Court Opinion

ID: 9536198
Source: CourtListenerOpinion
Date Created: 2023-08-07 06:56:10.191009+00
Date Added: 2024-06-11T13:33:28.936241
License: Public Domain

MOSK, J.
I dissent.
Once again the majority of this court impose upon private hospitals —as they did in Ezekial v. Winkley (1977) 20 Cal. 3d 267 [142 Cal. Rptr. 418, 572 P.2d 32]—a burden that is likely to interfere with the efficient administration of such institutions. I adopt much of the same rationale that impelled me to dissent in Ezekial (id., p. 280-284).1
Here the majority by ipse dixit declare that rules for staff admission applicable to public hospitals apply equally to private hospitals. With one significant exception, there is no authority in statute or case law to justify that conclusion. Private institutions, whether eleemosynary or operated for profit, may employ their facilities with considerably more freedom from external intervention than may those hospitals supported by the taxpayers of a state, county, city or district.
As authority to the contrary the majority rely on Willis v. Santa Ana etc. Hospital Assn. (1962) 58 Cal.2d 806, 810 [26 Cal.Rptr. 640, 376 P.2d 568], and Blank v. Palo Alto-Stanford Hospital Center (1965) 234 Cal.App.2d 377, 383 [44 Cal.Rptr. 572]. I submit that neither case is apposite. Willis permitted a suit to be brought under the theory of a common law conspiracy to restrain competition; obviously conspiracies *637by any agencies, public or private, are prohibited. Blank merely assumed the issue arguendo and cited Willis.
The one exception that may justify interference with operations of a private hospital arises in those instances in which the institution enjoys monopoly status. From James v. Marinship (1944) 25 Cal.2d 721 [155 P.2d 329, 160 A.L.R. 900], the seminal case on this subject by Chief Justice Gibson, to Justice Tobriner’s opinion in Westlake Community Hosp. v. Superior Court (1976) 17 Cal.3d 465, 486 [131 Cal.Rptr. 90, 551 P.2d 410], “Our past decisions demonstrate that this court has been adamant in its endeavor to eradicate monopolistic control of professional opportunities.” The operative words are “monopolistic control.”
If this plaintiff can factually establish that the defendant hospital has such a monopoly in its area, and that denial of staff membership at that hospital has the effect of preventing him from pursuing his profession, then he may seek to invoke procedures comparable to those applicable to public hospitals.
In the absence of such evidence, however, I would reach the same conclusion as that of Justice Kaufman, dissenting in the Court of Appeal, a position urged upon us by amicus curiae California Medical Association. Therefore I adopt in toto Justice Kaufman’s opinion as my own. It follows: I dissent. In a misguided effort to rescue one litigant from the consequences of his own irresponsible irascibility the majority preclude every hospital in the State of California from considering in medical staff admission decisions a factor vital to the competent operation of a hospital and the delivery of high quality medical services— the ability of the physician-applicant to work cooperatively with others.
As has been cogently noted, “... it is difficult to understand how a hospital is to adhere to modern concepts of hospital administration if it cannot consider the ability of its staff members to cooperate. .. . ” (Note, Hospital Staff Privileges: The Need for Legislation (1965) 17 Stan.L.Rev. 900, 916.) “When considering the interest of the patient, it is not enough that his doctor possess the necessary skills of his profession. The absence of a compatible team working together could impair the doctor’s performance and consequently undermine the effectiveness of the treatment given the patient.” (Silver v. Castle Memorial Hospital (1972) 53 Hawaii 475, 479 [497 P.2d 564, 568].) “It has been pointed out that ‘considerations of team spirit and cooperativeness can be as important as technical skill in recommendations for staff appoint*638ments; or, put another way, professional competence in hospital practice should, according to modern hospital theory, include qualities needed for cooperative staff work.’” (Id., at p. 568, fn. 4, quoting from Hospital Staff Privileges: The Need for Legislation, supra, 17 Sir n.L.Rev. at p. 905.)
I do not quarrel with the majority’s statement of the rule of law that standards for admission to staff privileges may not be “so vague and ambiguous as to provide a substantial danger of arbitrary discrimination in their application.” (Rosner v. Eden Township Hospital Dist. (1962) 58 Cal.2d 592, 598 [25 Cal.Rptr. 551, 375 P.2d 431]; accord: Ascherman v. Saint Francis Memorial Hosp. (1975) 45 Cal.App.3d 507, 513 [119 Cal.Rptr. 507]; Martino v. Concord Community Hosp. Dist. (1965) 233 Cal.App.2d 51, 58-60 [43 Cal.Rptr. 255]; Wyatt v. Tahoe Forest Hospital Dist. (1959) 174 Cal.App.2d 709, 715 [345 P.2d 93].) However, the conclusion of the majority that the standard here at issue is invalid under the stated rule is not required by the decisions nor does it serve sound public policy or promote the delivery of good medical services.
Admittedly, the substantive content of the standard “ability to work with others, with sufficient adequacy to assure... a high quality of medical care” cannot be quantified with precision, but “‘in the area of personal fitness for medical staff privileges precise standards are difficult if not impossible to articulate. . . . The subjectives of selection simply cannot be minutely codified. The governing board of a hospital must therefore be given great latitude in prescribing the necessary qualifications for potential applicants ....’” (Huffaker v. Bailey (1975) 273 Ore. 273 [540 P.2d 1398, 1400], quoting from Sosa v. Board of Managers of Val Verde Memorial Hospital (5th Cir. 1971) 437 F.2d 173, 176-177.)
The evil in overly vague standards is the possibility of discriminatory or nonuniform application. (See Rosner v. Eden Township Hospital Dist., supra, 58 Cal.2d at p. 598; Martino v. Concord Community Hosp. Dist., supra, 233 Cal.App.2d at pp. 59-60; Wyatt v. Tahoe Forest Hospital Dist., supra, 174 Cal.App.2d at p. 715.) In my view, the standard, “ability to work with others, with sufficient adequacy to assure.. .a high quality of medical care,” is not so vague and indefinite as to require its invalidation.
*639Courts are required to apply laws uniformly and in nondiscriminatory fashion too, and judges appear to have no great difficulty in doing so even when dealing with such standards as “reasonable,” “good cause,” and “abuse of discretion.” Courts are called upon every day to apply standards the substantive content of which is no more definite than the standard here in question. The jurisprudential technique for insuring reasonably uniform and nondiscriminatory application of most legal standards is review for abuse of discretion. The same technique would serve well in the problem at hand. As the Supreme Court of Oregon stated in Huffaker v. Bailey, supra, 540 P.2d at pp. 1399-1400: “Rather than curtailing the discretion at the outset for failure to define that which would be difficult to define in any event, the court should more appropriately look to the exercise of the discretion to see if it has been abused.”
The trial court determined that respondent’s decision not to grant appellant’s application for staff membership was supported by substantial evidence and was not arbitrary or discriminatory and did not constitute an abuse of discretion. The trial court’s determination was clearly correct. Viewing the evidence most favorably to the judgment and the administrative determination, a duty entirely neglected by the majority, an abundance of evidence is apparent from which respondent could quite properly conclude that appellant’s admission to staff would, without any redeeming justification, be disruptive and endanger the quality of medical service to patients.
Dr. Russell Dunlop, a physician specializing in general surgery practicing in Indio and a member of the staff of respondent as well as the staffs of Indio Community Hospital and Valley Memorial Hospital, testified that appellant’s reputation in the community for getting along with other members of the medical profession was bad; that “Dr. Miller creates dissension.” That virtually the entire staff at Indio Community Hospital was unhappy about appellant being on the staff there; that at least 10 named physicians on the staff at Indio Community Hospital had expressed to him their feeling that appellant should not be on that staff and 4 other physicians on that staff had expressed their unhappiness with appellant’s staff membership, all within the preceding year. Dr. Dunlop stated that one of the reasons for appellant’s reputation was the manner in which he conducted the emergency room at Indio Community Hospital when he was in charge of it. In Dr. Dunlop’s opinion appellant admitted too many people to the emergency room and over-*640treated such people in an attempt to get the hospital “out of the red into the black.” Moreover, it was Dr. Dunlop’s opinion that appellant had damaged the reputation of Indio Community Hospital by his conduct while in charge of its emergency room. In this regard Dr. Dunlop testified that when Indio Community Hospital was sold to a group of physicians, the purchasers required the sellers as a condition of the sale to pay off the appellant’s emergency room contract; they would not enter into the transaction if appellant remained in charge of the emergency room.
Dr. Harold Tar letón who had been practicing in Coachella Valley testified that appellant did not get along with most members of the medical community. Dr. Tar letón also stated that the ability to get along with others in the hospital milieu, including committee work and staff work, is important to the overall quality of patient care and that appellant’s inability to get along or work with others would impair respondent’s ability to render effective patient care and would impair the quality of care furnished.
Appellant’s inability to work well with others was verified to a large degree even by his own witnesses. For example, Dr. Pinnell stated that appellant had brought a number of different physicians to Coachella Valley to work with him and that many of them had become dissatisfied, apparently because they could not get along with appellant.
In addition, it cannot be overlooked that when appellant was asked whether he realized he had been involuntarily terminated from his internship at Cook County Hospital he gave evasive and less than candid answers. At the appellate review hearing a letter was introduced from the medical director of Cook County Hospital which showed that appellant served seven months of a rotating internship at Cook County Hospital from July 1961 until February 1962; that he received “D” (poor) for “physical examination, attitude toward patients, cooperation with other hospital personnel, and personality and appearance”; and that he was “asked to leave on February 1, 1962, before the completion of his Internship, because he did not assume his responsibilities to the hospital and his patients.” It is unlikely appellant “didn’t remember” the details of the termination of his residency.
The cases relied upon by the majority do not compel invalidation of the standard. In Wyatt v. Tahoe Forest Hospital Dist., supra, member*641ship to the medical staff was limited to licensed physicians and surgeons “whose background, experience and training insures, in the judgment of the Board of Directors, that any patient admitted... or treated... will be given the best possible care and professional skill.” {Id., at pp. 712-713.) After holding that the applicable statute did not authorize the promulgation of such a standard the court “also... noted” that the rule was too vague and uncertain. (174 Cal.App.2d at p. 715.) The court’s rhetorical questions are revealing: “What is the best possible care and professional skill? Would it limit the practice of medicine in the Tahoe District Hospital to physicians and surgeons who are recognized authorities in their respective fields? By what standards do the directors who are all lay individuals determine what is the best possible care and professional skill? The standard set up is such that admission to the staff can depend on the whim and caprice of the directors.” {Id., italics added.)
In Martino v. Concord Community Hosp: Dist., supra, the bylaws of the medical staff authorized the credentials committee “‘to conduct a hearing at which the applicant shall be examined orally and in writing, be given such tests, oral and written, as the Credentials Committee shall in its discretion determine.’” (233 Cal.App.2d at p. 54.) The court concluded: “[T]he examination requirement set forth in the medical staff bylaws.. . authorizes the credentials committee to require that an applicant take tests covering far more than his competence in his own particular field of medicine. It is.. . apparent that the examination requirement is couched in such vague and ambiguous language as to furnish the committee with no adequate standards for applying said requirement.” (233 Cal.App.2d at p. 60.)
Cursory analysis of Rosner v. Eden Township Hospital Dist., supra, does lend some support to the majority’s position. However, more detailed analysis discloses that it is not controlling. There the governing instruments provided “that an applicant for membership shall submit proof of worthiness of character, excellence of reputation as to professional ethics, and general suitability for hospital practice, and that the credentials committee in investigating the applicant shall determine his ‘characteristics of cooperation, apparent ability to get along with others, and general qualifications of personality which would insure in the opinion of the committee that the applicant would be temperamentally and psychologically suited for cooperative staff hospital functions with other members of the Medical Staff and with other hospital personnel.’” (58 Cal.2d at p. 596.)
*642The court first restrictively interpreted the applicable statutory provisions and held that a public hospital district was not statutorily authorized to adopt such a standard for staff admission. Then the court, as a “[m]oreover,” stated the rule that standards that are so vague and ambiguous as to provide a substantial danger of arbitrary discrimination in their application are invalid. However, the court’s application of the rule was to that part of the standard referring to temperamental unsuitability for hospital practice (58 Cal.2d at p. 598); in the paragraph setting forth and discussing the void-for-vagueness rule, the part of the standard relating to the applicant’s ability to get along with others was not mentioned. What the court stated with respect to that part of the standard was: “The fact that a doctor, due to criticisms made by him relating to treatment of patients or hospital practices, has been ‘unable to get along with’ some doctors or hospital personnel is not a sufficient ground to exclude him from the use of hospitals. Obviously physicians will not always agree as to the proper treatment for a patient or as to the proper practices in a hospital.” (58 Cal.2d at p. 598, italics added.)
A judicial decision cannot be properly interpreted without reference to its facts. With respect to that part of the standard dealing with inability to get along with others, what the court said and what it meant in the Rosner decision was that where the inability to get along with others is shown to have resulted from criticisms of treatment and procedures that the applicant felt were substandard, even negligent, the applicant cannot be denied admission to staff on that account. The facts in Rosner were that the applicant had criticized certain treatment, procedures and personnel to the end of obtaining better treatment for patients. As the court observed: “Insofar as the merits of the controversies occurring at those hospitals can be determined from the record before us, Dr. Rosner appears in a more favorable light than the other medical personnel involved.” (58 Cal.2d at p. 595.) Dr. Rosner stated his opinion that certain events constituted malpractice and had apparently testified for plaintiffs in malpractice cases. Underlying the entire decision was the court’s revealing statement: “The goal of providing high standards of medical care requires that physicians be permitted to assert their views when they feel that treatment of patients is improper or that negligent hospital practices are being followed. Considerations of harmony in the hospital must give way where the welfare of patients is involved, and a physician by making his objections known, whether or not tactfully done, should not be required to risk his right to practice medicine.” (58 Cal.2d at p. 598.)
*643In the case at bench the evidence firmly supports the conclusion that appellant’s inability to work with others was not substantially related to any attempt on his part to improve the quality of medical services being furnished to patients. It is true that the executive committee introduced into evidence a letter written by appellant to the executive director of the Comprehensive Health Planning Association objecting to the granting of an application for additional beds by Desert Hospital in which he made derogatory statements about respondent, Desert Hospital and a number of other persons. A fragment of this letter (approximately one-half page of a five-and-a-half page letter) is set forth in footnote 9 of the majority opinion. The fragment of the letter selected by the majority depicts appellant in a favorable light. In fact, however, in the letter appellant stated as facts that Desert Hospital had falsified the statistical data presented to CHPA, that Desert Hospital and respondent had colluded and entered into a secret agreement to eliminate all opposition to Desert Hospital’s proposal for additional beds, that such agreement was carried out through misrepresentations “by attorneys and other community politicians” and constituted the “deliberate suppression of material contrary to Desert Hospital’s proposed plan for additional hospital beds. . .because those individuals so representing the opposition were ‘bought off '. . . . ”
The trial court did not find that appellant was denied staff admission because of the fact he wrote that letter, and although the majority imply that that might have been a reason appellant’s application for staff privileges was rejected, they refer to no evidence supporting that implication. Moreover, on being questioned about the letter appellant admitted that, other than hearsay, he had no awareness of the results of the Stanford University research project or, indeed, whether any such project was ever conducted. He could not recall whether he knew who was “bought off.” When asked whether he believed his statement that respondent hospital was supported by millionaires strictly as a tax gimmick, appellant stated: “Oh, I may have made a mistake at the time and I’ll admit a lot of it was hearsay....” In addition appellant admitted he did not have any facts with respect to the alleged tax gimmick involved and stated: “[M]aybe I was a little presumptuous.”
Were there a factual finding supported by evidence that appellant was denied staff membership on the basis of his writing the letter, the case might fall within the purview of the Rosner decision, but I am aware of no such finding or evidence. Moreover, it would hardly be unreasonable or irrational to conclude from the evidence that appellant’s *644writing this letter, having the potential of seriously affecting the delivery of health care services in the desert area, without investigating the facts constituted the height of irresponsibility.
Appellant’s other contentions are without merit. I would affirm the judgment.
Clark, J., concurred.

It is perplexing that Justice Manuel, who joined my dissent in Ezekial, now emerges as the author of the majority opinion in the instant case.