Court Opinion

ID: 3184444
Source: CourtListenerOpinion
Date Created: 2016-03-10 16:16:41.699291+00
Date Added: 2024-06-11T07:38:59.452969
License: Public Domain

Mar 10 2016, 7:45 am

ATTORNEYS FOR APPELLANT                                    ATTORNEYS FOR APPELLEES
Kevin W. Betz                                              COMMUNITY HOWARD
Sandra L. Blevins                                          REGIONAL HEALTH, INC. ET AL.
Jamie A. Maddox                                            Sherry A. Fabina-Abney
Courtney E. Endwright                                      L. Alan Whaley
Betz & Blevins                                             Melanie E. Harris
Indianapolis, Indiana                                      Olga Voinarevich
                                                           Ice Miller LLP
                                                           Indianapolis, Indiana

                                                           ATTORNEYS FOR APPELLEES THE
                                                           CLEVELAND CLINIC FOUNDATION
                                                           ET AL.
                                                           Ronald A. Mingus
                                                           Logan C. Hughes
                                                           Reminger Co., L.P.A.
                                                           Indianapolis, Indiana

                                                           ATTORNEY FOR AMICUS CURIAE
                                                           THE INDIANA HOSPITAL
                                                           ASSOCIATION
                                                           Angela M. Smith
                                                           Hall, Render, Killian, Heath &
                                                           Lyman, P.C.
                                                           Indianapolis, Indiana

                                            IN THE
    COURT OF APPEALS OF INDIANA

Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016                          Page 1 of 16
      Michael E. Ritchie, M.D.,                                      March 10, 2016
      Appellant-Plaintiff,                                           Court of Appeals Case No.
                                                                     34A02-1505-PL-385
               v.                                                    Appeal from the Howard County
                                                                     Superior Court 2
      Community Howard Regional                                      The Honorable Brant J. Parry,
      Health, Inc., et al.                                           Judge
      Appellees-Defendants.                                          Trial Court Cause No.
                                                                     34D02-1411-PL-952

      Bailey, Judge.

                                              Case Summary
[1]   The Medical Executive Committee (“the MEC”) of Community Howard

      Regional Health, Inc. (“Community”) issued a precautionary suspension of

      medical staff privileges1 extended to Michael E. Ritchie, M.D., the President

      and CEO of Ritchie Cardiology, P.C. Dr. Ritchie filed suit for breach of

      contract, defamation, tortious interference with a business or contractual

      relationship, intentional infliction of emotional distress, and breach of fiduciary

      duty.2 He sought temporary, preliminary, and permanent injunctive relief. A

      1
        Section 5.3 of Community’s By-Laws provides for a “precautionary suspension” when “failure to take
      action may result in imminent danger to the health or safety of any individual or may disrupt the orderly
      operation of the Hospital.” (App. at 189.) Subsection (c) specifies that a precautionary suspension “is an
      interim step in the professional review activity, but it is not a complete professional review action in and of
      itself.” (App. at 189.)
      2
       The defendants included Community, Interim Chief Executive Officer Ron Lewis, Techsin Ty, M.D.,
      Community staff (Eric O’Banion, M.D., Erika Cornett, M.D., James Downing, M.D., Andrew Mandery,
      M.D., Mohammad Nekoomaram, M.D., John Salter, M.D., Carol Sheridan, M.D., Blake Marti, M.D.,

      Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016                             Page 2 of 16
      temporary restraining order was granted but later dissolved and Dr. Richie was

      denied a preliminary injunction. He appeals, presenting the sole consolidated

      and restated issue of whether the trial court clearly abused its discretion.3 We

      affirm.

                               Facts and Procedural History
[2]   For twelve years, Dr. Ritchie, who maintained a private practice, provided

      services as an interventional cardiologist at Howard Regional Hospital in

      Kokomo. On July 1, 2012, Howard Regional Hospital became part of

      Community Health Network (“CHN”), and Community Physicians of Indiana,

      Inc. d/b/a Community Physician Network (“CPN”) became the exclusive

      provider of cardiovascular services at Community.

[3]   In 2013, CHN contacted the Cleveland Clinic Foundation (“Cleveland”) to

      discuss a potential CHN affiliation with Cleveland as to the provision of

      Ramaroa Yeleti, M.D., Lawrence Gehring, M.D., Lawrence Klein, M.D., Michael Koelsch, M.D., Blaire
      McPhail, M.D., Rajesh Mallella, M.D., Jaro Mayda, M.D., Ghaith Nahlawi, M.D., and Dorian Beasley,
      M.D.), and Cleveland Clinic defendants (The Cleveland Clinic Foundation, The Cleveland Clinic Health
      System Physician Organization, Joseph Cacchione, M.D., Christopher Bajzer, M.D., and Amar
      Krishnaswamy, M.D.). The providers were named as defendants individually and in their official capacities.
      3
        Dr. Ritchie articulates an additional issue, supported by a cursory allegation that the good faith
      presumption in Indiana’s peer review statutory scheme “has no connection to a proven fact” and is thus void,
      unenforceable, and unconstitutional. Appellant’s Br. at 45. However, he does not assert that he filed a claim
      for a declaratory judgment, providing the defendants with an opportunity to respond, or that he gave timely
      notice to the Indiana Attorney General to facilitate intervention. See Ind. Code § 34-14-1-11 (providing in
      relevant part: “In any proceeding in which a statute, ordinance, or franchise is alleged to be unconstitutional,
      the court shall certify this fact to the attorney general, and the attorney general shall be permitted to intervene
      for presentation of evidence[.]”). Dr. Ritchie’s bald assertion of unconstitutionality does not properly raise
      an issue of alleged trial court error for review.

      Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016                              Page 3 of 16
      cardiovascular services. A services agreement was executed in February of

      2014 and CHN agreed to pay Cleveland a consulting fee for a “quality

      assessment for cardiovascular product line for the entire network.” (App. at

      1182.) After evaluation, Cleveland could determine whether or not CHN

      would be offered participation in the Cleveland national cardiac network.

[4]   Dr. Ritchie was advised, by a letter dated December 19, 2013, that a provider

      not becoming a part of CPN “[as] an employee or independent contractor with

      CPN” could exercise clinical privileges up to midnight on December 31, 2013.

      (Ex. 102.) Pursuant to a verbal agreement with CPN President Dr. Ramarao

      Yeleti, Dr. Ritchie was permitted to continue exercising his medical staff

      privileges and performing procedures at Community as an independent

      contractor.4 On November 3, 2014, a hand-delivered letter addressed to Dr.

      Ritchie advised: “Effective immediately, we are terminating the verbal

      agreement with Ritchie Cardiology, PC and you to provide professional

      cardiology services to Hospital patients.” (Ex. 8.)

[5]   At some point, the MEC requested that Cleveland “do a medical review” of

      three procedures at Community. (App. at 1184.) On June 25, 2014, the MEC

      imposed a moratorium on three procedures: use of Impella devices,5 balloon

      4
       Dr. Yeleti explained that a hospital board of directors extends privileges to a physician, but “delivery of the
      privileges” requires employment or an independent contractor agreement with the network of physicians
      having an exclusivity agreement with the hospital. (Tr. at 337.)
      5
          Dr. Ritchie described this as a “support device” or “little pump” placed in a heart ventricle. (Tr. at 91.)

      Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016                               Page 4 of 16
      valvuloplasties,6 and percutaneous atrial septal defect closures.7 These

      procedures had been performed at Community exclusively or almost-

      exclusively by Dr. Ritchie. A peer review letter informed cardiologists and

      cardiothoracic surgeons of the moratorium and further advised:

                 Similar to Community Health Network’s arrangement with the
                 MD Anderson Cancer Network Affiliation, Community Health
                 Network is working toward an affiliation with the Cleveland
                 Clinic for its cardiology service lines. As part of that endeavor,
                 the Cleveland Clinic has been evaluating the policies, procedures,
                 and practices of the various cardiovascular programs within the
                 network including Community Howard Regional Health.

      (App. at 114.)

[6]   On September 4, 2014, Community’s Medical Audit and Review Committee

      concluded an audit sampling 40 of 93 of Dr. Ritchie’s cases and advised Dr.

      Richie by written memorandum:

                 Congratulations are extended as you demonstrated excellent
                 performance and documentation. We are proud to have you on
                 our staff.

      (App. at 117.)

      6
          Dr. Ritchie described this as “a balloon that cracks open the valve.” (Tr. at 91.)
      7
          This was described as something “like an umbrella.” (Tr. at 91.)

      Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016                 Page 5 of 16
[7]   On October 16, 2014, the MEC held a regularly scheduled monthly meeting.

      At that meeting, Cleveland presented its evaluation of the cardiovascular

      services of Community. The MEC discussed this evaluation and other alleged

      complains regarding Dr. Ritchie. After the meeting concluded, the interim

      CEO and the Chief of Staff of Community verbally informed Dr. Ritchie of an

      adverse recommendation concerning his hospital privileges.

[8]   On October 18, 2014, the MEC issued a written “Notice of Precautionary

      Suspension and Recommendation to Terminate Membership and Privileges”

      with regard to Dr. Ritchie. (App. at 147.) Dr. Ritchie was informed that the

      recommendations were based upon results of case reviews conducted by

      Cleveland physicians. Allegedly, “a significant number of the cases … were

      found to be outside the appropriate standard of care.” (App. at 147.) Dr.

      Ritchie was advised that he was entitled to a non-hearing meeting with the

      MEC within fourteen days of the suspension, and that he could request a

      hearing before a committee of three physicians from the active medical staff

      (“the By-Laws hearing”).8 The By-Laws hearing would involve the opportunity

      for the MEC and Dr. Ritchie to call, directly examine, and cross-examine

      witnesses.

      8
       Pursuant to Indiana’s Peer Review Act, a physician facing charges that, if sustained, could result in an
      action reportable to a medical licensing board, must be afforded one evidentiary hearing before a peer review
      committee of the medical staff and one appeal before the governing board of the hospital or a committee
      appointed by the governing board. I.C. § 34-30-15-5.

      Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016                         Page 6 of 16
[9]    The MEC held two additional meetings – on October 30 and November 3, 2014

       – to “[give] the opportunity for Dr. Ritchie to provide further information[.]”

       (Tr. at 208.) Dr. Ritchie appeared, read a statement, and challenged the

       process implemented by Cleveland. Dr. Ritchie was advised to submit any

       additional patient-care materials for consideration by November 7, 2014.

[10]   On November 7, 2014, Dr. Ritchie filed a complaint naming as defendants

       Community, CHN, CPN, the Cleveland Clinic Foundation, the Cleveland

       Clinic Health System Physician Organization, and various health care providers

       and hospital administrators. Dr. Ritchie’s complaint alleged that the peer

       review process was a sham proceeding, he had provided appropriate and

       independently reviewed cardiology services, the MEC and Cleveland Clinic

       defendants had an economic interest in divesting Dr. Ritchie of his patients,

       patients were put at risk by the suspension, and the reporting of suspension of

       privileges to state and federal entities could irreparably damage Dr. Ritchie’s

       professional reputation and practice.

[11]   Dr. Ritchie requested a temporary, preliminary, and permanent injunction that

       would require Community to restore Dr. Ritchie’s medical staff privileges,

       prohibit reporting of the suspension to third parties, and halt the “sham

       process” implemented by Community. (App. at 112.) Dr. Ritchie also sought

       compensatory and punitive damages and attorney’s fees.

[12]   On November 10, 2014, the trial court issued an order granting to Dr. Ritchie a

       portion of the temporary injunctive relief he had requested. Although Dr.

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016   Page 7 of 16
       Ritchie did not obtain restoration of his clinical privileges or a moratorium on

       the peer review proceedings, the defendants were enjoined from making reports

       concerning Dr. Ritchie to: The National Practitioner Data Bank; the Medical

       Licensing Board of Indiana; the Indiana Professional Licensing Agency; the

       Indiana State Department of Health; the Indiana Department of Insurance; the

       Office of the Indiana Attorney General; any other state licensing agency; and

       “any other entity to whom the Defendants feel they are obligated by law to

       report the suspension or termination of privileges of staff members.” (App. at

       386.)

[13]   After the commencement of his lawsuit, Dr. Ritchie requested a By-Laws

       hearing and provided medical records to the MEC. He also requested a

       continuance of the By-Laws hearing, pending the resolution of his petition for

       injunctive relief in state court. The medical records were reviewed at a third

       special meeting of the MEC on December 3, 2014.

[14]   The defendants filed a Motion to Dismiss the Application for Injunctive Relief

       and Dissolve the Temporary Restraining Order. The trial court denied the

       motion on December 1, 2014. On December 8 and 11, 2014 and on January 8,

       2015, the trial court conducted evidentiary hearings on injunctive relief.

[15]   On April 20, 2015, the trial court issued an order denying Dr. Ritchie’s request

       for a preliminary injunction and dissolving the temporary restraining order of

       November 10, 2014. The trial court concluded that Dr. Ritchie failed to

       exhaust his administrative remedies available in Community’s peer review

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016   Page 8 of 16
       process, thus foreclosing a review of the likelihood of success on the merits; he

       did not show requisite bad faith on the part of the peer review committee to

       overcome a peer review anti-injunction statute; and he fell short of establishing

       the essential elements for injunctive relief. This appeal ensued.

                                  Discussion and Decision
                                            Standard of Review
[16]   The grant or denial of a preliminary injunction rests within the sound discretion

       of the trial court, and our review is limited to whether there was a clear abuse of

       that discretion. Ind. Family & Soc. Servs. Admin. v. Walgreen Co., 769 N.E.2d 158,

       161 (Ind. 2002). An abuse of discretion occurs when the trial court’s decision is

       against the logic and effect of the facts and circumstances before the trial court

       or when the trial court misinterprets the law. Aberdeen Apartments v. Cary

       Campbell Realty Alliance, Inc., 820 N.E.2d 158, 163 (Ind. Ct. App. 2005), trans.

       denied. When determining whether or not to grant a preliminary injunction, the

       trial court is required, pursuant to Indiana Trial Rule 52(A), to make special

       findings of fact and conclusions of law. Id. When findings and conclusions of

       law are made, the reviewing court must determine if the trial court’s findings

       support the judgment. Id. We will reverse the judgment only when it is clearly

       erroneous. Id. Findings of fact are clearly erroneous when the record lacks

       evidence or reasonable inferences from the evidence to support them. Id. We

       will consider the evidence only in the light most favorable to the judgment and

       construe findings together liberally in favor of the judgment. Id.

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016   Page 9 of 16
[17]   Additionally, Dr. Ritchie is appealing from a negative judgment and must

       therefore establish that the trial court’s judgment is contrary to law. Pinnacle

       Healthcare, LLC v. Sheets, 17 N.E.3d 947, 953 (Ind. Ct. App. 2014). A judgment

       is contrary to law if the evidence of record, together with the reasonable

       inferences to be drawn from that evidence, is without conflict and leads

       unerringly to a conclusion opposite that reached by the trial court. Id.

                                                     Analysis
[18]   To obtain a preliminary injunction, the moving party bears the burden of

       showing by a preponderance of the evidence each of the following: (1) the

       movant’s remedies at law were inadequate, causing irreparable harm pending

       resolution of the substantive action; (2) the moving party had at least a

       reasonable likelihood of success at trial by establishing a prima facie case; (3)

       the threatened injury outweighs the potential harm resulting from the granting

       of an injunction; and (4) the public interest would not be disserved. Id. A

       preliminary injunction is an extraordinary remedy that should be used only in

       rare circumstances in which the law and the facts are clearly within the moving

       party’s favor. Crossman Communities, Inc. v. Dean, 767 N.E.2d 1035, 1040 (Ind.

       Ct. App. 2002).

[19]   Additionally, Indiana’s Peer Review Act, Indiana Code Sections 34-30-15-1

       through 34-30-15-23, limits the availability of injunctive relief. Indiana Code

       Section 34-30-15-18 provides:

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016   Page 10 of 16
               No restraining order or injunction shall be issued against a peer
               review committee or any of the personnel thereof to interfere
               with the proper functions of the committee acting in good faith in
               regard to evaluation of patient care as that term is defined and
               limited in IC 34-6-2-44.

[20]   Indiana Code Section 34-30-15-23 provides:

               In all actions to which this chapter applies, good faith shall be
               presumed, and malice shall be required to be proven by the
               person aggrieved.

[21]   Also, as the defendants point out, “[i]t is fundamental Indiana law that a party

       must exhaust his administrative remedies before suit may be brought in a trial

       court.” St. Joseph’s Hosp., Inc. of Ft. Wayne v. Huntington Cnty. Dep’t of Pub.

       Welfare, 405 N.E.2d 627, 630 (Ind. Ct. App. 1980). Accordingly, to be entitled

       to the injunctive relief requested, Dr. Ritchie first had to show that the peer

       review anti-injunction provision was inapplicable and that he should be excused

       from compliance with exhaustion of administrative remedies, and then he had

       to establish the requisite common law elements for a grant of injunctive relief.

[22]   The trial court concluded that the MEC was functioning as a peer review

       committee, presumptively acting in good faith, and that Dr. Ritchie had not

       proven that the MEC acted with malice. Thus, the anti-injunction provision

       was applicable. Moreover, the trial court concluded that, if the anti-injunction

       provision was inapplicable to some aspects of the relief sought, Dr. Ritchie

       established less than all of the requisite criteria for injunctive relief. According

       to the trial court, Dr. Ritchie presented evidence that irreparable harm to him

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016    Page 11 of 16
       might ensue (but, based on testimony by Community’s expert, damages for

       such were calculable); a reasonable likelihood of success on the merits could not

       be determined at such an early stage of proceedings; Dr. Richie’s threatened

       harm outweighed the threatened harm from granting an injunction (because the

       precautionary suspension removed Dr. Ritchie’s ability to practice on patients);

       and the element as to public service was not established.9 Ultimately, the trial

       court found “the Plaintiff is asking the Court to substitute its judgment for that

       of the MEC and the doctors that it consulted with.” (App. at 85.)

[23]   As for exhaustion of administrative remedies, Dr. Ritchie claims that he is

       entitled to the benefit of an exception for futility, 10 because the MEC is engaging

       in sham proceedings. According to Dr. Ritchie, there are hallmarks of such;

       more specifically: The Cleveland Clinic reviewers had a conflict of interest

       because there is a financial arrangement between Community and The

       Cleveland Clinic; The Cleveland Clinic is motivated to impose its own

       protocols; the reviewers acknowledged the need for more information as a

       predicate to the issuance of a report with “complete perspective”; the charges

       were lodged shortly after Dr. Ritchie was commended by Community reviewers

       for his excellent work; and the Cleveland Clinic reviewers stopped short of

       9
         The trial court misstated Dr. Richie’s burden of proof as requiring him to show that a preliminary
       injunction would serve the public interest, as opposed to showing that the public interest would not be
       disserved.
       10
         See Smith v. State Lottery Comm’n, 701 N.E.2d 926, 931 (Ind. Ct. App. 1998) (recognizing an exception to
       the exhaustion requirement when the remedy is inadequate or would be futile, or when some equitable
       consideration precludes application of the rule).

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016                         Page 12 of 16
       clearly proclaiming that the evaluated patients had been placed in danger. (Ex.

       6 pg. 4.)

[24]   Apparently due to a firm conviction that the peer review proceedings

       surrounding the presentation of the Cleveland report were fundamentally

       flawed, Dr. Ritchie’s presentation of evidence to the trial court was largely an

       attack on the process. He purported to shed light on Community’s true

       motivation: diversion of Dr. Ritchie’s patients and consequent financial gain.

       Witnesses testified to instances in which they believed insurance considerations

       or data collection took precedence over patient care considerations at

       Community. Meanwhile, Dr. Ritchie was portrayed as professional, attentive,

       even a lifesaver.

[25]   With this background, and his insistence that professional reporting of even an

       interim suspension would irreparably harm his career, Dr. Ritchie claims that

       he has demonstrated the futility of continuing with the By-Laws hearing. We

       acknowledge Dr. Ritchie’s frustrations with the lack of fixed time limits in the

       By-Laws and his fear of damage to his professional reputation. Nonetheless,

               the overwhelming majority rule is that harm to professional
               reputation is not the kind of irreparable injury that forms the
               basis for equitable relief. Bad publicity generated by revocation
               of a license is not deemed to be the type of irreparable injury
               contemplated, and injunctions have been almost uniformly
               denied to professionals seeking to stop license revocation
               hearings because of damage to their reputation.

       Thompson v. Medical Licensing Bd., 389 N.E.2d 43, 49 (Ind. Ct. App. 1979).

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016    Page 13 of 16
[26]   Moreover, even if we agree that there is significantly more at stake than

       monetary loss, we simply cannot, as a practical matter, reach a well-advised

       conclusion on the limited record developed. As the trial court observed, the

       lack of finality to the administrative proceedings hampers examination of the

       likelihood of success on the merits of Dr. Ritchie’s multiple claims.

[27]   By Dr. Ritchie’s own account, more information was needed to form a final

       opinion on his compliance with an appropriate standard of patient care.

       Indeed, Dr. Ritchie’s application for a temporary restraining order and

       preliminary injunction asserted: “because Dr. Ritchie has a separate,

       independent practice from the hospital and CPN, the Cleveland Clinic

       reviewers did not review 80% of the information they needed to assess Dr.

       Ritchie’s performance.” (App. at 158.) However, the By-Laws hearing (with

       opportunity for Dr. Ritchie to offer information and conduct cross-

       examination) was not concluded before suit and the trial court was asked to

       assess merits that would predictably be impacted upon by greater inclusion of

       materials. Rather than focusing on whether Dr. Ritchie was likely to prevail on

       his claims, the trial court hearings focused upon alleged deficiencies of the peer

       review committee. By launching an early attack on the process and members of

       the peer review committee, Dr. Ritchie has diverted attention from the

       provision of medical services and delayed any ultimate decision.

[28]   Dr. Ritchie would suffer greater harm than would Community from

       dissemination of adverse reports if Dr. Ritchie did not and does not pose a

       danger to patients. The public would not be dis-served, and indeed would be

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016   Page 14 of 16
       served, by allowing a competent interventional cardiologist to exercise his skills.

       However, only limited records have been examined. The focus of Dr. Richie’s

       expert witness Dr. Huntoon has largely been upon whether a sham process was

       in progress. Dr. Ritchie has essentially sought a determination of the adequacy

       of peer review proceedings.

[29]   But ultimately, the peer review proceedings – and Dr. Ritchie’s expectation of

       success on the merits of his claims – concern the adequacy of care provided to

       patients. Indeed, Dr. Thomas Forbes executed an affidavit in which he stated

       that, “after reviewing the additional documentation from Dr. Ritchie that Drs.

       Krishnaswamy and Bajzer should have reviewed before issuing their report and

       the MEC should have reviewed before imposing a precautionary suspension,”

       he had concluded that Dr. Ritchie “performed his professional duties

       appropriately.” (App. at 528.) Noticeably, the “additional documentation”

       was not submitted to the MEC in a By-Laws hearing. The By-Laws hearing is

       the statutory means of reviewing the adequacy of patient care. It may be

       followed by an administrative appeal. See I.C. § 34-30-15-5.

[30]   As the trial court observed:

               The Indiana General Assembly has specifically created statutes
               entrusting the governing boards of hospitals with the “supreme
               authority” to control, operate, and manage the hospital, as well
               as appoint, reappoint, and assign privileges of the medical staff.
               The Legislature has enacted a framework of peer review where
               [a] physician’s competence, conduct, and patient care are
               reviewed by other medical staff of the hospital. The Legislature
               has indicated how important the peer review procedures are by

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016     Page 15 of 16
               establishing immunity for boards and their agents[.] … These
               actions by the General Assembly demonstrate the important
               public policy aimed at improving the quality of care within our
               hospitals.

       (App. at 85.) Absent malice, the peer review committee is the legislature’s

       choice for dealing with these issues. Courts are ill-equipped to conduct an

       independent review of patient care absent evidence from expert witnesses on the

       standard of care and any countervailing evidence in opposition thereto.

       Because of this limitation, state trial and appellate courts cannot serve as

       substitutes for peer review committees and the aggrieved party cannot

       circumvent the administrative process.

                                                Conclusion
[31]   Dr. Ritchie did not demonstrate his entitlement to extraordinary equitable

       relief. Accordingly, the trial court did not clearly abuse its discretion by

       denying the request for a preliminary injunction.

[32]   Affirmed.

       Vaidik, C.J., and Crone, J., concur.

       Court of Appeals of Indiana | Opinion 34A02-1505-PL-385 | March 10, 2016   Page 16 of 16