Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca7-14-01775/USCOURTS-ca7-14-01775-0/pdf.json

Nature of Suit Code: 442
Nature of Suit: Civil Rights Employment
Cause of Action: 

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In the 

United States Court of Appeals 

For the Seventh Circuit ____________________ 

No. 14-1775 

KATHERINE LIU, 

Plaintiff-Appellant, 

v.

COOK COUNTY, et al., 

Defendants-Appellees. 

____________________ 

Appeal from the United States District Court for the 

Northern District of Illinois, Eastern Division. 

No. 10 C 6544 — George M. Marovich, Judge. 

____________________ 

ARGUED SEPTEMBER 9, 2015 — DECIDED MARCH 15, 2016 

____________________ 

Before POSNER, MANION, and HAMILTON, Circuit Judges. 

HAMILTON, Circuit Judge. Dr. Katherine Liu worked as a 

general surgeon at Cook County’s Stroger Hospital for more 

than two decades before she lost her surgical privileges and 

was denied reappointment in 2008. Cook County and the 

three individual defendants, Dr. Richard Keen, Dr. James 

Madura, and the estate of Dr. Phillip Donahue, contend that 

those actions were based on Dr. Liu’s repeated refusal to operate on patients with appendicitis. Dr. Liu claims that their 

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reasoning masked unlawful discrimination and retaliation. 

She brought a number of claims against defendants, including alleged violations of Title VII of the Civil Rights Act of 

1964, 42 U.S.C. §§ 2000e-2(a) & 2000e-3(a), and 42 U.S.C. 

§ 1981. 

The district court granted defendants’ motion for summary judgment, finding that no reasonable trier of fact could 

conclude their reasons were pretextual. We agree. Dr. Liu 

has presented only the sparsest evidence of animus based on 

her race, sex, and national origin, none of it linked to the decisions at issue. She has also failed to present evidence creating a genuine dispute of fact as to whether the defendants’ 

stated reasons for disciplining her were honest. We therefore 

affirm the decision of the district court. 

I. Background

A. Facts for Summary Judgment

In assessing whether the defendants were entitled to 

summary judgment, we examine the record in the light most 

favorable to Dr. Liu as the non-moving party, resolve all evidentiary conflicts in her favor, and grant her all reasonable 

inferences that the record permits. Coleman v. Donahoe, 667 

F.3d 835, 842 (7th Cir. 2012). 

1. The Parties

Dr. Katherine Liu is an Asian woman of Chinese descent. 

She began working at Stroger Hospital in 1984. With the exception of 1985, when she received a “good” performance 

appraisal from the Department of Surgery, she consistently 

received ratings of “excellent” and “superior” up until annual appraisals were discontinued in 1999. 

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As for the individual defendants, Dr. Keen was Chairman 

of the Department of Surgery. Dr. Madura was Chair of the 

Surgical Oversight Committee, or SOC. Dr. Donahue was 

Chief of the Division of General Surgery. All three had managerial responsibilities related to patient care at Stroger. 

In 2001, a patient at Stroger died from a ruptured appendix. That tragedy prompted Dr. Keen to write to the Hospital 

Surgical Oversight Committee advising that as a corrective 

action the Department of Surgery would admit patients with 

abdominal pain to surgical service so the hospital could recognize problems requiring surgery and operate on them early. This pro-surgery approach set the stage for the eventual 

conflict between the defendants and Dr. Liu. 

2. Early Disputes

Dr. Liu says that the discrimination began in 2003, when 

Drs. Keen and Donahue began sending a disproportionate 

number of her cases to review committees as compared to 

her white male colleagues. Her declaration does not provide 

enough detail about her colleagues to support the claim of 

disproportionality, but she says that throughout 2003 and 

2004, she met with Dr. Bradley Langer, the interim Medical 

Director at the time, to discuss the disparities she perceived. 

She has offered no direct evidence that Drs. Keen and Madura harbored animus toward her based on race, sex, or national origin. As for Dr. Donahue, Dr. Liu points to a handful 

of inappropriate remarks he made, including: (1) in 2000, he 

called her a “good girl” until she asked him to stop; (2) when 

she requested a raise, he asked why she needed one because 

her husband worked; and (3) he asked Dr. Susan Gilkey outside of Dr. Liu’s presence why all female doctors “have to be 

bitches.” 

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3. The Appendicitis Cases

In December 2004, the SOC discussed a case in which Dr. 

Liu treated a nineteen-year-old patient with appendicitis 

non-operatively and the patient suffered a heart attack. The 

minutes indicated that “Timing of operating was delayed” 

and that Dr. Donahue would “counsel Dr. Liu regarding 

treatment of appendicitis.” The minutes also stated, however, that “Dr. Liu’s care was deemed adequate.” 

This was the first in a series of clashes between Dr. Liu 

and the Stroger Hospital administration regarding her professional judgment as it pertained to the non-operative 

treatment of appendicitis.1 On April 7, 2005, the SOC met 

and discussed I.G., a patient who presented with appendicitis and whom Dr. Liu treated non-operatively. The minutes 

stated in part: 

Dr. Donahue has counseled Dr. Liu (who is the 

Attending surgeon) about her method of treating appendicitis by antibiotics only without initial surgical intervention as being nonconventional. If Dr. Liu is going to treat acute 

appendicitis w/ antibiotics, then it has been requested that it be done in a prospective manner under research protocol with IRB approval. 

 

1 Dr. Liu also received some criticism for non-appendicitis cases over the 

next few years, including a reprimand for delaying an operation in October 2006, an SOC review of a patient with a “subclinical dehiscence,” 

or partial separation of a previously closed incision, in the same month, 

an order restricting her ability to handle esophageal cases in February 

2007, and a reprimand in August 2007 for a gastroesophagectomy she 

performed. She says all these criticisms were unjustified. The nonappendicitis cases do not play a role in our decision. 

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There was no further discussion necessary, because the care 

was deemed appropriate in this case. 

In December 2006, the SOC discussed another of Dr. Liu’s 

appendicitis cases. The minutes contained little detail about 

the case itself, but the consensus was “that the management 

process was not adequate; deficient care.” Dr. Liu was supposed to be invited to the next meeting to offer her own 

views on the case, but she says that never occurred. 

In May 2007, Dr. Madura wrote to Dr. Donahue after attending a Mortality and Morbidity Conference. The conference featured a case involving a 25-year-old male patient, 

J.E., who presented with twelve hours of right lower quadrant pain, elevated white blood cell count, and a CT scan 

clearly showing acute appendicitis with a fecalith (a hardened mass of feces). Dr. Liu treated him with antibiotics and 

did not perform surgery. Seven to ten days later, the patient 

returned with an abscess and spent several days in the hospital. According to Dr. Madura, the audience unanimously 

agreed that J.E. should have received an operation when first 

admitted. He wrote that he was concerned that Dr. Liu was 

deviating from the standard of care for research purposes 

and that he was referring the J.E. case to the SOC. 

Before the SOC reviewed the case, Dr. Keen received a 

letter from resident physician Dr. Niki Christopoulos expressing similar concerns about the management of J.E.’s 

case. Dr. Christopoulos wrote that J.E. had “begged” for an 

operation during his first admission, but that Dr. Liu had decided to manage his case non-operatively. Dr. Christopoulos 

believed Dr. Liu had “grossly mismanaged” the case. 

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The SOC reviewed the J.E. case twice, on June 7 and July 

19, 2007. It recorded the following list of issues in its minutes 

for both meetings: 

1. No protocol for antibiotic management 

2. Patient is not advised of surgical vs. antibiotic management. 

3. Misinterpretation of data 

4. Inconsistency with resident & Attending 

reports. 

5. Failure to treat non-improving condition. 

The SOC decided to send a letter to the Division Chief regarding “Dr. Liu’s ongoing mismanagement of appendicitis 

calling for corrective action/disciplinary action.” It also considered recommending that Dr. Liu be sent to Peer Review, 

although it put the vote on hold until Dr. Liu could present 

her side of the case. 

On September 6, 2007, the SOC met to discuss several of 

Dr. Liu’s cases. The SOC had previously discussed two of 

them, I.G. and J.E. A third appendicitis case was erroneously 

attributed to Dr. Liu but actually belonged to a different 

physician. A fourth was unrelated to non-operative appendicitis treatment but instead involved Dr. Liu’s failure to diagnose a patient with cancer. The SOC agreed to generate a letter to Drs. Donahue and Keen expressing its view that Dr. 

Liu’s care and management of appendicitis were deficient 

and recommending a reprimand. Dr. Madura read the letter 

addressed to Dr. Donahue at an SOC meeting on October 4, 

2007. 

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On October 16, 2007, Dr. Donahue wrote Dr. Liu regarding her approach to appendicitis. He proposed that in cases 

of acute appendicitis, she simply perform an appendectomy, 

and, if she believed operation was inappropriate, she consult 

with a colleague. Dr. Liu responded via letter dated November 8, 2007. She defended non-operative appendicitis treatment as medically sound and wrote that she did not recall 

Dr. Donahue requesting that she operate on all cases of suspected acute appendicitis. She further wrote that she would 

have proceeded to surgery immediately if she had previously understood his position. She professed to be willing to follow Dr. Donahue’s request that “all cases of suspected uncomplicated acute appendicitis in our institution receive 

surgery,” at least pending the development of a formal protocol for non-operative management. 

Four days later, Dr. Madura wrote a letter to Dr. Donahue 

about three additional cases purportedly involving Dr. Liu’s 

non-operative treatment of appendicitis. (Dr. Liu contends 

just one of the patients actually had appendicitis.) So Dr. 

Donahue wrote Dr. Liu again on November 16, citing wasted 

resources and increased morbidity risk when appendicitis 

was treated without surgery. He instructed her to develop a 

protocol for non-operative management of appendicitis if 

she believed it appropriate. He also warned her that failure 

to comply with division policies would lead to censure. At 

Dr. Keen’s request, Dr. Madura conducted a departmental 

quality control project comparing operative and nonoperative appendicitis treatment in nearly 1,200 past appendicitis cases at Stroger. He concluded that acute appendicitis 

required urgent surgery. Dr. Liu was notified of this recommendation. 

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Nevertheless, on January 14, 2008, Dr. Madura discovered the case of F.G., another appendicitis patient whom Dr. 

Liu treated with antibiotics. He wrote to Drs. Donahue and 

Keen that he believed F.G.’s care was “inappropriately managed” and concluded: “It is only a matter of time before a 

tragic outcome results from this problem.” Dr. Donahue 

wrote to Dr. Liu on February 22: 

Following an earlier note in which I asked that 

you desist from your practice of experimental 

treatment of acute appendicitis[,] I was disappointed when your case of a similar nature was 

presented at morbidity conference, since the 

young patient had additional CAT scans and 

unnecessary hospital days. Also, the young 

man has his diseased appendix in situ, and is 

still at risk of complications in the future. 

In my note of October 16th, I directed you to 

consult with another surgeon if you felt compelled to consider antibiotic treatment in cases 

of acute appendicitis. You did not do so [in] 

this case, and possibly others. It is inappropriate to not follow directions from a Division 

Chief, and such deficiencies will have to be 

considered when reappointments are pending. 

Please comply with Division policies in the future. 

The SOC likewise disagreed with Dr. Liu’s treatment of F.G. 

On March 6, 2008, the SOC concluded there had been “inappropriate management” and agreed to send a letter to Dr. 

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No. 14-1775 9

Liu “stating that the committee disagrees with her continued 

management of appendicitis.” 

4. Dr. Liu Continues Non-Operative Treatment

Dr. Liu apparently did not change her approach to appendicitis cases. On April 10, Dr. Donahue wrote her another 

letter reading in part: 

Following two earlier cases, I asked that you 

desist from your unorthodox treatment of 

acute appendicitis. I was disappointed to read 

your note that a patient with acute appendicitis 

was being treated with antibiotics for invalid 

reasons. When he failed to improve several 

days later, his appendix was removed. This patient was placed at unnecessary risk because of 

your approach, which I categorize as “poor 

judgment” as well as failure to consult with 

another surgeon for your unorthodoxy. As the 

agenda showed in the Division meeting this 

morning, judgment as well as conformity to 

Division policies will be considered in the reappointment process. 

On May 2, Dr. Liu responded. She said she “agreed to 

perform appendectomy for all cases of noncomplicated appendicitis” but contended the case had involved complicated 

appendicitis, for which antibiotic treatment is “accepted 

management.” Three days later, Dr. Madura also wrote to 

Dr. Liu, informing her that her ongoing mismanagement of 

appendicitis cases and failure to comply with Dr. Donahue’s 

proposal would be presented to the Hospital Oversight 

Committee. He wrote that what concerned the Committee 

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most was Dr. Liu’s “insistence that you should not have to be 

subject to the plan of action outlined by Dr. Donahue because you too are a senior attending.” 

The conflict soon came to a head. On July 19, a young patient of Dr. Liu’s named Sandoval ended up in the surgical 

intensive care unit with serious complications. The Hospital 

Oversight Committee reviewed ICU admissions daily for 

quality assurance purposes. That same day, a member of 

Quality Assurance contacted Dr. Keen to tell him about 

Sandoval. Two committees met in special session to address 

the case: the Hospital Oversight Committee on July 21, and 

the SOC on July 24. The SOC determined that Sandoval’s 

ruptured appendicitis was apparent in a CT scan, but Dr. Liu 

did not operate until the next morning. Dr. Madura wrote to 

Drs. Keen and Donahue on July 24 informing them of the 

SOC’s unanimous conclusion that Dr. Liu’s treatment of appendicitis fell below the standard of care and was jeopardizing patients’ lives. 

Around this same time, Dr. Liu was taking action to 

combat what she felt was unfair disparagement of her practices. On July 18, she received a memo written by Dr. Donahue months before, which opened: “Previously I have 

asked that you operate on all cases of suspected acute appendicitis, since that is the way that American surgeons treat 

adult patients with acute appendicitis.” The memo repeated 

Dr. Donahue’s earlier proposal that Dr. Liu consult with a 

colleague if she felt operative treatment was inappropriate in 

a particular case of appendicitis. On July 22, Dr. Liu sent a 

memo defending her performance to Dr. Donahue, copying 

Dr. Keen and the new interim Medical Director, Dr. Maurice 

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Lemon. She also met with Dr. Lemon to complain of discrimination on July 25. 

5. Suspension, Review, and Termination

Soon after, Dr. Keen took decisive action of his own. On 

August 4, 2008, he suspended Dr. Liu’s surgical privileges 

and limited her cases to those of “low complexity.” He notified Dr. Liu, Dr. Janice Benson, President of the Medical 

Staff, and Dr. Jay Mayefsky, Chair of the Peer Review Committee. Dr. Liu was on leave at the time. Dr. Keen’s letter was 

re-sent to her late in August. 

Two weeks after she was suspended, Dr. Liu met with 

Drs. Langer and Lemon. They asked her to resign and forgo 

peer review, but she refused. On August 22, they proposed 

that in exchange for restoration of her privileges, Dr. Liu 

agree to a departmental policy regarding acute appendicitis 

treatment and acknowledge that she could have operated on 

Sandoval earlier. Dr. Liu agreed, but on August 26, Dr. Langer indicated that Dr. Keen and the SOC wanted “something a 

bit more all-encompassing than that.” He asked her to 

acknowledge that she could have operated earlier in several 

other cases. Dr. Liu did not reply. On August 29, Dr. Langer 

indicated that he could not restore Dr. Liu’s privileges. 

Stroger Hospital’s bylaws require the standing Peer Review Committee to review summary suspensions. Over the 

next few weeks, members interviewed Drs. Keen, Liu, and 

others. The Committee also reviewed medical records and 

reports from the Hospital Oversight Committee and Drs. Liu 

and Keen, and received correspondence from other physicians. Drs. Keen, Madura, and Donahue did not control the 

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tee at all. Dr. Liu suggests that the proceedings were nonetheless unfair because she had insufficient notice of the conduct she was to rebut and was forced to review cases that 

were several years old. 

Though the timing is unclear, during the review process, 

another appendicitis case involving Dr. Liu came to Dr. 

Keen’s attention. Sometime in October 2007, Dr. Liu had 

been an attending physician for a patient named Diane 

Bucki. Dr. Liu was part of the decision to treat Bucki’s appendicitis with antibiotics. Bucki’s appendix eventually perforated, and she received emergency surgery at a different 

hospital. She sued the County, Dr. Liu, and a former intern 

for malpractice. The case eventually settled for $190,000, 

though Dr. Liu was dismissed from the lawsuit before the 

execution of the settlement. The County told Dr. Keen of the 

case around the time of the settlement. He added that case to 

the mix. 

On September 25, the Committee issued its unanimous 

report. As “Complaints,” the report listed Dr. Liu’s nonoperative management of appendicitis despite repeated instructions to the contrary and her “large number of complications on more complex cases,” although the Committee 

also “felt that she is bright and a competent surgeon.” The 

Committee found: 

1. The process of oversight in the Department 

of Surgery is not without the potential for 

bias, and this may lead a department member to feel that she/he is the subject of unfair 

scrutiny. This can cause animosity, and elicit stubbornness and reluctance to change. 

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2. That being said, there is sufficient evidence 

to support the complaints against Dr. Liu. 

She is not managing appendicitis as per the 

accepted standard of care at Stroger Hospital, and some of her patients have therefore 

experienced complications. She has refused 

to follow the directives of her department 

and division chiefs. She has exhibited poor 

judgment in the management of several 

other types of surgical cases. These have led 

to [a] number of complications. 

3. The Committee is especially concerned 

with Dr. Liu’s lack of insight into her problems. 

The Committee recommended that the suspension continue 

until Dr. Liu completed counseling, “with the goals of gaining insight into her problems, accepting responsibility for 

her actions, and learning how to change in response to feedback.” The Committee recommended restoring her privileges once she completed counseling. 

The Executive Medical Staff, or EMS, is composed of 

about 40 individuals and is responsible for independently 

reviewing peer review reports. No single person controls the 

EMS. Pursuant to the bylaws, the EMS met and discussed 

Dr. Liu’s summary suspension three times in October. 

Though the EMS voted against terminating Dr. Liu on October 14, ultimately, on October 22, all the EMS members present (save one who abstained) voted to keep the suspension 

in full force and to reduce Dr. Liu’s clinical privileges to a 

limited number of general surgery cases. 

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At Stroger, every physician must reapply and be reappointed to the staff every two years. In Dr. Liu’s case, the 

Credentials Committee recommended denying reappointment. Drs. Madura and Donahue were recused from the 

Committee but spoke about Dr. Liu’s clinical deficiencies. Dr. 

Keen was never part of the Committee; he, too, spoke about 

Dr. Liu. Dr. Mayefsky summarized the Peer Review Committee’s findings on the summary suspension. During her own 

appearance before the Credentials Committee, Dr. Liu defended her conduct by stating that she was “entitled to treat 

patients in the way she sees best.” 

The EMS adopted the Credentials Committee’s recommendation against reappointment by a vote of eighteen to 

one, with two abstentions. Dr. Liu appealed both decisions. 

A three-person committee selected by medical staff president 

Dr. Benson conducted an evidentiary hearing in the fall of 

2009. A successful appeal required the physician to show by 

clear and convincing evidence that the EMS decision was arbitrary, capricious, or unreasonable—a task presumably 

made difficult by the fact that the EMS did not keep records 

of its decision-making process. After nine sessions, including 

fifteen witnesses and dozens of exhibits, the leader of the 

committee, Dr. David Levine, drafted unanimous recommendations finding that Dr. Liu had not proven her case and 

upholding both the summary suspension and the denial of 

reappointment. Drs. Keen and Madura had no control over 

the hearing committee. By the time the hearing committee 

issued its recommendation, Dr. Donahue had passed away. 

Dr. Liu nevertheless attacks this process as unfair, primarily 

because the number of cases asserted against her increased 

throughout. 

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This was not quite the end of the process Dr. Liu received, though. Pursuant to the bylaws, on January 12, 2010, 

EMS adopted the hearing committee’s recommendations by 

a vote of eighteen to seven, with three abstentions. The Joint 

Conference Committee upheld that determination by a vote 

of six to three in March. The Health System Board of Directors upheld the determination again in April. 

Finally, also in January 2010, Dr. Liu was terminated for 

her behavior during the suspension and reappointment proceedings. She accessed patient records to try to prove that 

her performance was better than that of her colleagues. Dr. 

Keen brought disciplinary charges against her. Following a 

hearing before an independent hearing officer, she was discharged, ostensibly for violating the Health Insurance Portability and Accountability Act, or HIPAA, the Cook County 

Health and Hospital System Privacy Policy, and Stroger’s 

own HIPAA policy. 

B. Procedural History

Dr. Liu brought suit alleging race, sex, and national 

origin discrimination, as well as retaliation and harassment. 

She asserted a number of other claims as well, but those are 

not at issue in this appeal. Defendants moved for summary 

judgment, and the district court granted that motion in its 

entirety. With respect to the Title VII discrimination and retaliation claims, the court assumed without deciding that Dr. 

Liu could establish a prima facie case of discrimination. It 

then identified the defendants’ stated non-discriminatory 

reason for disciplining Dr. Liu—the failure to treat appendicitis with surgery—and held that Dr. Liu had failed to raise a 

genuine dispute of fact as to whether that reason was a pretext for discrimination based on race, sex, or national origin. 

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The court also rejected the harassment claims because the 

letters and reprimands Dr. Liu received were neither objectively offensive nor related to her sex, race, or national 

origin. Finally, on her retaliation claims, the court held that 

Dr. Liu had produced insufficient evidence to show causation under the direct method and that she could not prevail 

under the indirect method due to a lack of evidence of pretext. Dr. Liu appealed with respect to these claims. We have 

jurisdiction pursuant to 28 U.S.C. § 1291. 

II. Analysis

We review de novo the district court’s decision to grant 

summary judgment. Ripberger v. Corizon, Inc., 773 F.3d 871, 

876 (7th Cir. 2014). In discrimination and retaliation cases 

under Title VII, a plaintiff may defeat summary judgment 

via either the direct or indirect method of proof, id. (discrimination); Harper v. C.R. England, Inc., 687 F.3d 297, 306 (7th 

Cir. 2012) (retaliation), though it is a mistake to adhere too 

rigidly to those methods. The proper question under either 

method is simply whether a reasonable trier of fact could infer retaliation or discrimination. See Castro v. DeVry University, Inc., 786 F.3d 559, 564 (7th Cir. 2015), citing, among other 

cases, Bass v. Joliet Public School Dist. No. 86, 746 F.3d 835, 840 

(7th Cir. 2014), and Coleman v. Donahoe, 667 F.3d 835, 863 (7th 

Cir. 2012) (Wood, J., concurring) (arguing that “the time has 

come to collapse all these tests into one”). The substantive 

standards and methods of proof that apply to Title VII race 

discrimination and retaliation claims also apply to Dr. Liu’s 

claims under 42 U.S.C. § 1981. Smith v. Bray, 681 F.3d 888, 896 

(7th Cir. 2012). We follow Dr. Liu’s lead in considering her 

claims for discrimination and retaliation together before 

turning to her hostile work environment claim. 

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A. Discrimination and Retaliation

The district court analyzed Dr. Liu’s national origin and 

sex discrimination claims under both the direct and indirect 

methods of proof, her race-based discrimination claims under the indirect method only, and her retaliation claims under the direct and indirect methods. On appeal, Dr. Liu argues only that her claims should have survived summary 

judgment under the indirect method of proof. Under the indirect method, a plaintiff must establish a prima facie case of 

discrimination or retaliation, after which the burden shifts to 

the employer to articulate a non-discriminatory reason for its 

action. Then, the burden shifts back to the employee to show 

that reason is pretextual. Collins v. American Red Cross, 715 

F.3d 994, 999–1000 (7th Cir. 2013) (discrimination); Harper, 

687 F.3d at 309 (retaliation). Of course, “when all is said and 

done, the fundamental question at the summary judgment 

stage is simply whether a reasonable jury could find prohibited discrimination.” Bass, 746 F.3d at 840. 

Like the district court and the parties, we focus our analysis on the question of pretext. The burden is on the plaintiff 

to offer evidence that her employer’s stated nondiscriminatory reason was a lie intended to mask unlawful 

discrimination. E.g., Harden v. Marion County Sheriff’s Dep’t, 

799 F.3d 857, 864 (7th Cir. 2015); Widmar v. Sun Chemical 

Corp., 772 F.3d 457, 465 (7th Cir. 2014); Naik v. Boehringer 

Ingelheim Pharmaceuticals, Inc., 627 F.3d 596, 601 (7th Cir. 

2010). “The question is not whether the employer’s stated 

reason was inaccurate or unfair, but whether the employer 

honestly believed the reason it has offered” for the adverse 

action. O’Leary v. Accretive Health, Inc., 657 F.3d 625, 635 (7th 

Cir. 2011). 

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Even if an employer’s decision is mistaken, there is no 

pretext so long as the decision-maker honestly believed the 

non-discriminatory reason. Hague v. Thompson Distribution 

Co., 436 F.3d 816, 823 (7th Cir. 2006), quoting Ballance v. City 

of Springfield, 424 F.3d 614, 617 (7th Cir. 2005); see also Yindee 

v. CCH Inc., 458 F.3d 599, 602 (7th Cir. 2006) (“It is not 

enough to demonstrate that the employer was mistaken, inconsiderate, short-fused, or otherwise benighted; none of 

those possibilities violates federal law. Poor personnel management receives its comeuppance in the market rather than 

the courts.”) (citations omitted). A plaintiff may show a genuine dispute of fact on pretext by identifying “such weaknesses, implausibilities, inconsistencies, or contradictions” in 

a stated reason that a reasonable trier of fact could find it 

“unworthy of credence.” Harper, 687 F.3d at 311, quoting 

Boumehdi v. Plastag Holdings, LLC, 489 F.3d 781, 792 (7th Cir. 

2007). 

To justify the actions taken against Dr. Liu, defendants rely on her failure to operate immediately in appendicitis cases. Over several years, Dr. Liu received frequent instructions 

to operate when patients presented with appendicitis. The 

undisputed facts show that she repeatedly refused to do so. 

After several incidents in which patients suffered “complications,” a euphemism here for grave dangers to life and 

health, her privileges were suspended and she was denied 

reappointment to the hospital staff. These determinations 

were affirmed no fewer than six times by different medical 

committees, passing through the Peer Review Committee/Credentials Committee, the EMS, the three-person hearing committee, the EMS a second time, the Joint Conference 

Committee, and the Health System Board of Directors. 

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On this record, we cannot agree with Dr. Liu that the defendants’ stated non-discriminatory reason for the actions 

they took was “highly questionable.” Dr. Liu points to nothing in the record supporting her argument that defendants 

“created” a false “trail of alleged wrongdoing.” In fact, she 

continues to defend on the merits her many decisions not to 

operate on patients with appendicitis. And her complaints 

about the fairness of the process she received and defendants’ tendency to introduce additional evidence do not show 

that defendants secretly “directed” all the stages of independent review or served as “the prosecutors, the witnesses, 

and the jury.” While Drs. Keen, Madura, and Donahue were 

certainly involved in presenting the case against her, she has 

presented no evidence that they controlled these bodies’ decision-making. 

Dr. Liu argues that defendants were medically off-base in 

condemning the non-operative approach to appendicitis. She 

asserts that the use of antibiotics to treat appendicitis has 

support in the medical literature and that it was appropriate 

for the patients she treated that way. For purposes of summary judgment, we must allow for the possibility that defendants were unduly narrow-minded on the medical issues. 

But this would not make their reasoning any less believable, 

particularly given the complications that some patients like 

J.E., Diane Bucki, and Sandoval suffered when Dr. Liu delayed operating or chose not to operate at all. 

Dr. Liu also points to purported weaknesses in defendants’ reasoning, which, as we have said, can permit an inference of pretext. Harper, 687 F.3d at 311. She first attacks the 

punishment imposed upon her as inconsistent with her supposed transgressions. If her failure to perform surgery truly 

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drove defendants’ decisions, she argues, the proper course of 

action would be to encourage surgery by instituting a proctorship or ordering her to operate on appendicitis patients. 

But the record demonstrates that defendants attempted to do 

exactly that for months. They directed Dr. Liu to operate on 

appendicitis patients or to consult with a colleague if she believed operating was inappropriate in a given case. She repeatedly refused to comply. The fact that defendants eventually decided to restrict Dr. Liu’s privileges altogether does 

not, in light of her history, undermine the credibility of defendants’ concerns over her repeated refusal to operate on 

appendicitis patients as directed. The undisputed facts show 

her history of non-compliance with earlier efforts to encourage her to operate, supported by her statement to the Credentials Committee that she was “entitled” to treat patients 

as she saw fit. 

Dr. Liu also argues that a trier of fact could infer pretext 

because she was punished for treating appendicitis nonoperatively when defendants themselves admit that other 

general surgeons also use non-operative treatment at least 

two to three percent of the time without repercussions. But 

Dr. Liu has presented no evidence that any other surgeon (1) 

managed appendicitis non-operatively after explicit instructions not to do so; or (2) caused, or appeared to cause, the 

complications that Dr. Liu’s treatments appeared to cause. 

Put another way, Dr. Liu oversimplifies the conduct for 

which she was punished. After she refused to comply with 

repeated instructions to operate on appendicitis patients and 

her patients experienced several near-tragedies, Stroger terminated her privileges and denied her reappointment. She 

has pointed to no other surgeon who engaged in a comparable course of conduct. 

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No. 14-1775 21

Next, Dr. Liu argues that the other reprimands she received show pretext because those clashes were not related 

to her treatment of appendicitis. But Dr. Liu does not explain 

how these earlier admonitions, even if we presume they 

were unfair, call into question the legitimacy of defendants’ 

concern about her repeated non-operative treatment of appendicitis. To the extent her theory is that these nonappendicitis reprimands were part of a broad conspiracy to 

discriminate, the theory is not a reasonable inference on this 

record. The evidence of unlawful animus is minimal, and 

defendants’ non-discriminatory justification is wellsupported. Without supporting evidence, Dr. Liu’s attempt 

to characterize the appendicitis dispute as one more volley 

in a discriminatory “assault on her professional competence” 

is only speculation. See Matthews v. Waukesha County, 759 

F.3d 821, 824 (7th Cir. 2014) (non-moving party is not entitled 

to the benefit of “inferences that are supported only by speculation or conjecture”). 

Finally, Dr. Liu argues that the offer of what she calls the 

“backroom deal,” in which she was offered the chance to 

avoid peer review if she agreed to abide by a departmental 

policy for treatment of appendicitis and to admit her errors 

in a number of cases, suggests pretext. In her view, the offer 

shows that no one truly believed she was a danger to patients because she could have kept her privileges and her 

appointment if she had “submitted.” Again, that inference is 

not reasonable on this record, which is replete with undisputed evidence that defendants and the SOC believed Dr. 

Liu’s approach was dangerous—to say nothing of the complications that actually occurred in some cases. 

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22 No. 14-1775 

The same is true of what Dr. Liu calls the HIPAA “ruse.” 

She says that she was well within her rights to access patient 

information to prove that her colleagues erred more frequently than she did, and that defendants’ HIPAA expert 

was unaware of any cases in which a physician was terminated for violating HIPAA. But the pretext inquiry turns on 

honesty, not correctness, and even if we assume a less severe 

punishment might have been more appropriate, that fact 

does not, without more, provide evidence of pretext. See Zayas v. Rockford Memorial Hospital, 740 F.3d 1154, 1158–59 (7th 

Cir. 2014) (“Thus, it is irrelevant if Zayas’ emails were not 

egregious enough to justify her termination, as long as 

Griesman believed they were. ... Therefore, we have no 

trouble finding that Zayas’ emails were not a pretextual basis 

for her termination.”). 

As a matter of medical science, we must assume for purposes of summary judgment that Dr. Liu might ultimately be 

correct that her approach to appendicitis treatment will 

prove to be sound. But as we have said many times, we do 

not sit as a super-personnel department, examining the wisdom of employers’ business decisions. E.g., Widmar v. Sun 

Chemical Corp., 772 F.3d 457, 464 (7th Cir. 2014); Traylor v. 

Brown, 295 F.3d 783, 790 (7th Cir. 2002); see also Forrester v. 

Rauland-Borg Corp., 453 F.3d 416, 418 (7th Cir. 2006) (in analyzing pretext, “the question is never whether the employer 

was mistaken, cruel, unethical, out of his head, or downright 

irrational in taking the action for the stated reason, but simply whether the stated reason was his reason: not a good reason, but the true reason”) (emphasis in original). By the same 

token, we certainly do not sit as a super-medical review 

committee. Nothing in the record before us suggests that defendants’ concern with Dr. Liu’s repeated refusal to operate 

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No. 14-1775 23

on appendicitis and the repeated dangerous “complications” 

was false. The district court correctly granted summary 

judgment for defendants on these claims for race, sex, and 

national origin discrimination and for retaliation. 

B. Hostile Work Environment

To survive summary judgment on her claims for hostile 

work environment, Dr. Liu must have presented sufficient 

evidence to present a material issue of fact on four elements: 

(1) her work environment must have been subjectively and 

objectively offensive; (2) her race, sex, and/or national origin 

must have been the cause of the harassment; (3) the conduct 

must have been severe or pervasive; and (4) there must be a 

basis for employer liability, meaning either that a supervisor 

participated in the harassment or that Stroger Hospital was 

negligent in discovering or remedying co-worker harassment. Montgomery v. American Airlines, Inc., 626 F.3d 382, 390 

(7th Cir. 2010). 

Dr. Liu contends that the reprimands she received, including those unrelated to her treatment of appendicitis, 

constituted harassment sufficiently offensive, pervasive, and 

severe to overcome summary judgment. We need not decide 

this question, however, because no evidence permits a reasonable inference that those reprimands were related to Dr. 

Liu’s membership in any protected class. Dr. Liu proffers only Dr. Donahue’s statements to prove a connection: (1) he 

called her a “good girl” in the year 2000; (2) he once asked 

Dr. Liu why she needed a raise when her husband worked; 

(3) he asked a different female doctor, outside of Dr. Liu’s 

presence, why all female doctors have to be “bitches”; and 

(4) he sent the May 2, 2008 memo stating that “American 

surgeons” treat appendicitis with surgery. Dr. Liu has ofCase: 14-1775 Document: 43 Filed: 03/15/2016 Pages: 24
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fered no evidence that the first three remarks, none of which 

came from Drs. Keen or Madura, are connected in any way 

to the memoranda and reprimands she received much later. 

Dr. Donahue’s “American doctors” remark did appear in one 

of the letters that Dr. Liu condemns as harassment, but that 

single ambiguous remark, bolstered by nothing more than 

Dr. Liu’s own speculation, cannot support her theory that 

national-origin bias motivated the defendants’ behavior in 

communicating their disagreement with the quality of care 

she provided to patients. 

The judgment of the district court is AFFIRMED. 

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