Opinion ID: 761706
Heading Depth: 2
Heading Rank: 1

Heading: Brader's Problems in the Operating Room and with Hospital

Text: Personnel 4 Brader is a surgeon who joined AGH's provisional medical staff on July 1, 1988. Under AGH's Bylaws, which govern the rights and responsibilities of both permanent and provisional medical staff members, a doctor initially serves as a provisional staff member and requests advancement after one year at that level. See Bylaws Art. III § 1.A. Dr. Diamond, the director of the Division of General Surgery, was Brader's direct supervisor. Dr. Magovern was Chairman of the Department of Surgery and Diamond's supervisor. 5 Soon after his arrival at AGH, Brader performed an abdominal aortic aneurysm (AAA) repair on a patient. During the course of the operation, the patient allegedly sustained a number of visceral injuries and died on the operating table. Diamond, who observed the surgery at its tail end, concluded that the patient died not from the aneurysm but as a result of bleeding from the injuries. He also believed that Brader had delegated too much responsibility to a resident during the operation and that Brader had failed to resume control fast enough when the operation began to go badly. 6 On May 29, 1989, Brader operated on a patient who had sustained a stab wound to the chest. Brader argued with Dr. Demmy, the cardiothoracic surgical resident on call, over the proper surgical approach to the patient. Brader overruled the resident's approach--even though the attending cardiothoracic surgeon had approved Demmy's plan--and proceeded to operate using a median sternotomy. However, it became clear during the surgery that this approach was not adequate, and Brader's incision had to be extended significantly, resulting in a longer patient recovery. Magovern felt that Brader's approach was a serious departure from the way AGH handled stab wounds to the chest, and that the wound could have been handled much more judiciously using Demmy's plan. Brader's explanation (in his testimony) was that he was the physician responsible for the patient, and that he was not about to relinquish the care of this critically ill patient at that point to a cardiothoracic surgery fellow whom he had not met before. 7 This incident led to the first of several meetings between Diamond and Magovern about Brader's personal and professional behavior. Magovern indicated that he wished to fire Brader based on the incident with Demmy, but Diamond defended Brader's action. Diamond encouraged Magovern to talk to Brader. Magovern did so, but according to both parties, the meeting was a disaster. Brader testified that Magovern was out to get him from the minute one, whereas Magovern felt that Brader's tone was rude, offensive, and insubordinate. Magovern emerged with the impression that Brader would not accept AGH's triage protocol, under which patients with chest wounds were to be treated by the cardiothoracic service. 8 The record portrays Brader as a disruptive force in the hospital. Not only did he cause friction between the cardiothoracic unit and the trauma service, but he also told orthopedic trauma surgeons that they were not using the proper procedures for certain traumas. As a result, Diamond had to intercede to calm the waters. Brader allegedly made derogatory statements to nurses, but at a meeting organized by Diamond to address the issue, Brader refused to act in a conciliatory manner. Diamond testified, It really was incredibly unpleasant, time consuming, and literally every day there was a new nightmare of some kind that he had to solve. 9 On October 27, 1989, Brader operated on another stab wound patient but did not notify the cardiothoracic service that the patient had a chest wound. Brader's decision again created controversy, since it violated hospital protocol. On January 7, 1990, during an elective AAA repair, Brader was unable to control the bleeding, and was forced to sacrifice the patient's left kidney. The patient's spleen was lacerated as well. The patient died a few hours later. By virtue of these events, AGH decided on February 27, 1990, to extend Brader's provisional Medical Staff membership for a year rather than promote him to attending status. 1 B. The Internal Review 10 In the spring of 1990, several AGH anaesthesiologists approached Magovern about the amount of time taken and quantity of blood used in AAA procedures. In response, Magovern asked the Quality Assurance Department (QAD) to compile data for each AAA procedure performed. The QAD broke out its results for each physician. Magovern testified that [w]hat was striking was that of the 5 people who had done the [AAA] cases, one surgeon accounted for 50 percent of the mortality in the ruptured abdominal cases, whereas the other 4 people ... [had approximately] 10 percent each. That one surgeon was Brader. Magovern felt that it was a difference enough within [Brader's] group that it should be looked into, and asked Diamond to do so. 11 Diamond reviewed and compared the AAA procedures performed by Brader and the other surgeons. He concluded that Brader's operative record reflected deficiencies in skill, as well as unconscionable judgment. Diamond was less concerned with Brader's mortality rate than with the injuries and complications that occurred during his surgeries, and the fact that he gave residents too much responsibility. On May 25, 1990, Diamond and AGH Vice President Virginia Opipare met with Brader about these findings. Brader did not have advance notice of the meeting. The trio agreed that the Hospital would seek an outside reviewer to look over Brader's AAA procedures, and that Brader would temporarily, and voluntarily, stop performing AAA repairs. 12 Three days later, Brader sent Opipare a note stating that the impromptu nature of this meeting was most unfair to me. Brader also indicated that he had spent the weekend reviewing his AAA experience and results. According to his calculations, his mortality rate stood at 52.9%. His letter also stated that he had reviewed 165 AAA cases from AGH and calculated the overall mortality rate as 52.7%; that in 1988 AGH had two full time attending surgeons with mortality rates over 70%; and that a prompt reversal of [their] decision to suspend [his] abdominal aortic aneurysm privileges [was] necessary and clearly warranted. C. Suspension of Brader's AAA Privileges 13 After some difficulty finding an outside reviewer, AGH found a New Orleans surgeon named Dr. John Ochsner to review Brader's file. Brader agreed to Ochsner's selection. The Hospital sent Ochsner the AAA Quality Assurance study, individual case lists for general surgeons, case summaries prepared by Diamond, and pertinent patient records. Brader also submitted his own summary and interpretation of his AAA procedures. Brader requested that he be available to answer any questions the reviewer might have and that he be able to meet with the reviewer before any decision was made, although it is not clear whether Diamond and Opipare agreed to this request. 14 In a letter dated September 27, 1990, Ochsner submitted to AGH a summary of his findings. In it, he stated: 15 Of greatest concern ... was the fact that of the twelve ruptured abdominal aortic aneurysms there were a tremendous number of complications.... The mortality rates for such cases can be quite high. However, the thing that concerned us most was that there were many complications and many maneuvers in what we would consider poor surgical judgement.... In general, intra-abdominal visceral injuries are quite rare during aortic surgery but there were fifteen different intra-abdominal visceral injuries in the twenty patients.... In conclusion, at our institution if a staff surgeon had this sort of record on his vascular operations, we would insist that he be supervised by more experienced surgeons for a period of time until his technique and judgement could be ascertained to be adequate or not. 16 On October 12, Magovern and Opipare met with Brader to discuss the Ochsner report. Magovern requested that Brader continue to refrain from performing AAA repairs without supervision. Brader refused, stating that he would perform any such procedures that came in while he was on call. Brader stated that the only way for Magovern to prevent him from doing AAA repairs was to suspend his privileges. Magovern thereupon suspended Brader's AAA privileges and reported the suspension to Anthony Sanzo, President of AGH. In his letter to Sanzo, Magovern stated that he had determined it would be necessary, in order to prevent 'an imminent danger to the health of any individual,' to suspend Dr. Brader's privileges to perform abdominal aortic aneurysm procedures. Sanzo wrote to Brader the same day, informing him that his AAA privileges had been suspended and advising him of his procedural rights under the Bylaws. 17 D. Denial of Brader's Advancement to Attending Staff Status 18 While these events were unfolding, Diamond had decided that he could not support Brader's advancement to full membership on the medical staff. In an August 1, 1990 letter to Magovern, Diamond stated that he had defended Brader in the past, but had reached the conclusion that Brader has not changed significantly and that he will continue to be disruptive and unable to satisfy Allegheny's standards of patient care and teaching. Magovern agreed, and said so in his letter to Dr. George Berg, Chairman of the Medical Staff's Credentials Committee (CC). The CC, which had before it Brader's request for advancement from his provisional staff status, considered Diamond's and Magovern's letters, letters from Brader to the CC, and letters of support for Brader from various doctors and hospital employees. On October 15, the CC voted 7-1 to recommend to the Executive Committee (EC) that Brader not be advanced to attending staff membership. Berg testified that the CC made its decision in order to safeguard AGH's patients. 19 The CC's recommendation went to the EC. The EC considered the CC recommendation and asked Diamond and Magovern to elaborate on the bases for their recommendations, which they did. The EC concluded that (1) Brader was unable to work harmoniously with others at AGH; (2) Brader had exercised poor surgical judgment, which posed a threat to patients; and (3) he was unable to take directions and accept others' authority. The EC voted unanimously that Brader not be advanced; Diamond and Magovern refrained from voting. Sanzo wrote to Brader on the same day, informing him of the EC decision and of his due process rights. E. Suspension of All Clinical Privileges 20 In the same EC meeting, the Committee expressed concern that Brader was a loose cannon who would present a risk to patients and therefore discussed suspending all of Brader's clinical privileges. Although the EC took no formal action, it suggested that Magovern evaluate whether it was appropriate for Brader to continue to exercise any clinical privileges. The next day, Magovern recommended to Sanzo that Brader's privileges be summarily suspended, stating that a failure to suspend all his privileges has substantial potential for exposing the hospital's patients to imminent danger. Sanzo accepted this recommendation and notified Brader by letter of Sanzo's decision and of his due process rights. 21 F. Hearing on the Decision to Suspend Brader's AAA Privileges 22 Following these three decisions--to suspend Brader's AAA privileges, not to recommend his advancement to the attending staff, and to suspend all of his clinical privileges--Brader exercised his rights under the Bylaws and requested hearings with respect to each decision. According to the Bylaws, the purpose of a hearing is to recommend a course of action to AGH's Board of Directors, and should be conducted in as informal a manner as possible. Bylaws, Art. VIII § 1. The hearing panel is required to support the original finding unless the recommendation at issue in the hearing is unreasonable, not sustained by the evidence, or otherwise unfounded. Id. § 3 .H.iii. 23 During the five-day hearing in 1991 regarding Magovern's suspension of Brader's AAA privileges, Brader called seven witnesses. AGH called five, each of whom was subject to cross-examination by Brader's counsel. The hearing panel had before it Ochsner's report, as well as testimony about the October 12, 1990 meeting of Brader, Magovern, and Opipare, and written arguments by Brader. At the hearing's conclusion, the panel unanimously recommended: (1) that Magovern had the authority to suspend Brader's privileges; (2) that Magovern's actions had been proper; but (3) that Brader's suspension should be lifted because the panel concluded that his performance of AAA surgery did not constitute an immediate danger to the health of any patient. This recommendation, which Brader did not appeal, was forwarded to AGH's Board of Directors for further action. 24 G. Hearing on the Total Privilege Suspension and the 25 Decision Not to Advance Brader to Attending Status 26 The second hearing, held over ten days in 1992, reviewed the decision to totally suspend Brader's clinical privileges and the decision not to advance him to the attending staff. Brader called two witnesses (including himself) and AGH called six, each of whom was subject to cross-examination. The panel called two witnesses of its own, who also were subject to cross-examination. The panel heard testimony about Brader's AAA procedures, Ochsner's report, Brader's reaction to that report, and Brader's hostile interactions with others. At the end of the hearing, the panel upheld the summary suspension of Brader's privileges, but recommended that the suspension be lifted as moot, since by then Brader had relocated to North Carolina. In addition, the panel noted that because of difficulties accepting guidance and acting collegial, the Executive Committee of the Medical Staff's recommendation to not advance Dr. Brader from Provisional Staff status was made in good faith and based on proper and reasonable evidence and should be sustained. H. Appellate Review 27 Brader appealed the 1992 panel's recommendation to an appellate review panel, as provided for in the Bylaws. The Bylaws state that the grounds for appeal shall be that there was a substantial failure to comply with the Bylaws, the recommendation was arbitrary or capricious, or the recommendation was not supported by the evidence. Bylaws, Art. VIII § 4.B. The panel reviewed written submissions from and heard oral argument by both sides. The appellate panel upheld the hearing panel's recommendation that Brader not be granted attending status, deciding that Brader was not denied due process, that he received a fair hearing, and that the recommendations of the CC, the EC, and the hearing panel were substantially supported by the evidence. However, the panel recommended that the summary suspension of all of Brader's clinical privileges be lifted because there was insufficient substantive medical evidence to warrant continued suspension. These recommendations were sent to the Board.