Medical appeal board

This is not the original version of this decision. It is a revised version that has been edited for public disclosure to protect confidential and third party personal information. Dr. Frances Forrest-Richards, Member Counsel for Appellant Heard at Port Alberni, B.C. on July 9 & 10, 1990, in Vancouver, B.C. on January 14 & 15, 1991 and at Nanaimo, B.C. on April 12, 1991.
Majority Opinion

T.C. Marshall
This is an appeal from the order of the Board of Trustees of West Coast General Hospital of Port Alberni, B.C. (the “Hospital”) made on Feb. 9, 1990 whereby the Hospital Board concurred in the recommendation of the Medical Advisory Committee that the Appellant not be granted admitting privileges as a Member of the Associate staff “on the grounds of significant concerns regarding her interpersonal and clinical skills.” The grounds of the appeal dated March 15, The Appellant is of good character, is duly qualified, and is a member in good standing of the B.C. College of Physicians and Surgeons, and as such is entitled to privileges at the The Board of Trustees of the hospital erred in ruling that interpersonal skills were proper grounds on which to deny the Appellant’s application for privileges. There is no evidence to substantiate the conclusion reached by the Board that the Appellant’s clinical skills are inadequate. By an amendment to the Notice of Appeal, dated May 14, 1990 a further ground In the alternative, if there is some evidence that either the Appellant’s interpersonal or clinical skills are deficient, that deficiency is not of a sufficient degree to warrant a denial of The first ground of appeal was abandoned by Counsel at the commencement of In her Answer dated April 17, 1990 counsel for the Hospital set out as the reasons for the Hospital Board’s decision to refuse privileges; inadequate clinical skills, including but not limited to failure to diagnose, misdiagnosis, pharmacological mismanagement, poor medical judgment, excessive us of diagnostic tests, overly aggressive treatment, and insufficient understanding of lack of adequate, pertinent positive references and existence poor interpersonal skills and conduct such that effective communication between professional staff, administrative personnel, and the Appellant was jeopardized. are interpersonal skills a proper ground for denial of hospital was there some evidence to support the conclusion that the Appellant’s clinical skills were inadequate? It is common ground that an appeal to this Board is, by virtue of the Hospital Act and Regulations, an appeal de novo. This Board must strive to place itself in the shoes of the Hospital Board and consider all of the evidence placed before it and any additional evidence coming to light between Feb. 9, 1990 and the hearing before this Board. In light of the Notice of Appeal and Answer it became the duty of this Board, in essence to determine whether the Appellant was sufficiently competent, as a family practitioner, to be granted admitting privileges at the Hospital and secondly, whether in any event her “interpersonal skills” were so The Appellant’s curriculum vitae (Ex 1, Tab 3) discloses that she received her early education at Duncan, Tzoulhalem, Vancouver and Victoria, mostly in Roman Catholic schools. In 1962, at age 19, she entered the Child Jesus convent in North Vancouver as a novitiate and remained there for three years, studying French, Philosophy, Theology and History and teaching Latin in Grades 9 and 11. For several years she followed a teaching career and then enrolled in university, graduating from the University of Saskatchewan in 1971 with a B.Sc. in the pre- medical program. Following her graduation in 1975 she did electives in several hospitals in Toronto, Regina, Rosetown and Humboldt and in 1976 – 1977 a rotating internship in St. Paul’s hospital, Saskatoon, devoting several months each to Surgery, Medicine, Paediatrics and Obstetrics, Emergency and In 1983 she received a B.A. degree, majoring in Philosophy and Psychology. She left her Catholic Order that same year and is now a member of the Sisters for Christian Community. Under the aegis of the former Order she went where she was ordered and had no right to any earnings. This is no longer the case since The Appellant has had a varied working career, doing locums in Ontario and British Columbia and serving in many capacities under the appointments made by her former Order, in Africa, including six months in 1980 in Monrovia, Liberia where she obtained experience in Obstetrics and Gynecology, Medicine, Surgery and Paediatrics. Following a brief return to Canada, where she did some work in Ontario and later in Vancouver at St. Vincent’s Hospital and Vancouver General Hospital she went to South Africa for three years and on her return again to Canada she did a locum in Fort St. Jean for three months in 1987. Later that year she successfully applied for a post at Baffin Regional Hospital in Iqaluit, N.W.T. as a G.P./Anaesthetist. She spent eight months in this posting and then did a three months’ locum at Williams Lake. Late in 1988 she underwent major surgery and was on the sick list until May 17, 1989 when she first applied for admitting privileges at the Hospital on the basis of doing a locum for Dr. N who had been chronically ill and unable to carry on with his comfortably large practice. The period of her privileges as a locum tenens was from May 23 to The Credentials Committee recommended her for temporary locum tenens privileges, noting that written references had been requested although satisfactory telephone references had been obtained. The privileges the Appellant sought were Family Practice, Obstetrics, Emergency, On the date of application she signed the usual declaration whereby she agreed to abide by the constitution and Bylaws of the Hospital and by the bylaws of the Medical/Dental Staff. She also stated she had never been denied privileges. She had applied at Nanaimo, Duncan and Ladysmith but each of this hospital had required proof of her doing a locum first, hence her application in Port Alberni. The Appellant testified that, other than a very brief, 15 minute tour of the Hospital, conducted by the wife of Dr. N, she received no orientation. She said she was not really informed what, as a locum she would be permitted to do. But on a further document dated June 14, 1989, unsigned by the Appellant but bearing the signature of the Chairman of the Credentials Committee and entitled “Procedural Privileges” there is ticked off “Normal Labour and Delivery” as the sole area of her obstetrical privileges. In June, 1981, the Hospital composed a manual for physicians employing locum tenens and physicians practising in locum tenens. Paragraph 3 provides: The employing physician is responsible for designating a colleague from the active staff to be made available to provide advice and information to his locum tenens. The manual goes on to state that privileges awarded to G.P. locums are restricted. In order to obtain more specialized privileges in obstetrics, surgery, medicine etc. a locum must demonstrate his or her skills to designated members of the active medical staff, preferably the Chiefs of the various departments. There is then listed the procedures locums may do and what they may not do. The guidelines further provided that a doctor must be in attendance at the Hospital within 10 minutes of being called. This will be further alluded to. The document finally provided that any significant problems with a locum are to be reported to the Chief of Staff and Head of the Credentials Committee. Ms. F (Administrative Assistant) testified that she gave a copy of these Rules to the Appellant. Under cross-examination she said she was 90% sure she had done so although no receipt was given. The Appellant denied she had received a copy. Whether she did or not, there was evidence before us that the whole system was undergoing changes due to accreditation requirements and that the administration was in a state of flux due to a change of administrators. Nevertheless the Appellant ought to have made sure that she read and understood the Medical Staff Bylaws and the instructions for locums. On June 14, 1989 the Acting Administrator informed Admitting, Maternity and Nursing departments that the Appellant had been granted privileges in Obstetrics for normal Labour and Delivery. Meanwhile on June 9, Dr. K informed the Credentials Committee that he had supervised a delivery done by the Appellant requiring outlet forceps and that he was “exceptionally pleased with her performance.” It should be noted that at this point, June 9 she had no privileges. Her appointment was not approved by the Board of Trustees until On June 27 she wrote a handwritten note to the Head of Surgery requesting permission to do twenty procedures. (Ex. 1 Tab 6B). On July 21 she addressed a more formal letter to the Surgical Committee requesting permission to do a large number of procedures. In the field of Obstetrics with which this appeal is largely concerned she requested, under that heading: In an accompanying form she also requested privileges in many other areas with She testified that while the first four of the obstetrical procedures were not included in her privileges the last two were included. She said her other locums had permitted her to do an episiotomy as a part of normal delivery but admitted that every hospital is different in this respect. She said she performed low forceps deliveries, episiotomies and induction when she thought they were required and that no one had challenged her. She said she had done these The Appellant’s initial term was extended to December 1989. In November she terminated her locum for Dr. N and considered purchasing another practice which During the latter months of 1989 complaints against her were expressed by the nursing staff and it was alleged that she had over-subscribed for laboratory tests (See Ex. 1 Tab 9) to the extent of costing more than all the other physicians combined. Her choice of drugs was challenged by the Nursing staff. (See Ex. 1 Tab 10) and her alleged failure to obtain a consultation in the case of fetal distress involving passage of meconium was also noted. On November 28 a report from Dr. HN of the medical staff (Ex. 1 Tab 12) stated that the Appellant had admitted a patient suffering from depression on November 22. The patient had a history of drug abuse. Dr. HN was called in to discharge him on November 23 since the patient appeared to have recovered from his acute emotional distress. Dr. HN concluded, after seeing the patient that he was entitled to discharge. He said the Appellant had refused to sign or do the patient’s summary report and he had hesitated to do so since the Appellant knew him better. His report concluded that, on her return from vacation, the Appellant confronted him in a hostile manner, accusing him of improperly discharging a patient who had a severe suicide wish. His report indicates that at least one member of the medical staff expressed his concern about the Appellant’s alleged Meanwhile an obstetrical audit had been carried out for the period of May 1 to – October 31, for the purpose of comparing the Appellant’s practice with that of the remaining Hospital staff and that of the Krikke & Bell studies (Ex. 1, Tab 13). In this audit the Appellant did not come off too well and in an in-hospital study conducted by Dr. W, Head of Obstetrics, it was alleged that the average length of stay by the Appellant’s patients was 5.4 days as against 2.3 days for the patients of other doctors. The audit also indicated that she induced more patients than the rest of the medical staff. The methodology employed was not, in our view, without serious flaws and the Appellant’s pattern of practice cannot be judged by these tests alone. A further audit, prepared in February or March, 1990 and unavailable to the Hospital Board, (Ex. 1 Tab 14) examined the Appellant’s use of the drug Dilantin during the months of July and August, 1989. The information was taken from patient charts. It revealed a mean length of stay for the Appellant’s patients of 8 days (adjusted) as against 3.5 for other patients, a greater number of drug levels and tests per patient and a greater number of drug changes. We were asked to conclude that this represented either muddled thinking or a deficient knowledge of pharmacology on the part of the Appellant. Again, we are not persuaded this evidence, taken by itself, is proof of inadequate As time went on the medical staff became increasingly concerned with her work. It first surfaced on October 6 in the form of a memorandum from Dr. W, Chairman of the Obstetrics Committee, to the Chief of Staff, Dr. M (Ex. 1 Tab 15). It concerned a patient, S, and represented that the members of the Committee were unanimous in finding that the clinical judgment in this case was poor. Even more damning was the statement: … there was a consensus that this may be a more widespread and pervasive problem concerning this physician which would not be easily remedied by a brief trip to a teaching environment The last paragraph set the stage for what was to follow: The Chairman of the Credentials Committee may wish to advise this physician that should there be further applications for privileges at (this hospital) they will be subjected to a critical review and should be accompanied by letters of support from the department heads. We note that the Appellant’s application was for a three month’s period only. This would have expired at the latest, on October 11, being three months after the formal approval by the Hospital Board, or, at the earliest, on August 22, being three months after the recommendation of the Credentials Committee. The administrative procedure left something to be desired as there was, in our view, some doubt as to the Appellant’s status in the autumn of 1989 (Ref. Ex. 1 The MS case was exhaustively analyzed by Dr. W, Dr. H, head of the UBC Department of Family Practice, and Dr. R, former Chief of Staff of Nanaimo General Hospital. The first two were critical of the Appellant’s clinical skills. Dr. R, with a wide experience in Obstetrics and Gynecology, less so. The patient had been admitted to the Hospital in her first trimester suffering from hyperemesis and losing weight. Intravenous Imferon was prescribed but was subsequently cancelled by Dr. W who was of the opinion that since the patient did not have anaemia Imferon was not indicated. He suggested that the Appellant should use the drug Diclectin instead and directed her to some medical literature which dealt with the use of this drug (Ex. 1 Tab 10) and recommended that “the drug should be used during pregnancy only when the potential benefits justify the possible risks to the fetus.” Dr. H agreed, in her written opinion and in her oral evidence, that there was no justification for the use of Imferon unless there was severe Dr. W testified that the matter had been brought to his attention by the Nursing Staff on the ward who questioned the order for Imferon. Following this matter the Committee undertook an audit of all the deliveries performed in the Hospital from May to October, 1989. From a total of 18 or 19 cases of the Appellant, 6 or 7 attracted his interest because they included “matters that I didn’t think were handled quite correctly” (Transcript, p. 4l). This represented about one-third of the total charts examined and, according to Dr. W, was “much higher than the average pattern of practice in this hospital” (Transcript, p.42). The other cases referred to hereinafter identified by initials only may be A.D.: A 17 year old girl who appeared at the Hospital, complaining of constipation. She was sent to the Appellant who examined her but failed to detect that the girl was pregnant, although she used her stethoscope. Twenty- four hours later she appeared at the Hospital and gave birth to a healthy baby at the entrance, still clad in her track suit which had to be cut in order to effect the delivery. Another physician on staff delivered the baby then sent the mother up to the case room with the placenta still inside. Dr. H was critical of the Appellant, saying she should have carried out a more thorough examination. Dr. R observed there was little a doctor can do when a patient will not cooperate. The patient chart shows that the nursing staff had asked her when she was due, that the girl asked “what do you mean?” She was asked “you are pregnant, aren’t you” and Dr. W further testified that the Appellant was annoyed that she had not been called and was concerned about the billing and who was going to be able to claim As an aftermath, the patient did not wish to breast-feed her baby. The Appellant prescribed Diazyde which Dr. H criticized as it causes a loss of fluid in the entire body and that Parlodel was the drug of choice since it has few side effects. S.K.: This patient, who had already had one baby, was admitted in her 37th week with ruptured membranes for 17 hours. The Appellant ordered Prostiglandin. The patient went into what Dr. W described as “tumultuous labour.” He said the Appellant telephoned to the Hospital and ordered Demerol and Gravol. The Appellant then came to the Hospital and examined the patient who proceeded into a short second stage of ten minutes during which period the fetal heart rate dropped. Dr. W concluded that the use of Prostiglandin in this type of situation is not well advised. Dr. H referred to its use as not a common practice. Instead, i.v. Oxytocin is more easily controlled and maintains a balance. Dr. R, on the other hand stated that Prostiglandin was used correctly. Dr. W contended that induction by the use of this drug does not fall within “normal labour and delivery” which was included in the Appellant’s privileges. Dr. R observed that whether or not to induce is a judgment call and that there is L.M.: This patient had ruptured membranes for 12 1/2 hours at thirty- eight weeks on admission. Prostiglandin was ordered. This -patient went into strong labour and delivered after eight minutes. Dr. W said the use of this drug accounted for her very fast second stage. Dr. R agreed with the use of this drug. Dr. H said its use is not common practice for induction but added that some consultants would agree with the decision to induce. N.M.: This patient had had a caesarian section in 1979 and three subsequent deliveries, two of them complicated, Dr. W claimed that the whole subject of vaginal birth after a caesarian is new and controversial in Canada and, since they had no back-up material from the hospital where the caesarian had been performed. he felt it desirable to have had a consultation during labour. One had been obtained earlier from a physician in Nanaimo. Dr. R disagreed with Dr. W, testifying that vaginal deliveries after a caesarian are not new and have reached 85% level in some centers and, further, that a second consultation would have been redundant. Dr. H supported Dr. W’s view that a consultation during labour would have been advisable. Dr. W also criticized the Appellant’s choice of Phenobarbital as a sedative and Dr. H referred to it as “not the current drug of choice.” The Medical Staff Regulations of the Hospital (Ex. 1 Tab 1 p. 5) provide that consultations must be obtained in all cases undergoing a first caesarian section and in all cases with a history of a previous caesarian section undergoing a trial of labour, and complicated deliveries (e.g. twins, breach etc.) where the medical care is not being provided by a qualified specialist S .S.: When admitted she was in spontaneous labour and six centimeters dilated. Her first stage lasted 61 minutes and her second stage 25 minutes, not unusual for a multiparous according to Dr. W. A vacuum extractor was used instead of forceps. The Appellant prescribed Phenobarbital as a sedative which was criticized by both Dr. W and Dr. H. The use of the extractor was justified by the Appellant because she said the fetal heart rate had dropped but Dr. W said it was fine until five minutes before delivery. Dr. R did not comment directly on this case. No fetal monitoring strip was produced at the hearing and this case remains open, to some extent, to conjecture. K.R.: This was the case, on which the Appellant has been supervised by Dr. K. The delivery required the use of outlet forceps, and this procedure would ordinarily have required the approval of the Obstetrics Committee and two obstetricians to be present. Dr. W provided more details. A fetal monitor was applied to the patient’s abdomen but the strip was undecipherable and so Dr. W concluded there was insufficient data to justify the use of forceps. Dr. H merely referred to it as “probably unnecessary” Dr. R said the case was well handled. The Appellant said she had to use low forceps because the fetal heart rate had Dr. W also testified that the privileges form which was a part of the application process has a special area for induction of labour and augmentation and that the Appellant had not been granted such privileges. In other words she was acting beyond the scope of her authority as a locum. He testified that “normal deliveries” would exclude forceps deliveries, caesarian sections, breach deliveries, manual removals of placenta and twin pregnancies. This was his interpretation although admittedly a definition of “normal delivery” was not When asked by Ms. Dillon what procedure would be required to expand a locums privileges he admitted that at that time the procedure was “somewhat unclear” (Transcript, p.36) but added they would expect the locum to provide evidence of further training, to provide further references and “possibly being supervised.” He went on to admit that the question of obstetrical privileges for locums had presented a recurring problem. He said (Transcript. p. 36): … unfortunately obstetrics is one area where things can go wrong rather rapidly and so the pendulum has swung between locums not doing any obstetrics whatsoever to locums being allowed to do what they feel they are able to do provided they can demonstrate The Appellant, in her evidence, stated she had always, on the basis of her experience, felt totally capable of doing all the procedures she had done. The second area of the Obstetric Committee’s audit concerned the pharmacological knowledge of the Appellant. Dr. W referred to her use of Phenobarbital in each of the 19 charts reviewed and stated she seemed to prescribe 30 milligrams at night whereas Halcion, Dalmane or Restoril are generally regarded as the current hypnotics of choice. He said Pheonobarbitol was not prescribed in the Hospital as a sedative but rather as an anti-convulsant and it appeared odd to him if all the Appellant’s patients were in a continuous state of convulsions. He said her orders kept changing from day to day and in some cases she had left the dosage in the hands of the nurses who generally do not make such decisions. Dr. W was also critical of her use of the drug Dilantin. He said the normal practice, is to change the dose and then wait for up to 10 days before another drug level is done and then possibly change the dose again. The charts studied indicated that some of her patients were having their Dilantin changed or their anticonvulsant levels changed every day “rather like one who would manage a diabetic who is very unstable, on insulin” (Transcript, p.63). None of the charts indicated that any of these patients were so unstable as to warrant sending them to a secondary-care facility. Hence the frequent changes of Dr. W also carried out an audit with respect to the Appellant’s use of Vermox, a drug which he testified was used to de-worm patients. Because worm infection in this part of the world is very low it is not carried in the Hospital pharmacy. He said the Appellant had prescribed Vermox for two patients during her time at the Hospital but “no one had demonstrated the presence of worm eggs in the stools of the patients before the drug was prescribed” (Transcript, p.67). He agreed it was a safe drug but maintained the treatment of worms does not require the In cross-examination he agreed that Dr. C, an internist had ordered Vermox Dr. W also looked into the Appellant’s use of Deferoxamine in the case of one patient who had been admitted for investigation of liver nodules. This drug, he said, is a chelating agent which removes iron from serum and is useful in the treatment of acute iron poisoning in children. The Appellant’s diagnosis of iron overload was based on only one measurement of the serum ferritin, a protein in the blood which reflects the levels of iron in the iron stores. Asked if there had been an established diagnosis prior to the prescription of this drug he said: There had been no established diagnosis of hemochromatosis in the In cross-examination Dr. W was questioned by Mr. Giovando in respect to the Dilantin audit and agreed there were really only two cases which were beyond the normal range. He was closely questioned concerning the methodology used in preparation of the Dilantin audit. Nothing is to be gained by a line by line review of this evidence. We entertain serious doubts as to its probative value and our conclusion is not based either on that audit alone or on the obstetrical audit alone. But we note that while the obstetrical audit was available for the Hospital Board, the Dilantin audit was not completed until march 1990 and therefore constituted fresh evidence before this Board. Turning now to the evidence of the two expert witnesses, Doctors H and R, the former stated in her opinion letter of July 4, 1990 (Ex. 5B) that the use of phenobarbital for a patient with jaundice of pregnancy was not an appropriate choice. She wrote that the Appellant’s use of Dilantin with multiple drug changes indicated a lack of understanding of the pharmacology of the drug. As to the use of Vernlox for treatment of worm infestation she was of the view that it would have been appropriate to order stool samples and await treatment. She said the chart did not make it clear why treatment was not delayed. And she referred to Deferoxamine as an unusual drug to be used by a family physician and that a single measure of Ferritin is insufficient investigation prior to using the drug. Dr. H found the Appellant to be more interventionist than the general practice at this Hospital or in low risk settings as described by the Krikke & Bell study which, although presenting a fair standard for a hospital obstetric unit, may have presented a flawed result having in mind the small number of records (19) for the Appellant compared with the much larger number used in the study itself. In her oral testimony she admitted under cross-examination that she had never practised in a rural setting and that such a practice differs from her experience. But in re-examination she said her work takes her around the Province a good deal so she does have knowledge of rural problems. She agreed she had no expertise beyond family practice. She. was not aware that A.D. had concealed her pregnancy until she saw a copy of Dr. R’s letter of October. 24, 1990 (Ex. 11) or heard it from him verbally. In the N.M. case she was not aware that a paediatrician had seen her in Nanaimo and said she felt more comfortable when she learned of this. Similarly she was not aware that Dr. K had been present during the K.R. delivery and had assisted the Appellant. In his opinion letter Dr. R dealt with the Appellant’s drug problems in some detail. He wrote that for decades Syntocin has been virtually the only drug available for induction. But it has to be given i.v. and requires someone to sit with the patient during administration to ensure tetanic contractions do not occur and patients vary in sensitivity. He felt that doctors being conservative by nature, they have become used to the drug. He concluded however, that as more doctors became used to Prostiglandin it will gain wider use. In his comment on the use of Phenobarbital he wrote that it has been used for h.s. Sedation for a very long time but has now fallen from favour. He said he does not like Halicion, favoured by the Hospital, as it is a potent drug and produces He wrote that while Diazide does no good, neither does it do any harm. He said Parlodel, acts on the pituitary gland, has become the drug of choice but he does not favour such a potent drug as he is not convinced of its value to dry up Dr. R confessed some difficulty regarding a comment on the use of Demerol in the S.K. case – without seeing the patient. He concluded the Appellant’s use of it was basically sound. He referred to her use of it as really a judgment call. He commented on the induction of labour at some length. He said episiotomy is very controversial in obstetrics, natural birth being a modern cult. He himself does not agree with this trend. He wrote that an episiotomy can shorten labour and, even though it can cause complications in later life most women welcome it. He saw nothing wrong with the Appellant’s intervention. He concluded his opinion by stating that her practice of obstetrics was acceptable and would not be a reason to deny her privileges. This of course is a matter for this Board to We will later deal with the Appellant’s evidence regarding the allegations of poor practice and mismanagement but meanwhile return to a narrative of the events leading up to the Hospital Board meeting of February 9, 1990. On June 27, 1990 the Appellant wrote, presumably to the Head of Surgery, requesting privileges to do some 20 items of minor surgery for which she had not applied previously and on July 21 she addressed a typewritten letter to the Surgical Committee requesting permission to do a number of minor surgical procedures and, as well, the following procedures under the heading of Obstetrics: caesarean section, breach delivery, forceps delivery – to and mid, manual removal – placenta, induction of labour – medical and normal labour and delivery. As already indicated she had previously been granted privileges for As time went on the Appellant testified that she became increasingly frustrated over not being able to obtain satisfactory information from the medical staff as to the limit of her privileges, particularly in Obstetrics. She testified that she was not really informed what she could do. She said she believed all the foregoing procedures came under the heading of “normal labour and delivery” as well as an episiotomy. In her other locums she had been permitted to do an episiotomy which she considered to be a part of normal delivery. She admitted she had performed low forceps deliveries, episiotomies and other forms of induction at other hospitals and no one had challenged her. Her initial three months’ locum was extended for a further three months which brought it to the year-end. Finding that she liked Port Alberni and her work in the Hospital she terminated her locum for Dr. N and negotiated with another doctor to take over his practice for what was apparently a nominal price. She acquired the practice on December 1 and is still carrying on that practice with a substantial number of patients but without admitting privileges of any kind. On November 14 the Appellant completed a four page hospital form in which she ticked off both surgical and obstetrical privileges she wished to have (Ex. 1 Tabs 16B and C). Dr. JF, Chairman of the Surgical Committee replied in writing on November 16 (Tab 18) stating he had reviewed her request personally, wished to discuss the item of colonoscopy with her but that he would recommend the approval of her application pro forma and forward the recommendation to the Credentials Committee. On November 21 a meeting was arranged by the Chief of Staff for the Appellant to meet with her, the Chairman of the Manpower and Credentials Committee, the Administrator and Doctors ME and HU. The Chief of Staff testified that she said the Hospital was having some difficulties with the Appellant and would be seeking further information for extending her locum status. She said she told her they already had concerns and the Credentials Committee was involved and was looking at these concerns. She went on to [the Appellant] asked us to be specific as to what our concerns were, and we felt that as this was an informal meeting to clarify to her that we did already have concerns, we did not want to proceed with any detail as to specific cases that we were concerned about and sources of reference. (Transcript, p.15 1.) The Appellant testified that at this meeting she repeatedly asked for reasons why they were concerned. She said the Chief of Staff held something in writing but did not disclose the contents. She told the Appellant she should have waited until she obtained privileges before buying a practice. The Chairman of the Manpower Committee confirmed that the Appellant asked several times what the problems were, what it was specifically that was of concern. He said the Chief of Staff told her that it was not the purpose of the management to discuss individual matters. He said the Chief pointed out to the Appellant that no application (from the Appellant) had been received and no application had been reviewed, hence it was inappropriate to discuss specifics. Significantly, he The purpose of the meeting was merely to provide [the Appellant] with as much insight and forewarning as we thought we could give and we believed that we were doing what was in [the Appellant’s] Dr. S further testified that as Chairman of the Credentials Committee, he told the Appellant, that he personally had some concerns about her practice of medicine and that should she apply for Associate status her application would be reviewed in great detail. She asked him what his particular concerns were but again he told her that as Chairman of the Credentials Committee, since no application was before him he could not discuss specifics. He then suggested to her that she should obtain letters of reference from the Chiefs of Staff of all the hospitals in British Columbia in which she had worked. He warned her that on the basis of the information he had it was his opinion that the Credentials Committee would have difficulty in recommending the granting of privileges. Dr. S testified that he had, prior to this meeting received the letter from the Chief of Staff at Cariboo Memorial Hospital in Williams Lake which appears at Tab 19. The letter was dated November 17 and is addressed to the Chief of Staff. There is no doubt in our minds that this letter influenced those at the November 21 meeting and for this reason we quote excerpts. The Chief of Staff at Cariboo The doctors who arrange the slates for anaesthetics in the operating room found [the Appellant] virtually impossible to get along with. There were some reservations expressed at the Quality Assurance Committee about her ability to practice medicine. Perhaps, with upgrading in trauma, acute medical emergency care and obstetrical care, [the Appellant] could do well in a practice. However, without this upgrading I would be very reluctant to recommend her for medical staff privileges. This letter was not shown to the Appellant either at the meeting or afterward. The Appellant stated that she was very upset at the meeting and was at one point reduced to tears when she failed to elicit any specific charges against her. On the day following the meeting Dr. HU, Secretary to the Medical Staff Executive, wrote letters requesting references, to Baffin Regional Hospital, and Fort St. John General Hospital (Tabs 21 & 22). On November 24 the Appellant wrote to Dr. W requesting an answer to her second request for obstetrical privileges. She had apparently given him the official form for procedures and she asked him to pass it on to Administration. On December 6, Dr. W addressed a letter to Dr. S, Chairman of Manpower and Credentials. Dr. S reported that his committee had met on November 30 to review her obstetrical practice. He stated: Severe reservations were expressed concerning her knowledge, judgment and obstetrical skills. In addition she would appear to have problems with interpersonal relationships. (Tab 25) On the same day he informed the Appellant in writing that he had reported to the Credentials Committee in regard to her application for privileges but did not On December 8 the Appellant directed a note to “Dear Doctor and Executive”, requesting an appointment to the Associate Staff (Ex. Tab 16A). This, then, was the situation at year’s end. While, strictly speaking, her status was in some doubt she had made application for appointment to the Associate Staff, inquiries were being made and she was carrying on with her extensive Sometime after January 24, 1990 a reply was received from Baffin Regional Health Board over the signature of Dr. MN. Dr. S was not sure whether he received it before or after the Hospital Board hearing of February 9, 1990 but said he was certain he did not place either of these letters before that Board. The reference attached, addressed “To Whom it May Concern”, referred to the Appellant as being a conscientious, competent and caring physician, but one … did lose her temper quickly at times (but) she cooled off just as rapidly and she had a good relationship with the nursing staff and her colleagues when she left … I found [the Appellant] a very reasonable colleague. Her clinical knowledge and scientific awareness was well above average. (Tab 33 B) The letter of transmittal provided additional information, apparently in response to a telephone call from Dr. S concerning the Appellant’s interpersonal skills, in particular, whether there had been any disputes. Dr. MN wrote: In the last 2-3 months that she was here our then surgeon swung from being totally in favour to antagonistic. He had got braver in the kind of cases he was booking and [the Appellant] had remained as cautious about accepting high risk patients. The surgeon as then Chief of Staff felt he could “order compliance. (Tab 33A) Dr. MN appeared before this Board to give evidence. Her comments generally about the Appellant’s personality and her medical skills were all very positive and she blamed the doctor concerned for the one incident referred to in her letter. She referred to the Appellant’s clinical skills as very good, her knowledge of drugs and medications as above average and her record and chart keeping as very good. She said the Appellant strove to keep her medical knowledge current. She said her obstetrical skills were “very adequate” and she had been involved in In cross-examination she said when the Appellant lost her temper it was usually when she had a problem with someone and she felt that things were not happening appropriately. She had had confrontations with the nurses about medication that had not been given or orders that had not been followed. She I then said to her something along the lines of, you know, if your anger goes on, sometimes people stop listening because you are angry and you have a resistance there. (Transcript, p. 130) What emerges from this evidence is that the Appellant got on reasonably well with the nursing and medical staff but there were occasions when she became extremely upset at what she considered to be incompetence and lost her temper. Dr. MN also said that she cooled off in a few minutes. Sometime in December, 1989 the Appellant composed a 2 1/2 page summary of her complaints about the nursing staff in the Obstetrics ward at the Hospital (Tab 28). It is addressed to no one in particular but various initials indicate it was directed to or seen by Doctors M and S and by the Administrator. It would appear to have been received on January 2, 1990. Even allowing for the fact that the Appellant was frustrated over not being able to get a straight answer from the medical staff together with the fact that she was in an emotional frame of mind, the lengthy tirade is astonishing. In cross-examination she admitted that she wrote it in frustration and in hurt. It can perhaps be compared with a possible reply and counterclaim she might have filed in response to actual charges made against her because she concluded by writing that since she was unaware of why she was being denied privileges she was showing what problems she had had with that one Department and that there was nothing in it to show any reason why she should not be able to practice medicine in the Hospital. In eight numbered paragraphs the Appellant itemized her alleged difficulties with the nursing staff, covering most of the cases referred to earlier in the Obstetrical In each case she alleged the nurse involved had acted improperly or unprofessionally. Many of her comments confirmed her anger. She referred to an outburst from the Head Nurse as a “show of power.” Her comment on another patient about the nurse in charge was “obvious bias.” And she added: When I discuss it with another nurse I get blamed for being rude and argumentative. I say same to her. Why don’t you curtail her In regard to the M.S. case she wrote that the nurses had given the patient and herself a hard time and that the Head Nurse, had even goaded the patient into going home though she was still sick but that she realized the patient was not ready when the Appellant got to talk to her. A further confrontation occurred in regard to the patient M.I. where the Appellant and the Head Nurse had speeded up the i.v. drips which brought on a seizure. She said the nurse phoned her, because an Incident Report would have to be filled and the nurse felt the patient should not have been on her floor. The Appellant wrote that she told her all she had to do was watch an i.v. Her note That’s when she turned on me about the patient described in case 6 (M.S.). Then she turned sweet again once she thought she had Her final complaint involved a delivery she had planned to do but the patient was early. She booked on a Thursday for Saturday morning. The patient stated she wanted the baby circumcised but the Appellant had not yet received a response to her earlier application for surgical privileges and she said Dr. S had allegedly phoned her to tell her she couldn’t do it as she was still a locum. Having no answering service, she said she did not know about it until the nurse told her when she arrived. She had a further complaint to make about Dr. S in regard to their periods of being on call. She said she was the victim of an uneven trade and that is when she realized Dr. S was unfair. She said she had never had an Initially she said she had given the memo to someone in Administration and they discussed how to handle it. The latter asked the Appellant what she wanted done with the memo. She said it was intended for further discussion only and that she was disappointed and felt it was a breach of trust that the memo had been circulated. The fact is, however, that it was circulated and must have affected the ultimate decision of the medical staff to not recommend her for associate privileges. It was material that was properly before the Hospital Board Her application eventually came before that Board on February 9, 1990. The circumstances were somewhat unusual. She had been informed, she said, by a patient that the matter was on the agenda for a meeting of the “Committee of the Whole” to be held on February 1 at 9:35 p.m. The title given this meeting is unusual but in any event it was attended by most Board Members including Dr. M. Between items 2 and 3 on the agenda, according to the copy of the minutes filed but not marked as an exhibit, the Chairman said the Appellant had asked permission to speak to the board about her privileges. On a motion, leave was [The Appellant] asked about her hospital admitting privileges and was advised by Mr. MK (Chairman) that the Board had not received a recommendation from the Credentials Committee … and therefore The Appellant testified she asked for reasons but none were forthcoming. She was told her case would be dealt with later in the evening. She was not invited to remain and so left the meeting. The minutes indicate that later in the meeting there was considerable discussion with regard to the Credentials Committee’s recommendation that she not be granted privileges. The members felt there was not enough information available to render a decision. On Motion it was then resolved that a special meeting of the Board of the Credentials Committee be set up to discuss the Committee’s decision. The minutes do not show what, if any, written material was placed before the Hospital Board at this meeting. Prior to this meeting, however, Dr. HU had received a-reply from Fort St. John General Hospital (Tab 29). It was not complimentary. It referred to some of her treatments as being unusual and gave as examples: Treating newborn jaundice with Phenobarbital. Stimulating milk production with Chlorpromazine. Treating minor head injuries (concussions) with Other questionable uses of Corticosteroids. The writer, Dr. L, said he had tried to discuss these matters with the Appellant but his comments were not well received. His letter concluded with this I must say … that [the Appellant] did raise more red flags in the hospital setting than the number we have normally observed in This letter was made available to the Hospital Board. In addition the findings of the Credentials Committee meeting held on January 9 must have been disclosed to the meeting of the Hospital Board on February 1. Dr. S, in his evidence (Transcript, pp 187-188) informed this board that the Committee had reviewed all the information then available to them. They discussed a number of incidents where the Appellant had apparently crossed swords with some of the medical staff and reviewed information they had received from Doctors B and RB, both radiologists. These doctors were not called on to give evidence, however, and we do not know what their complaints, if any, were. But the Committee did review the letter from Dr. K, the Obstetrical audit (but not the Dilantin audit) and Dr. W reviewed the cases dealt with on that study as well as the Krikke & Bell Dr. S said they spent a good deal of time discussing the lengthy memorandum prepared by the Appellant and reviewing the cases it referred to. The committee also looked at Dr. L’s letter and Dr. S reported on his telephone conversation with Dr. MN from Baffin Island. Her written reference had not yet been received. The committee also reviewed the letter from the Chief of Staff in Williams Lake and the other references the Appellant had supplied. Dr. S said the references were not too helpful. What the committee was seeking was references from those who had had a longer working relationship with, and a long term knowledge of, the Appellant. They regarded the letters from Dr. L and the Chief of Staff in Williams Lake as “very significant” and in support of their own feelings based on The Committee voted unanimously to recommend that privileges not be granted to the Appellant. The Chairman communicated this decision to the Chairman of the Quality Assurance Committee for his committee to review the Appellant’s hospital practice in detail. The Medical Advisory Committee held a meeting on January 10. The negative recommendation was presented to it and accepted and the recommendation went to the February 1 meeting of the Hospital Board. Dr. S I attempted as carefully and properly as I could to present to the Board all the information both in writing and of an informal verbal nature that I or other members of the Committee had been aware of at the time that we made our decision to not recommend granting of privileges on January 9. (Transcript, p. 190.). The letter from Dr. MN which arrived subsequent to January 10 was never disclosed to the Hospital Board, nor was any other communication or other None of the information received by the Committee was passed on to the Appellant either before or after the Hospital Board meeting on February 1 and it was only made available to her for the purpose of this Appeal. A special meeting of the Hospital Board was held on February 9. Doctors S and M were both present. Dr. M presented the recommendation of the Medical Advisory Committee and Dr. S reviewed the information which formed the basis for the report. Both doctors answered questions put to them by Board members and then, upon motion, the Medical Advisory Committee’s report was accepted. The Appellant was not invited to this meeting and was not informed of it. The allegation that the Appellant was seriously lacking in interpersonal skills was referred to in part by several members of the Nursing Staff. Nurse O was Head Nurse in the Obstetrics Department at the material times. She recounted an instance involving the Appellant requesting that Demerol be given to a multiparous patient who was at six centimetres of dilation. Nurse O said the Appellant wanted the nurse on duty to give the patient the drug without checking the patient first and Nurse O told her to make a note of it, which she did, but the note was subsequently thrown away. She said the nurses were concerned about the Appellant prescribing Imferon. The opinion of Pharmacy was sought and it was their opinion that the patient’s condition did not justify the risk involved in using this drug. Nurse O said four other nurses had been reluctant to administer Imferon in this case. She mentioned another case in which the Appellant had ordered medication for a patient who was admitted pregnant and with toxemia but no high blood pressure and the nurse felt uncomfortable about giving the medication. She was critical of the Appellant ordering Demerol in case No. 1 referred to in Tab 28 and said it was not accepted nursing practice to give it at this stage of pregnancy. She questioned the Appellant’s decision not to give Parlodel in the case of A.D. as well as her not noticing that the patient was pregnant. She responded to the Appellant’s complaint referred to in paragraph 3 of Tab 28 by admitting she may have said something similar to what the Appellant alleged because it was against hospital rules to take a premature baby and she said she had referred the Appellant to She further commented on the L.B. case. She was critical of the Appellant being in Nanaimo when she was on call and that she had arrived six minutes after the delivery. She was also critical of the Appellant performing a circumcision when, clearly, this surgical procedure was not included in a locum’s privileges. Nurse K, who was acting head nurse in the Obstetrical ward from early March to early July, was directly involved in an incident concerning a patient, L.B. The Appellant, having stayed overnight in Nanaimo while on call, had been unable to arrive at the Hospital in time for the delivery. She said the Appellant told her they could use the doctor on call in Emergency but Nurse K told her that wouldn’t do since often there was only a locum in Emergency without obstetrical privileges. The Appellant said she was only 50 minutes away but the nurse told her that was well beyond the time limit for on-call, which should be 10 or 15 minutes. She said she agreed with the warning given the Appellant regarding the use of Imferon. Nurse K had fourteen year’s experience behind her in the Hospital. In cross-examination she expanded on the L.B. incident. She said it was a heated discussion that she was only stating the Hospital policy but the Appellant became angry and yelled at her loud enough to be heard across the hall. The Appellant denied this. In answer to questions from the Chair Nurse K said the duty nurse or head nurse can question a medication but one must consult with the doctor first. She had had occasion to do so over the years but usually about a wrong dose rather than the wrong drug. Dr. AF a general practitioner gave evidence regarding an incident involving a male patient, V.H. He had been called by the duty nurse to change an order previously written by Dr. C. She had been unable to reach him. The request was to change the order from intramuscular to Demerol by mouth. He so ordered and said it was a perfectly straightforward matter. He referred to it as a non-issue. The next morning the Appellant approached him in the Medical Records room, demanding to know why he had changed the order. He explained why. He described her manner as “slightly aggressive” and “a one-sided sort of approach.” Following this incident, he said the Appellant had ordered both Demerol and Gravol but had not specified the route they were to be given. He said she seemed upset at his “interference.” He felt that the Medical Records room was not an appropriate place for a conversation of this nature. In answer to questions from Mr. Farquhar he said that he found it difficult to explain to the Appellant the reason for his changing the order and to interact in any meaningful conversation during the “little lecture” she was giving him. In fairness, Dr. AF, conceded he got on all right with her at other times. Finally Dr. JF was called by the Hospital. At the material times he was chairman of the Surgical Committee and had been at the Hospital for seven years. He confirmed he had approved the procedures the Appellant had requested at February 16 save for colonoscopy. She had assisted him in appendectomies and, in cross-examination, he said he was satisfied, that her diagnoses were reasonable, and he described her referrals in relation to other doctors “sometimes better, sometimes worse.” He had found nothing bizarre about her treatments and said he had found no case where her prescribed medication was inappropriate. He agreed with Mr. Giovando’s suggestion that it is not possible to get along with everyone who is working in the Hospital and agreed there are often personality conflicts. He confirmed that the recommendation made to the Credentials Committee was that she be granted admitting privileges for those In our review of the evidence it is clear that the Appellant got off to a bad start. We refer to the absence of an orientation program and the uncertainty as to what actual material, if any, she was given to read. But she had several years of practice behind her in various sized hospitals and must have been aware that there was partly a duty on her part to familiarize herself with the procedures she could undertake as a locum. Her failure to learn the Hospital rules for being on- call is inexcusable. The 50 minutes’ drive from Nanaimo was well outside the limits imposed by the Medical Staff Bylaws. Admittedly, part of her experience was in Africa where one can assume she worked in sometimes primitive conditions and as the result probably had little time for the niceties of hospital organization. But that considerable prior experience must surely have taught her that all hospitals have rules and regulations. We view the Appellant as a person of considerable energy, intelligence and devotion to her profession but lacking in the tact that is so essential in the modern hospital setting. As well, she displayed considerable, antagonism to anyone who disagreed with her. It seems that fairly early her clinical judgment and pharmacological knowledge came to the attention of the medical staff. Despite the evidence of the staff doctors who were called, the evidence of Doctor H, and the evidence of the two nurses we are unable to conclude that on those grounds alone the Hospital Board’s refusal was justified. But the letters from Fort St. John Hospital and Cariboo Memorial Hospital which were not before the Hospital Board but form part of the material introduced in evidence at this hearing provide some confirmation for the view that there was a reason to question some areas involving her practice and procedures. In our view she seems to lack some understanding of the value of certain more modern drugs, those referred to by several witnesses as the “drug of choice.” This may be attributable in some Dr. AF found her work satisfactory but this was in relation to surgery only whereas most of the complaints stemmed from her Obstetrical practice. The evidence disclosed that she acted beyond the scope of her privileges but this was largely due to her interpretation of the term “normal labour and delivery.” It was not carefully delineated for he, but, again, we are of the view that she had enough prior experience to have alerted her to find out. It is not good enough for her to say simply that she knew she was capable of doing what she did. Many of her references supplied to the Credentials Committee and subsequently to the Hospital Board were, in many instances, several years old or non- committal, arose from entirely different circumstances or covered brief periods of time only. The principal positive reference was the one from Frobisher Bay, supplemented by the oral evidence of Dr. MN. But even this carried a strong hint of personality clashes and it was only the telephone conversation between Dr. S and Dr. MN that was reported to the Hospital Board. Most of these references were seen by the latter and must have been taken into account. We find that the Hospital’s concern with the Appellant’s lack of interpersonal skills was in itself a compelling reason for the refusal of privileges. We refer in particular to some, if not all, of the nurses’ evidence, her unjustified ignorance of the rules relating to discharge of patients, the unfortunate incident related to Dr. AF and the extraordinary memo she composed, which contained innuendo, glib comments and unprofessional statements. Despite her alleged frustration at the time – she said she felt a sense of hurt – it was tactless and ill advised. The doctors and the Administrator who met with her on November 21 did so in order to have a frank and perhaps helpful chat with her. They were not required to cite chapter and verse to her. They made it clear that they had concerns about her patterns of practice and warned her against buying a practice before she was assured of privileges. We question what more they could have done. Thereafter the matter followed a more or less conventional course. She applied for Associate status, referrals were made to the Committees concerned and eventually it came before the Hospital Board, February 9 at a special meeting, apparently called to consider only two matters of which this was one. We reject the findings of the Obstetrical and Dilantin audits for the reasons previously given. And we are not persuaded that the Laboratory report of the Appellant’s billings necessarily provides compelling proof of her over-use of It is trite law that a hospital board’s duty, in selecting doctors for its medical staff, is to have regard to the whole person, not merely that person’s qualifications and skills but the applicant’s character and personality as well. Every hospital has a duty imposed on it by the Hospital Act, RSBC 1979. Ch. 176. to provide a high level of patient care. That duty is owed to the community which, in this country, supplies through taxes, the greater portion of the costs of operating the public hospitals. The onerous task faced by a hospital board is to ensure that the institution is run competently and efficiently. It is a delicate mechanism. If the total trust, cooperation and general team work of any of its constituent parts breaks down the result can be unfortunate for the hospital and community. This has been demonstrated in other appeals before this Board. There was no evidence before us that the Hospital Board acted capriciously or maliciously or that the medical staff, whose duty it was to make a recommendation to the Hospital Board exhibited bias toward the Appellant Theirs was a judgment call and we are satisfied that they arrived at their judgment honestly and fairly. Although, prima facie, it seemed that the medical staff was unfair to the Appellant in refusing her particulars of their concern, they had no duty to do so either at the November 21 meeting or later. After the Appellant filed her application for Associate status the matter was, in our view, handled correctly and in accordance with the Hospital Act Regulations as well as the Hospital Bylaws. The Regulations do not create a right for an Appellant to be heard the first time around. If an Appellant so chooses he or she may appeal the initial finding to the Hospital Board where he or she is entitled to appear with Counsel. In this case the Appellant, as she is entitled to, chose to appeal directly to this Board. Thus we must place ourselves in the shoes of the Hospital Board and consider all of the evidence adduced before it. We must also have regard to those letters of reference which came in subsequent to February 9. In considering the Appellant’s suitability for Associate privileges the Hospital Board, and the medical staff whose duty it was to give or deny approval, had a duty to consider what was best for this Hospital, not whether the Appellant’s skill and knowledge were adequate in other hospitals (See Re: Board of Governors of the Scarborough General Hospital and Schiller (1974) 4 O.R. (2nd) at p-212. In Although we do not base our judgment alone on her patterns of practice, the concerns with her pharmacological knowledge, the Laboratory use or the Obstetrical and Dilantin audits, these factors, coupled with what, in our view, was a questionable inability to employ tact and a somewhat insensitive response to criticism is justification for a denial of privileges. The Hospital Board acted correctly and with the benefit of the additional material and evidence before us during the course of a five day hearing we cannot find reasons to reverse their We would add that the Appellant, who continues to practice in Port Alberni, has requested the College of Family Practice to audit her practice. She has also taken a number of courses to upgrade her skill and knowledge. She sat for written and oral examinations over a period of three days in April 1990, covering the entire range of general practice including drugs, geriatrics, paediatrics, obstetrics and gynecology. It may well be that her additional studies will prove For the foregoing reasons however we would dismiss the Appeal. Dated May 24, 1991
Dissenting Opinion
With respect, I dissent from the majority opinion for the reasons which follow. I have dealt with the many issues raised under separate headings. The Appellant supplied the Hospital with nine favourable references in May and June 1989. The references dated from 1979 to 1989 (Ex. 1, Tab 3H to 3N, 4B, 4C). In October, 1989, the Appellant was told that she would need to provide more references if she intended to apply for Associate Staff. She then provided about 14 positive references dating from 1976 to 1987 (Tab 34). The Hospital independently sought references and received two unfavourable references, one of which was politely unsupportive (Tab 29) and one which was strongly negative (Tab 19). One was strongly supportive (Tab 20). The Appellant did not receive copies of the unfavourable references and was never given an opportunity to defend herself. The Hospital also received a favourable reference dated January 20th and a memo January 24th 1989 (Tab 33), which it interpreted as negative, although in answer to questions from Mr. Marshall, Dr. S acknowledged that the letter was in part positive and in part neutral (Transcript, p. 203). The negative references were seen as “very significant” and the positive references were deemed “not pertinent” by the Credentials Committee (Transcript, pp. 189 and 200). The Appellant was criticized for being “aggressive” in her obstetrical practice. Dr. R, a retired specialist obstetrician and expert witness, reviewed six of her cases and felt that “her practice of obstetrics is acceptable” and would not be a reason to deny her hospital privileges. His report (Ex. 11) states: Of the case M.S., “The treatment of hyperemesis can be frustrating but fortunately it is usually self-limiting no matter what is done.” He did say of this case, “…there was no indication to give parenteral iron” but he “would not be concerned with it being harmful to the pregnancy.” Of the case A.D. who refused examination he said there is little a doctor Of the case S.K. he said, “Prostin was used correctly.” Of the case L.M. he said, “Correct action was taken.” Of the case N.M. he said, “The case was adequately handled with a Of the case K.R. he said it was monitored by Dr. K and he was “exceptionally pleased” with the Appellant’s performance. The Hospital’s senior general practitioner/obstetrician, Dr. K, supervised a delivery and stated in a letter of June 9, 1989 (Tab 8) that he was “exceptionally pleased” with her performance. The Appellant was granted privileges in Obstetrics for normal labour and delivery by administration in a letter dated June 14, 1989 (Tab 7). Dr. K commented that the Appellant used outlet forceps and “put them on in a very sleek fashion” (Transcript, p. 98). He also gave in evidence that he had “no objection if anybody wants to use outlet forceps. … It is The Appellant was also criticized for a high incidence of episiotomy. Dr. R described the damage to underlying tissues during delivery without an episiotomy which causes problems in later life. He also added that episiotomy can shorten labour. He said “I see nothing wrong with [the Appellant’s] In its obstetrical audit (Tab 13) the hospital used a reference which is misleading. It compares the obstetrical practice of the Hospital with that of the University Hospital in Edmonton as described in the Krikke & Bell article (Canadian Medical Association Journal March 15, 1989). The two hospitals are not comparable. This Hospital is a class one hospital, and the University Hospital is a class three hospital as well as being a University teaching hospital. Of 4,463 deliveries the K & B article studied, 32% of these deliveries or 1,456 were “low-risk pregnancies.” The West Coast General Hospital studied all of its deliveries not just low-risk pregnancies. The Edmonton Hospital had 50% midwives in the Obstetrical Unit and the West Coast General Hospital had 20% midwives (Transcript, p. 94). Although this obstetrical audit was used as part of the grounds for not granting privileges, it was acknowledged at the appeal that “there was too small a sample size for meaningful analysis.” The Appellant had “18 to 19” deliveries of which “6 or 7” were cause for concern (Transcript, pp. 41 and 42). It was also stated in evidence by the Chairman for Obstetrics, Dr. W, that the Appellant “ had relatively straightforward and easy deliveries to handle (Transcript, p. 58).” The Appellant was also criticized for the use of Demerol during delivery and other The Appellant was criticized for using Prostin instead of Syntocinon. Dr. R felt that she had “used it correctly to induce labour successfully in two patients.” The Krikke & Bell article cites the use of oxytocin or prostaglandin as used by both obstetricians and family physicians. Dr. W stated that he would use, in some cases, prostaglandin overnight and Syntocinon the next day (Transcript, p. 80). The Appellant was criticized for the use of Vermox when evidence showed that Dr. C, a specialist internist at the Hospital, had done the same (Transcript, p. A nursing report was made out because the Appellant had ordered Demerol for a woman in labour who was six centimetres dilated (Transcript, p. 149). The nurse refused to give the order. (This is item 1 in the Appellant’s angry rebuttal of January 2, 1990 – Tab 28.) One medical witness said she would give Demerol if the patient was five centimetres dilated. Dr. R in his review said “dilatation cannot be taken as a single entity.” He also added “A dose of analgesic at this time can be very effective. If the Demerol should affect the baby adversely an antidote can be given.” In any event the Appellant’s use of analgesics was less than the rest of the staff as shown in the obstetrical audit: 50% of her primips compared to 68% of the medical staff, and 10% of her multips compared to 35% of the total medical staff (Tab 13), (Transcript, p. 57). The Appellant was criticized for her use of phenobarb. Dr. R notes that she uses this for “h.s. sedation in a low dose for a short time.” He adds “phenobarb has been used in this way without problems,” for a long time. Dr. W gave evidence that Halcion was the drug of choice at the Hospital. Both expert witnesses, Dr. H and Dr. R, felt that Halcion was not recommended. The Appellant was told that Parlodel was the drug of choice in the Hospital and. this again led to another nursing report and another angry retort by the Appellant in her incident report of January 2, 1990. Dr. W acknowledged in his evidence that diuretics were used before 1975 but since then Parlodel was the drug of choice at the Hospital. Dr. R testified that Dyazide was not harmful and not beneficial and said that Parlodel was a potent drug. He added, “I am not convinced such a potent drug is proper for a benign self-limiting problem.” In reviewing the chart of patient M.S., Dr. R reported “parenteral iron was ordered because oral iron was not tolerated as expected.” However, there was in the chart “no indication to give parenteral iron.” He added however, because of his wide experience with parenteral iron, “I would not be concerned with it being There is no evidence as to why this iron chelating agent was used. The patient was said to have had a serum ferritin level done (Transcript, p. 68) but no lab report is available. The diagnosis was said to be iron overload (Transcript, p. An audit was done at the Hospital in July and August 1989 (Tab 14) to compare Dilantin levels and drug changes and length of stay of the Appellant’s patients with those of other medical staff. During the hearing before this Board an error was found in this audit which was corrected for the Board but presumably the Medical Advisory Committee reviewed the original. No diagnoses were given on any of the patients and the number of seizures per patient per day, if any, was not given so that it was not possible to judge the significance of the length of hospital stays or the significance of the frequency of drug levels or drug changes. Dr. H has a Fellowship in the College of Family Practice. She is an Associate Professor at the University of British Columbia in the family practice teaching field. Her expertise, according to the evidence, lies in teaching and research in the field of sexual assault, hypnosis and stress management. She travels widely to give lectures and interviews on these subjects. She is based at a large city Although he retired from active practice in 1987, Dr. R has a long history of practice as a certified specialist in Obstetrics and Gynecology. He practised in the Nanaimo area since 1959. Although the Nanaimo hospital is larger than the West Coast General Hospital it acts as a regional hospital for the smaller hospitals in that area. As well as being on the Active Staff of the Nanaimo Regional General Hospital, he was also on the Consulting Staff to the West Coast Because of Dr. R’s special expertise in the area of Obstetrics, more weight must, in my opinion, be given his evidence. His experience is also more relevant to the In the case of Kelowna General Hospital & Dr. T.J. O’Neil, heard by this Board in 1975, the Board held that the Appellant received fair and reasonable notice of the hearing before the Medical Advisory Committee, … “That he was made aware of the charges against him and was given every opportunity to speak to them.” The Appellant, although she attempted to speak to the Hospital Board February 1, 1990 was not given permission to speak and was not told about the next Board meeting of February 9th at which the decision was made. She asked in October and again in November 1989 as to what were the charges, but she was never told and was not given an opportunity to present her case (Transcript, p. She was not given copies of the unfavourable letters of reference and was not given an opportunity to refute them or defend herself (Transcript, p. 196). On January 10, 1990, a meeting of the Medical Advisory Committee was held as a meeting of the whole medical staff, to which she was not invited “because she was not a member of the medical staff’ (Transcript, p. 32). In Dr. D.R. Loewen and Cariboo Memorial Hospital heard by this Board October 8, 1985, the Appellant was not a member of the Medical Staff and yet had attended some 50 No consideration was given the fact that the Appellant had been off work because of back surgery from 1988 until May 14, 1989 and began work at the Hospital May 23, 1989 on very short notice because of Dr. N’s illness (Tab 4A, 4B). Although the Hospital instructions state that locums must be given an orientation and instructions in Hospital procedures by the hiring doctor or his substitute, she had no orientation other than a tour of the physical layout conducted by Dr. N’s wife. The instructions also state: “The employing physician is responsible for designating a colleague from the Active Staff to be available to provide advice and information to his locum tenens.” There is no evidence that this was done by anyone on behalf of Dr. N who was ill. It is acknowledged that the hospital administration was in a state of confusion, if not chaos, a few days after her arrival. There were changes of department heads in both Chief of Obstetrics, Chief of Staff and in Administration. The Hospital presented a study of lab tests done at a laboratory in the community. The hearing before this Board was given no report of lab tests done in the hospital laboratory. Although the Board was told that this report was not relevant since it had to do with practice outside the hospital, this study had already had some influence with the Medical Advisory Committee. In the case of patient A.D., an adolescent who concealed her pregnancy from her parents and her doctor, the Appellant failed to diagnose pregnancy. This patient delivered on July 21, 1989. The Appellant’s privileges were renewed for the period September 1989 to December 1989. The expectation, therefore, was that this failure to diagnose had been forgiven. Dr. R said of this case: “She refused to be examined. … there is little a doctor can do when a patient will not The complaints against the Appellant seemed to have arisen out of her relationships with the nurses, particularly in the Obstetrical Unit. The evidence seems to show that the Hospital attacked this problem not by meeting with the nurses and the Appellant to work out problems but rather, by examining the Appellant’s clinical expertise. This led to an obstetrical audit which, because of serious flaws, worked to the prejudice of the Appellant. There was evidence that the Appellant tended to lose her temper but it was described as short-lived and her “irritation and reaction was appropriate” (Transcript, p. 132). One of the nurses referred to an “angry conversation” between the Appellant and Dr. AF but the latter referred to it as a “conversational tone” and “only slightly aggressive in nature”. At the time he thought of it as an “isolated incident” and did not feel it necessary to report it until requests came in for reports concerning the Appellant (Transcript, pp. 139-140 and p. 142). He also testified that on September 3, 1989 he was “lectured at,” by the Appellant but also said that at other times she was “passively pleasant” (Transcript, p. The incident involving Dr. HN is another instance in which the nurses seemed to be more upset about the verbal attack than the doctor. He did not report on it until “asked to” (Transcript, pp. 103 and 104). Dr. HN’s duty was to write the discharge summary. He did this. Nevertheless there was no excuse for the The Appellant revealed her temperament in her incident report concerning the nurses of the obstetrical department, January 2, 1990 (Transcript, p. 28). This report can only be described as irritable, angry, accusatory and mean-spirited. Nevertheless, it must be read in the context of a doctor who has been warned in October 1989 that her practice is going to be critically examined if she applied for Associate privileges. Accusations had been levelled against her and she was frustrated in not being able to find a forum to defend herself and discuss these In the Kelowna General Hospital & O’Neill case (supra), the Appellant was described as “abrasive, adamant, arrogant and dogmatic.” In spite of this he It might be said that since the Appellant was never on the permanent staff, the Hospital has no obligation to accept her. Nevertheless her locum status was renewed after three months, for a further three months extension, and this must have given her an expectation that she could continue to apply and expect a favourable result. She had applied for privileges to three other hospitals in the area but each had required proof of her having done a locum first. Therefore, having done a locum at West Coast General Hospital, the expectation would be that application for Associate Staff would be a natural progression of events and that preference might be given doctors who had done a locum there. Legal Authorities Cited By Hospital’s Counsel In Re Board of Governors of the Scarborough General Hospital & Schiller (Tab 4), of the Hospital’s legal authorities and reported in 4 O.R. (2nd) 201, it was the case of a specialist surgeon. The hospital showed that it had no need for another specialist. This case has no relevance for the present case in which the Appellant Andreas & Edmonton Hospital Board (Tab 5), and reported in (1944) 4 D.L.R. 747, is the case of a physician who was not already a member of the staff and “it made all the difference in the world” (page 752). The Appellant, although not a member of the Active or Associate staff, but as a locum whose term of three months was renewed for a further three months, had an expectation of The case of Tanhueco & Prince George Regional Hospital (Tab 8), an appeal heard by this Board in October, 1986 is not comparable. It concerned a physician not trained in a Canadian medical school, as was the Appellant. The case of Iqbal & Mission Memorial Hospital, an appeal heard by this Board in February, 1974, is also not relevant as the physician was never on staff and surgical The case of Loewen & Cariboo Memorial Hospital (Tab 10), an appeal heard by this Board in October, 1985, also concerned a physician who was never previously on staff and the evidence suggests he planned to use the appointment Griswold & Great Victoria Hospital Society (Tab 11), an appeal heard by this Board in 1986, concerned a specialist and is not, in my view, relevant for a The Respondent has not proven that the Appellant’s clinical skills are inadequate. The Appellant’s interpersonal skills are deficient but could be remedied and are In my opinion the Appellant should be granted admitting privileges as an Associate Member of the Medical Staff. During the period of probation, the Appellant must accept the Hospital’s standard of care as well as its Rules, Regulations and By-Laws. Where she disagrees she must bring her concerns to the appropriate Committees and when necessary to the Medical Staff meetings by proper motions duly presented and debated and she must accept the majority vote. She must not verbally castigate either nurse, staff or peers but carry complaints through appropriate channels. The issue of “coverage” must be In my opinion she should be reinstated to give her an opportunity to rectify any errors in communication the Hospital sees, and to give the Hospital an


Doxycycline an emerging therapy for prurigo pigmentosa

group: 25–34, 4.0%), but occurred earlier in women (age group:Comparisons with data from paediatric cross-sectional studies,showed that the relative prevalence of SD in Greek outpatient chil-dren aged 0–15 years (2.5%) was lower than that in Indian8Prurigo pigmentosa is a rare, idiopathic inflammatory dermatosis(11.3%) and Chinese9 (3.2%) children, whereas in adults (4.05%),that was firs

A Short, One-Pot Synthesis of Bupropion (Wellbutrin, Zyban)Adapted by R. Minard from a procedure by Daniel M. Perrine,* Jason T. Ross, Stephen J. Nervi, and Richard H. Zimmerman, Department ofChemistry, Loyola College, Baltimore, MD, J. Chem. Ed ., Nov. 2000 , 1479-1481 Introduction: Bupropion, 3b , the hydrochloride salt of (±)-2-(t-butyl-amino)-3-chloropropiophenone, has a unique phar

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