mark. As we have seen, the relevant focus is
whether the MEC had enough evidence to make an objectively
reasonable decision -- not whether, in any given instance, there
was a breach of the standard of care. Indeed, the Act itself "does
not require that the professional review result in an actual
improvement of the quality of health care." Imperial, supra, 37
F.3d at 1030. Given the detailed information Sinai had before it,
as revealed by the record, none of which Dr. Goodwich has directly
challenged, we conclude that Dr. Goodwich has not produced any
evidence tending to demonstrate a genuine dispute of material fact
as to whether Sinai made a reasonable effort to obtain the facts of
the matter. His allegations to the contrary are nothing more than
"general allegations that do not show facts in detail [or] with
precision," Gross, supra, 332 Md. at 255, 630 A.2d at 1160, which
33
cannot survive summary judgment.    
Dr. Goodwich's final contention is that Sinai's review action
was not taken in the reasonable belief that the action was
warranted by the facts known, thereby violating §11112(a)(4). As he
sees it, there was no admissible evidence to suggest that the
second opinions were necessary or that he represented a danger to
patient welfare. Essentially, his argument is that there was an
insufficient nexus between the March 8 abridgement and the factual
context in which it arose. To support this conclusion, he claims
that in many of the cases offered in support of abridgement, second
opinions "were in fact part of the file," and that Sinai made no
effort to discover the facts underlying the absence of a written
second opinion in the remaining cases "to see if patient welfare
was in jeopardy."      
We begin our analysis by addressing Dr. Goodwich's assertion
that there was no evidence to suggest that the second opinions were
necessary or that he represented a danger to patient welfare.
Without question, the record refutes both of these assertions. As
to the necessity of the second opinion requirement, Dr. Goodwich
himself repeatedly agreed to the wisdom of its use. Having said
that, we simply point out that such allegations are irrelevant to
our focus here -- a focus in which we must decide whether, upon
consideration of the totality of the circumstances, Sinai's
professional review action was objectively reasonable. For reasons
that by now should be apparent, we respond to this inquiry in the
34
affirmative.  
As to the remainder of Dr. Goodwich's argument on this issue,
specifically that in "many" of the cases at issue in the
abridgement process, second opinions were part of the file, the
only factual support he offers is Dr. King's testimony concerning
two cases he reviewed. At the April 30 Hearing, Dr. King testified
that in one case, there was a written consultation in the patient's
chart. Although he conceded that, in the other case, there was no
written second opinion in the chart, Dr. King maintained that the
chart did reflect that another attending physician was "actively
involved in the management of that patient." Such evidence hardly
supports the proposition that the MEC acted unreasonably,
especially when considered in the context of the numerous cases in
which no second opinions were obtained, of which it was made aware.
We have already addressed Dr. Goodwich's contention that Sinai
neglected to review the cases in which a second opinion was absent
to see if patient welfare was threatened.  
V.
In this case, the record reflects that the restriction of Dr.
Goodwich's privileges was limited to the activity prompting it,
namely his repeated failure to comply with the second opinion
requirement -- a requirement he voluntarily consented to many times
over a four-year period. In light of that noncompliance and the
record of patient care-related issues raised with him over an
35
extended period, the summary judgment record reflects clear
evidence sufficient to establish that the hospital, conscious of
the need to protect its patients, acted in an objectively
reasonable fashion in restricting Dr. Goodwich's privileges.
The evidence proffered by Dr. Goodwich, rather than rebutting
the 
objective 
reasonableness 
of 
those 
actions, 
addressed
preliminary and tangential matters, thus failing to demonstrate a
genuine dispute of material fact as to that issue, the only one
before the court. We hold, therefore, as did the Court of Special
Appeals, that the trial court was legally correct in its grant of
summary judgment. Goodwich, supra, 103 Md. App. at 353, 653 A.2d at
547.
Our decision is based upon HCQIA immunity provisions, so we do
not reach the applicability of the Maryland statutory provisions.
We, therefore, pause only to voice our agreement with the Court of
Special Appeals that because the Maryland statute requires that a
member of a review committee act in good faith, while the HCQIA
employs objective standards of reasonableness, "[t]he State law ...
may, in some circumstances, provide additional immunity or
protection to medical review bodies. The State law is preempted by
the Federal only to the extent that it provides less immunity than
the Federal, not to the extent it provides more." Id. at 355, 653
A.2d at 548.
36
JUDGMENT AFFIRMED, WITH
COSTS.