The most outrageous feature of the literature on the so-called disruptive physician is the presumptuous and flighty nature of the cultural framework its authors have concocted. Addressing it has been a disorienting exercise in wading through a fever-swamp of distortion and chimeric irreality. Its a dirty job but somebody has to do it. I apologize, in advance, for any lack of clarity, which I attribute to the difficulty of the task of trying to get inside the heads of the creators of the doctrine in an effort to figure out what they must be thinking.

In retrospect, I think I can attribute my own sensation of disorientation, during my abusive peer-review episode, to my involuntary entry into the realm of the accused physician, a realm governed by unsubstantiated opinions of doctrinaire administrationists and one very different from the rational realm of scientific medicine.

The disorientation seemed to come partly from immense difficulty in getting the most elementary cooperation from the hospital-hierarchy on the most fundamental principles of fair dealing and logic. Every prior premise I had come to accept as established came under fresh administrationistic scrutiny. Daily life resembled a constant anxiety-dream, in which every step was a major effort.

I welcome questions from readers, the better to clarify any obscure points.

The most important feature of the literature of the disruptive physician is the presence only of opinion -pieces and the absence of any objective evidence for any rational connection between either a physicians disruptive behavior or his ability to get along with others and the quality of medical care in his hospital. In the category of opinion-pieces, I include those that chronicle court-opinions. Those articles may seem to project an aura of objectivity, since their authors report a series of legal court-decisions but that aura vanishes upon examination of the legal decisions themselves, which are merely opinions of administrationists in black robes. An article consisting of discussion of a collection of opinions remains an opinion-piece.

The Semmelweis Society would do well to foster its legitimacy by keeping its feet on the ground and affirming the prevalence of science in all its endeavors, including challenging the false-propaganda campaign that surrounds disruptive-physician doctrine.

For the supposed nexus between disruptive behavior and quality of care to influence the decision of a court of law, the advocate thereof, whether a hospital-administrator or anyone else, should have to prove the efficacy, in enhancing the quality of medical care, of the typical bylaw-provision to the effect that a physician needs to demonstrate ability to work cooperatively with others, to the satisfaction of the governing body, or that a physicians disruptive behavior, even if proven, diminishes the quality of medical care. No hospital has or ever can prove those suppositions, since no evidence supports or ever can support either. The reason for that is that the term, disruptive, is a relative characterization, based on the viewpoint of the critic of the alleged disrupter. The salient questions are, What and whom does he disrupt?

If a physician asks for help in an emergency from a nurse involved in shift sign-out, a routinely sacrosanct time, among nurses, the nurse may claim that he disrupted the sign-out. On the other hand, if a nurse insists on focusing on the sign-out as she ignores a patient who is gasping for breath and is turning blue, she perpetrates a form of disruption of the patients expectation of prompt and ready succor in time of need.

Nobody would probably question the deleterious effect of and desirability to re-educate an extreme, raging-bull personality but, in practice, administrators and others have applied the term, disruptive behavior, to de minimis issues, as a means of exerting social control (a sociologic euphemism for oppression), over targeted individuals, chiefly physicians, through name-calling.

Only an enlightened minority of courts have decided in favor of accused physicians on the basis of the absence of such proof or the nebulous nature of the evidence presented. Three prominent cases among those enlightened decisions are Miller, McElhinney and Rosner . The majority of the courts deciding on such issues have rubber-stamped the opinions of the defendant-hospitals administrationistic governing bodies against the plaintiff-physicians and disregarded the absence of objective evidence of any connection between a targeted physicians ability to work cooperatively with others/disruptive behavior and the quality of medical care provided in the hospital. Those decisions, therefore, have no logical basis, yet they stand as legal precedents that hospitals will likely exploit, in perpetuity:

It is a maxim among lawyers, that whatever hath been done before may legally be done again; and therefore they take special care to record all the decisions formerly made against common justice and the general reason of mankind. These, under the name of precedents, they produce as authorities, to justify the most iniquitous opinions; and the judges never fail of directing accordingly.

- Jonathan Swift, Gullivers Travels

Under the influence of iniquitous noise from Horty, Springer and their like, hospitals will continue to oppress targeted physicians arbitrarily and courts will continue to rule against physicians much of the time, unless targeted physicians their attorneys challenge disruptive-physician doctrine on scientific grounds, with scientific evidence in any litigation that they undertake, bolstered by Miller, McElhinney and Rosner.

I dont dismiss the advantage of working cooperatively with others but, wheres the beef? Every physicians education and training is a protracted demonstration of his sterling ability to work cooperatively with others. No physician would be able to complete medical education and training without that ability. Yet, seemingly motivated only by a desire to exercise arbitrary power, hospital-governors illicitly apply specious evidence from disparaging reports on targeted physicians about peripheral issues to concoct witch-hunts against them, under false color of improving and protecting the quality of medical care in their respective hospitals, a matter on which members of governing bodies of hospitals are unqualified even to comment.

Even worse, the false presumption that ability to get along with others enhances the quality of medical care and that a physicians disruptive behavior diminishes the quality of medical care serves, as Steve Twedts series highlights, to encourage hospitals to grant themselves permission to scrutinize the physicians willingness to go along to get along with whatever substandard conditions the administration wants to inflict on patients, with a view to saving money, to threaten the physician with corrective action, and to strike fear into the heart of any other physician who contemplates objecting to the administrations decisions about anything.

The above bylaw-provision, to the effect that a physician needs to demonstrate ability to work cooperatively with others, to the satisfaction of the governing body, is a cunning use of a cardinal feature of the witch-hunt (Walton), namely, reversal of polarity or shifting the burden of proof from the accuser to the accused -- also a feature of Napoleonic Law. Rational principles of argumentation place the burden of proof on the accuser, not the accused, and the legitimate legal system, such as the American system, based on the English model, purports to govern itself accordingly.

Horty, Springer and their ilk know very well that no objective evidence supports the proposition that the trivial deviation from ability to work cooperatively with others that commonly governs adverse decisions against disruptive doctors, affects quality of medical care. The common ploy that sociopathic lawyers like Horty and Springer apply to handle that difficulty consists in illicitly wording the bylaw-provision to shift the burden of proof from the governing body to the applicant/accused. That ploy removes any influence of objective criteria on the selection-process and leaves the decision whether or not to appoint or reappoint the applicant to the medical staff wholly to the whim and fancy of the governing body and its medical-staff bedfellows.

The sociopathic lawyers of the IRS do much the same by illicitly obliging the citizen to assume the burden of proof, in his petition to the so-called Tax Court, and to accuse the IRS of overcharging him for income-tax. If the IRS were a legitimate agency, it would govern itself by Title 28, CHAPTER 176, Federal Debt Collection Procedures Act, 28 USC §3001 and properly assume the burden of proof by accusing the taxpayer of having paid insufficient income-tax. IRS-agents know very well that no law requires any citizen to pay income-tax, so, if they properly assumed their rightful burden of proof, they could never legitimately prevail in any income-tax case, as a matter of law, and they disregards and resists 28 USC §3001 with all their sociopathic might.

By chance, I rediscovered a 1972 case-study in my data-base about a disruptive physician, entitled, Board must guard public interest when granting staff privileges. Mod Hosp. 1972 Feb:118(2):74-5, that article antedates the oldest one in Trustee , from 1978, to which pubmed referred. Guess who wrote it. Who else? John F. Horty. Condemnation of the disruptive physician has been Attorney Hortys propaganda-concoction for decades.

Atul Gawande, in his New Yorker article, When good doctors go bad, describes the history of one supposedly typical orthopedic surgeon who had lost his license to practice because of clear injury to his patients from his carelessness, the consequences of his overwork, and development of depression. Gawande also refers to the work of psychiatrist Kent Neff, in salvaging that orthopedic surgeon and other physicians with depression and other frank mental illnesses. In the reference-list to the article, Rosenstein Alan H. Am J Nurs. Nurse-Physician Relationships -- Impact on Nurse Satisfaction and Retention. 2002 June;102(6).26-34, I found a reference to a book by Kent Neff, Understanding and managing physicians with disruptive behavior. According to Gawande, Neff works with physicians with frank mental illness, not with mere disruptive behavior. I havent been able to locate that book to date. Until I read it, I cant tell much but my impression is that Neff and others seem to exploit the bogus-term, disruptive behavior, as a nebulous bridging term in an illegitimate and finally nefarious effort, on behalf of hospital-hierarchies, to connect and finally equate physicians disruptive behavior, manifested in their justifiable objections to substandard or otherwise hazardous conditions in hospitals, with mental illness.

In an attempt to nail down the issues, the following two sets of eleven, the third group of fifty and the final group of nine seem informative:

The 11 Elements of Due Process (Friendly)

Judge Henry W. Friendly, cited, proposed an influential set of characteristics of due process in a fair hearing, chiefly applicable in administrative law, the branch of law that governs hospital-based and state-level peer-review:

(1) an unbiased tribunal

(2) notice of the proposed action and grounds asserted for it

(3) an opportunity to present reasons why the proposed action should not be taken

(4) the right to call witnesses

(5) the right to know the evidence against one

(6) the right to have decisions based only on the evidence presented

(7) counsel

(8) the making of a record

(9) a statement of reasons, that is, a written statement by the factfinders, setting forth the evidence relied on and reasons for acting

(10) Public Attendance

(11) Judicial Review

Judge Friendly depicts the elements of due process as variable and negotiable. Diligent provision of some elements may permit diminution or even omission of others, depending on circumstances and context. For example, in hospital-based medical peer-review, it has become a fixed principle that public attendance is impermissible because it would pose too great a liability-risk for the accused doctor, while state-level peer-review hearings permit public attendance. Yet the Joint Commission on Accreditation of Health Care Organizations has mandated revelation of medical errors to patients affected and their families. If that be the mandate, then public attendance at every hospital-based peer-review hearing should pose no objection, so long as the patients identity remained confidential. Still, the tradition of secrecy in that context remains and that secrecy plays into the hands of hospitals, the minions of which perpetrate sham peer-review, hidden from public scrutiny, with impunity.

The 11 Elements of the Witch-Hunt (Walton)

Walton has set forth 11 characteristics of a witch-hunt which, in aggregate, delineate an absence of the elements of due process, though the elements may not correlate, point-by-point, in opposition:

(1) pressure of social forces

(2) stigmatization of the accused

(3) climate of fear

(4) resemblance to a fair trial

(5) simulated evidence

(6) simulated expert testimony

(7) nonfalsifiability characteristic of evidence

(8) reversal of polarity

(9) non-openness to the possibility opposite to established opinion

(10) use of the loaded question technique

(11) characteristic dialogue-profile

Details and examples follow:

(1) pressure of social forces: The doctor is under social pressure to perform to a high standard and the peer-reviewers, also doctors, are under social pressure to police the profession, under color (often false color) of improving the quality of medical care.

(2) stigmatization of the accused: The doctor whose patient has a poor clinical outcome often falls under suspicion of having caused that outcome, hence of having committed a particularly repugnant, disgusting deed, so peer-reviewers often commit the fallacy of poisoning the well by demonizing him, considering him ethically, even psychologically compromised and therefore considering anything he says self-serving, evasive, dishonest or otherwise unworthy of belief.

(3) climate of fear: Medical regulators, the tort-attorneys and peer-reviewers, instigate the penal paradigm or criminal-justice model of medical-quality assurance and thus create a climate of fear among doctors.

(4) resemblance to a fair trial: The medical-staff bylaws prescribe certain elements of procedural due process but those who carry them out bend them to favor the whim and fancy of hospital-allies at every turn and fail to provide substantive due process.

(5) simulated evidence: guesswork, estimates, in the absence of documentation, and the like masquerade as evidence against the accused.

(6) simulated expert testimony: A common participant is the hired gun, posing as an expert witness, who swears to whatever the prosecution favors to earn his fee. Hearing-committee members may themselves pose as experts, even though their purported function is to serve as impartial adjudicators.

(7) nonfalsifiability characteristic of evidence: No matter what the evidence, the tribunal may not recognize even the possibility that the evidence against the accused might be erroneous.

(8) reversal of polarity: shifting of the burden of proof from the accuser to the accused.

(9) non-openness: The tribunal is not open to the possibility that the accused could be blameless for the bad clinical outcome under scrutiny.

(10) use of the loaded question technique: A loaded question is a question that entails a presupposition to which the accused has not committed. An example is Dr. Daviss question whether I thought further training might be in order, since, as he assumed, the patients vocal-cord laceration occurred during my intubation. His presumption was that my training was in some sense deficient, that something I had done in error and that might be amenable to further training, had led to the patients vocal-cord laceration, then to her tension-pneumothoraces but he had not established any foundation for any of that prior to posing his loaded question. The lawyers term for forestalling a loaded question is, objection -- foundation.

(11) characteristic dialogue-profile, at variance with that of a fair trial. The pressure is on throughout the procedure to condemn the accused at all cost.

How Medical Peer-Review and Evades or Denies Due Process, Merges Into a Witch-Hunt and Degenerates into Sham Peer-Review: The 50 signs of sham peer-review

From the example of the several processes I underwent, several characteristics of sham peer-review emerged. Some of them stand opposed to the foregoing elements of due process, some partake of foregoing characteristics of the witch-hunt and some seem uniquely characteristic of medical sham peer-review. The more of the following elements that a physician notices in the peer-review he undergoes, the greater becomes the likelihood that it might be sham peer-review. The elements corresponded to the several phases of the process:

A. The mission-statement phase

B. The organizational phase

C. The ground-rules phase

D. Hearing-minutes phase

E. The pre-hearing phase

F. The hearing phase

G. Post-hearing phase

H. Appeal-phase

I detail the elements seriatim:

A. The mission-statement phase

1. The mission of the regulatory healthcare-organization, under color of patients first, is threefold:

a. To justify its own existence

b. To place the empowerment and convenience of organizational personnel first, above the welfare of patients.

c. By the elements of abusive peer-review, to implement shock and awe to leave the accused physician in an emotional state of mental fibrillation, analogous to ventricular fibrillation of the heart: i.e., just as a state of ventricular fibrillation leaves the heart with no effective cardiac output, the extreme fear, anger and loathing puts the accused in such an emotional state of mental fibrillation that he has no effective mental output so that he cannot mount an effective defense as the peer-review juggernaut rolls over and crushes him. (climate of fear, witch-hunt element 3, characteristic dialogue-profile, witch-hunt-element 11)

B. The organizational phase

2. Governmental authority imbues the regulatory organization with the presumption of correctness (pressure of social forces, witch-hunt element 1, reversal of polarity, witch-hunt element 8).

3. The regulatory organization presumes it can read the minds of the regulated and control them (nonfalsifiability characteristic of evidence, witch-hunt element 7).

4. The regulatory organizations greatest source of authority is arbitrary position, not knowledge. Examples: hospital-administrators, DEA-agents, other law-enforcement officers (nonfalsifiability characteristic of evidence, witch-hunt element 7).

5. Authority is dissociated from accountability:

The mission that the healthcare-organization claims for itself is to implement the highest possible quality of medical care:

a. Physicians have the qualifications to fulfill the responsibility of implementing high-quality clinical care but, like the school-pupil, they are at the bottom of the authority-scale. Nothing a physician can do or say will lead to the termination of a nurse, administrator or member of the governing body.

b. Nurses are less clinically qualified than physicians but higher in authority. A nurses complaint can lead to the summary-termination of or to proceedings against any physician.

c. Administrators are less clinically qualified than nurses, yet hold more authority than nurses. An administrator can terminate any employee-nurse or employee-physician or prompt proceedings against any non-employee physician.

d. Caselaw-precedent has established that the hospitals governing body has the ultimate responsibility for the quality of medical care in its hospital, yet its members, other than physicians who are members of some governing bodies, always in a voting minority, are unqualified to fulfill that responsibility. That ultimate collective authority extends to all aspects of hospital-operations. The governing body has the authority to terminate any administrator. Yet, lawsuits over quality of care do not affect the pocketbooks of the governing-bodys members. Damage-awards to patients from malpractice-suits flow from the hospitals corporate coffers.

e. Complaints from patients, the least clinically qualified of all, influence the members of governing bodies the most by making them worry about the hospitals market-share.

One naturally wonders how the foregoing, unacceptable, topsy-turvy distribution of authority in hospitals could ever have gained acceptance.

Linney alludes to a possible irrationale in her article, cited, in which she elucidates the treatment of physicians, defined as disruptive, like children. On that basis, parallels between healthcare-organizations and schools seem evident.

Items 6-19, relating as they do to the nebulous and irreal realm of disruptive-behavior doctrine, are more conjectural and more difficult to pin down than the other elements of abusive peer-review. I have encountered no statements to the effect, Hospitals are like schools. Physicians are like children. Healthcare-organizational power-hierarchies need to govern themselves accordingly. I base my conjecture, instead, on the parallels in observe in the terminology that pervades the realm of schools (elementary and secondary) and the terminilogy that pervades the realm of disruptive-physician doctrine. In any case, I feel certain, that if the subject of peer-review detects the listed attributes of items 6-19 at work in his case, he may feel especially assured that he is undergoing abusive peer-review. I suppose that the proof of the validity of my conjectures is in how well the reader who has experienced abusive peer-review relates them to his own subjective experience.

6. The healthcare-organization thus correlates with an educational construct, in which a hospitals board of trustees or governing body is analogous to the local school-board, the hospital-administrator is analogous to the school-principal, the nurse is analogous to the school-marm -- the teacher, the medical-staff is analogous to the student-body, the chief of the medical staff is analogous to the student-body president, other influential medical-staff leaders are analogous to the subordinate student-body officer-cabinet, and the accused physician is analogous to the unruly school-pupil.

7. The terminology, associated with the organizational code of conduct for physicians, is, accordingly, redolent of standardized, school-marm-style terminology encountered in tracts on the tasks of the school-organization in socializing, educating and/or indoctrinating school-pupils to comply with societal norms, such as working cooperatively with others, citizenship and the like, and in disciplining pupils, the better to indoctrinate them into eschewing disruptive behavior.

8. The foregoing standardized terminology applies exclusively or predominantly to school-pupil physicians, rarely to nurses, never to administrators or trustees, since the last three groups comprise the presumably sane, responsible, adult supervisors of unruly school-pupil physicians.

9. Just as the school-pupils opinion, in any conflict with the power-hierarchy, labors under suspicion of being self-serving or of no account in a school-setting, the accused physicians opinion likewise labors under a similar suspicion in the hospital-setting.

10. Accordingly, the regulatory healthcare-organization may often have in force a code of conduct that leaves criteria for compliance in the realm of value-judgments, at the arbitrary will, whim and discretion of administrators and/or physicians who have a vested interest in excluding or expelling a physician-competitor or any other physician whom somebody influential dislikes.

11. The minions of the regulatory healthcare-organization resist applying objective criteria for their accusations.

12. If a physician, inspired by principles of medical science, raises objections to substandard conditions in a hospital, that could endanger patients, the power-hierarchy often peremptorily denounces him with the label, disruptive.

13. It is a fundamental constitutional principal that only adults, not children, have the right to due process and the controlling school-analogy carries over to the treatment of physicians in hospitals and other healthcare-organizations, notwithstanding incorporation, as window-dressing, of the AMA Code of Medical Ethics, which incidentally mandates peer-review, into many, though not all, medical-staff bylaws, a fact that the power-hierarchies of those that do suppress.

14. Going along with objectively substandard conditions to get along becomes a de facto criterion of working cooperatively with others.

15. Sanctions, available to the power-hierarchy against the incorrigible or recalcitrant school-pupil, are suspension and expulsion, analogous, in the hospital-setting, to the sanctions, suspension and revocation, against the incorrigible or recalcitrant physician.

16. Just as any instance of discipline, suspension or expulsion enters the unruly school-pupils permanent record, any instance of discipline, suspension or revocation enters the unruly school-pupil physicians permanent record in the National Practitioners Data Bank.

17. The ultimate sanction against a school-pupil consists in invoking scientism and labeling the disruptive pupil as suffering from a pejorative and medicalized condition, such as Attention-Deficit/Hyperactivity Disorder, which, since its psychological/neurological, may be treatable, is still presumably chronic and incurable. Similarly, the ultimate analogous sanction against a physician consists in labeling him disruptive, on the basis of an analogous pejorative, medicalized and treatable, though also chronic and incurable condition, often depression, personality-disorder, sociopathy, etc. (stigmatization of the accused, witch-hunt element 2)

18. Upon invoking such labeling, the Orwellian goal insidiously shifts from punishment, to the accuseds detriment, to psychiatric evaluation, counseling or treatment, for the accuseds ostensible benefit, of a condition for which the accused is not responsible, and due process, which has the purpose of establishing objective facts, in the context of prospective punishment, recedes from consideration.

Because treatment is regarded as a benefit, though it may involve pain, it is natural that less restraint is exercised in bestowing it, than in inflicting punishment.(Morris) (pressure of social forces, witch-hunt element 1, nonfalsifiability characteristic of evidence, witch-hunt element 7)

19. Thereupon, the organization can wrap itself in the flag of patient-safety and, with unrestrained severity, remove the sick doctor, for his own good, on the basis that hes unfit to treat other patients, like himself because the condition, for which he is not responsible, makes of him a person who is not responsible, in general, and, therefore, an unacceptable liability-risk. Through characterization, the organizations minions can thereby exert social control and invalidate the accused even more decisively than if they punished him (pressure of social forces, witch-hunt element 1, stigmatization of the accused, witch-hunt element 2) (Tulgan et al).

20. Apologists for the established power-hierarchy in healthcare-organizations consistently suppress their organizations patient-care mission, for the obvious reason that the seemingly analogous missions that school and healthcare-organization claim for themselves, to discipline and socialize pupils and physicians, respectively, would break down immediately, upon emphasis of the true respective organizational missions, namely, education and indoctrination of pupils, in the case of schools, a task that the school-marm members of the power-hierarchy are qualified to perform, and patient-care, on the other, a task that physicians are qualified to perform but that the members of the regulatory healthcare-organizations power-hierarchy are unqualified to perform. The best defense is the offense, and, in my view, the best offense would probably consist of pointing out such legally affirmed distinctions in qualification between those wishing to exert social control and those they wish to control.

C. The ground-rules (bylaws or hospitals corporate rules) phase:

The ground-rules:

21. Remove fundamental issues from dispute by granting all discretion to the hearing committee and no discretion to the accused, so the peer-reviewers are not peers (i.e., equals) of the accused, in terms of power and authority but, rather, his superiors, and the process in prospect is not peer-review but, rather, tyrannical review. Differential power is the elemental component of abusive peer-review.

22. Proscribe recording of hearings and meetings without the hospitals permission.

23. Often give lip-service to the AMA code of ethics (AMA), which includes a mandate, often ignored, for the organization to provide due process in peer-review (9.05).

24. Violate the elements of due process (Friendly).

25. Implement the elements of the witch-hunt (Walton).

D. Hearing-minutes phase:

Organizational minions:

26. Omit some or most of the contents of any hearing from the minutes of the hearing. Under cover of the proscription of alternative recordings of hearings (item 21, above), the organizations minions may thereby deliberately write inaccurate minutes of salient hearings or meetings and thereby to evade accountability for their violations with impunity (simulated evidence, witch-hunt element 5, nonfalsifiability characteristic of evidence, witch-hunt element 7).

E. The pre-hearing phase:

Organizational minions:

27. Apply demeanor and language, e.g., slogans suggestive of legitimacy, such as continuity of care, out of context, to foster an illusion of legitimacy, even as they violate legitimate elements of due process (prestige-jargon).

28. Apply demeanor of ridicule and language to vilify the accused, e.g., pretend that draconian action, usually reserved only for serious offenses, be justified in the case of the accused: Where theres smoke, theres fire. (stigmatization of the accused, witch-hunt element 2)

29. Manipulate the standard of proof, e.g., from by clear and convincing evidence to by the preponderance of the evidence, to make the task of proving a case against the accused easy.

30. Refuse to specify charges in advance of the hearing (absence of notice, due-process element 2).

31. Refuse to permit the accused to have a defense-attorney present at the hearing to represent him, if the hospital does not have its attorney present (absence of counsel, due-process element 7).

32. Repeatedly refer to what the bylaws, rules and regulations permit and do not permit, in claiming to resolve disputed issues in favor of the organization (absence of impartial tribunal, due-process element 1, nonfalsifiability characteristic of evidence, witch-hunt element 7).

F. The hearing phase:

Hearing-committee members:

33. Draw conclusions against the accused prior to hearing evidence (prejudice, absence of impartial tribunal, due-process element 1, nonfalsifiability characteristic of evidence, witch-hunt element 7, characteristic dialogue-profile, witch-hunt element 11).

34. Imply or declare that it be fair for the defendant (who should enter the hearing with prior knowledge of the charges against him and should be prepared to defend himself against them) to know as little of the charges against him (the defendant) as does the hearing-committee (whose members should enter the hearing without prior knowledge of the case): The defendant has received no notice, prior to the hearing, of charges against him? Well the hearing committee hasnt either. We have a level playing field. Thats fair. (absence of notice, due-process element 2, resemblance to a fair trial, witch-hunt element 4, characteristic dialogue-profile, witch-hunt element 11)

35. Engage in desultory questioning: the accused no sooner hears a question and tries to respond to it than the same or another interrogator rushes on to pose another question (absence of an opportunity to present reasons why the proposed action should not be taken, due-process element 3, characteristic profile, witch-hunt element 11).

36. Exaggerate evidence against the defendant (simulated evidence, witch-hunt element 5).

37. Produce witnesses who reinvent history (simulated evidence, witch-hunt element 5).

38. Treat value-judgments as if they were evidence (simulated evidence, witch-hunt element 5).

39. Heap blame on the defendant in terms of global generalizations, on the basis of specific allegations. For example, the accused must perforce hold opinions contrary to those of the prosecution or the hearing, which has the purpose of airing differences of opinion, would have no purpose. When a committee-member, siding with the prosecution, inevitably disagrees in principle on an issue with the accused, the committee may then conclude that the defendant is globally unreliable, globally dishonest, has globally poor judgment, shows global lack of care and concern, global lack of reliability or the like (demonization, witch-hunt element 2, simulated evidence, witch-hunt element 5, nonfalsifiability characteristic of evidence, witch-hunt element 7, characteristic dialogue-profile, witch-hunt element 11).

40. Reverse the purpose for apparently reasonable provisions in favor of patient-safety. For example, the hospital justified admitting the patient to my service, even though it never contacted me, on the basis of continuity of care and the ad hoc committee applied principles of qualification, based on documentation of experience in surgical procedures, not applicable to intubation, to attack my qualification to intubate the patient (simulated evidence, witch-hunt element 5)

41. Perpetrate fallacies, among others, fallacy of impromptu definition (simulated evidence, witch-hunt element 5, nonfalsifiability characteristic of evidence, witch-hunt-element 7)

42. Rely on the opinions of its peer-reviewer members and/or of hired-gun expert-witnesses engaged by and on the side of the organization, as it disregards the opinions of expert witnesses for the defense and disregards or holds in contempt published scientific evidence (absence of impartial tribunal, due-process element 1, simulated evidence, witch-hunt element 5, simulated expert testimony, witch-hunt element 6, nonfalsifiability characteristic of evidence, witch-hunt element 7).

43. Inappropriately dismiss defense-evidence or declare it irrelevant to the case (absence of impartial tribunal, due-process element 1, simulated evidence, witch-hunt element 5).

44. Apply double standards/special pleading: Hold hospital-allies to pliant, forgiving standards while holding the accused to harsh standards: e.g., The hospital is not on trial here!

Copious medical literature (Bates, Jellinck, Kefalides, Shine, Wu, among others) characterizes medicine as a team-effort, so the health-care team is, or should be, a structure with the virtue of balanced design, an engineering principle that force-loads every element of a structure equally or otherwise appropriately. By analogy, a uniform standard of performance and accountability for all members of the healthcare-team is indispensable and anything else is unacceptable. If the regulatory organization, hospital or otherwise, be justified in undertaking corrective action against one member of the healthcare-team, for allegedly falling short of a perfect standard of performance, the organizations impartiality should require it likewise to subject any other healthcare-team member whom it found to have fallen short of a perfect standard of performance, to similar treatment. Implementing a double standard, in holding various members of the healthcare-team accountable, according to standards that vary according to their political standing, must result in asymmetrical and dysfunctional loading and structural collapse of the healthcare-team, yet such the double standard is a cardinal feature of abusive peer-review.

Abusive adjudicators consider prosecution-witnesses mere memory of issues enough to satisfy the criteria of evidence, even without documentary support, while they dismiss the accuseds contrary memories of events and issues merely as his opinion (absence of impartial tribunal, due-process element 1, simulated evidence, witch-hunt element 5, simulated expert testimony, witch-hunt element 6, nonfalsifiability characteristic of evidence, witch-hunt element 7).

45. Apply implication and innuendo without committing to a logical sequence, leading to any rational conclusion (nonfalsifiability characteristic of evidence, witch-hunt element 7, loaded question technique, witch-hunt element 10).

46. Omit foundation for their statements (loaded question technique, witch-hunt element 10).

G. Post-hearing phase:

Hearing-committee-members:

47. Disregard the preferred charges and create new charges not previously preferred, without affording any prior notice of them to the accused (absence of notice, due-process element 2).

48. Omit mention of charges and do not clearly dismiss but de facto dismiss charges for which they adduce no support (absence of notice, due-process element 2).

H. Appeal-phase:

Appeal-tribunal members:

49. Accept the prosecutors disregard of the hearing-committees recommendation and reinstatement of charges that the ad hoc committee had already de facto dismissed (failure of notice, due-process element 2, nonfalsifiability characteristic of evidence, witch-hunt element 7).

50. Rubber-stamp the decision of the lower tribunal, unless the defense provides a very good reason for them not to do so, such as notice of the likelihood of further litigation, in case of an adverse decision (nonfalsifiability characteristic of evidence, witch-hunt element 7).

Nine common errors that the accused commits in response to abusive peer-review:

1. Obsequious acquiescence, by long habit, to arbitrary authority.

2. Failure to know and understand ground-rules prior to accepting association with an organization.

3. Failure to amend ground-rules after accepting them.

4. Failure to know the elements of due process and administrative law and failure to insist that the organization comply with them.

5. Failure to know the elements of the witch-hunt and failure to recognize and counteract them.

6. Presumption of the fair-mindedness of his colleagues, the peer-reviewers.

7. Attempt to curry favor with peer-reviewers by being a nice guy, in the vain hope of influencing them to render a verdict in his favor.

8. Failure to avail of opportunities to score against the organization as it perpetrates a witch-hunt against him and violates bylaws, rules, regulations, administrative law and due process.

9. Fixation on argumentation on clinical matters to the exclusion of any discussion of procedural and logical issues in the science of argumentation itself.

Disruptive-Physician Periodicals (listed in alphabetic order of titles of periodicals)

Williams Linda. The disruptive physician. AANA J. 1995 Oct;63(5):377-9. PMID: 7502639 (SF HS yes; UF HS yes; EU HS online; SC HS no): Typical of nursing journals, the article fixates on the alleged deficits of physicians, nurses favorite, perennial fall-guys, by reference to several court-decisions.

Rosenstein Alan H. Am J Nurs. Nurse-Physician Relationships -- Impact on Nurse Satisfaction and Retention. 2002 June;102(6).26-34: Am J Nurs : Rosenstein attempts to blame the nursing shortage on disruptive physicians, by applying illegitimate statistical manipulations in a futile effort to confer a phony aura of scientific epidemiologic cachet to his article. He lists several reasons why nurses leave their profession and all but one are under the exclusive control of administration, not physicians. The one exception, verbal abuse, could come from anyone. The favorite fall-guy of nurses is the physician, of course, even though no physician, unless be was a hospital-administrator, has ever hired a nurse for a hospital, no physician has ever fired a nurse from a hospital and the rich nursing literature on the subject affirms the fixation of the nursing-propaganda-apparatus on physicians. Strangely, considering the predominance of administrative influence on nurses hiring, firing and working conditions, Ive never seen even a single article in the nursing literature on how bad hospital-administrators are. Nurses presumably know when side their bread is buttered on.

Rosenstein takes a survey of attitudes among nurses, administrators and physicians on nebulous issues, such as nurse-physician relationships, nursing input and collaboration, disruptive physician-behavior (no mention of disruptive behavior of anyone else), administrative support of nurses in conflicts with physicians, physician-support of nurses in conflicts with physicians, satisfaction with the physician-counseling process (no mention of counseling of nurses, administrators or of anyone else) and his data consists of Likert-style ratings. Those are ordinal data, i.e., non-parametric data, yet he applies mean, standard deviation and F-test (variance-ratio) to them. Those statistics are applicable only to continuous, parametric-data and are all illegitimate statistics for ordinal data. His arithmetic manipulations generate decimal-fractions of ordinal data, which are meaningless. The median and interquartile range would have been appropriate for ordinal data (White)

Horty John F. The disruptive physician. Conn Med. 1985 Dec;49(12):805-19. PMID: 4085242 (SC HS yes): Conn Med: John Horty, founder of the notorious law-firm, Horty-Springer, of Pittsburgh, PA, duplicates the work of his partner, Springer, and his associate, Casale, in the following article from the Duquesne Law Review: like them, he recites cases that affirm the arbitrary will and whim of hospitals governing bodies to shaft physicians and condemns the few rational court-decisions that support physicians. Those court-decisions demonstrate their rational bases by questioning the absence of any credible evidence that supports any deleterious effect from physicians criticisms of hospital-procedures and by taking into account the value of the clinical contributions of physicians to the welfare of patients.

Casale Henry M., Springer Eric W. Hospitals and the disruptive health care practitioner: is the inability to work with others enough to warrant exclusion? 24 Duq L. R. 377 (1985) (SC Law yes): Duq L. R. : Springer and Casale, also of the notorious Horty-Springer: see above.

Pfifferling John-Henry. Managing the unmanageable: the disruptive physician. Fam Pract Manag. 1997 Nov-Dec;4(10):76-8, 83, 87-92. No abstract available. PMID: 10176011 (SC HS yes): Pfifferling rehearses worst-case scenarios of physicians who are probably mentally ill, not merely disruptive, per se.

Piper Llewellyn E. PhD, ACHE. Addressing the Phenomenon of Disruptive Physician Behavior. The Health Care Manager. 2003 October/November/December;22(4):335-339: ditto

Wilhelm Kay A, Lapsley Helen. Unprofessional interpersonal behaviour in doctors. Med J Aust. 2000 Oct 2; 173(7): 384-386: ditto

Bohigian GM, Croughan JL, Bondurant R. Substance abuse and dependence in physicians: the Missouri Physicians Health Program--an update (1995-2001). Mo Med. 2002 Apr;99(4):161-5. PMID: 11977480 (SC HS yes): references the 1995 publication of the Conjoint Board of Georgia, which put the concept, disruptive physician, on the map.

Horty John F. Board must guard public interest when granting staff privileges. Mod Hosp. 1972 Feb:118(2):74-5 (CSUN RA1 .M6): John Hortys early case-report of how a hospital shafted a disruptive physician.

Gawande Atul. When good doctors go bad. New Yorker. 2000 August 7:60-69. (GPC yes microfilm: Atul Gawandes article. Recounts the story of Hank Goodman (fictitious name), orthopedic surgeon, and the work of psychiatrist, Kent Neff.

Kissoon Niranjan, Lapenta Susan, Armstrong George. Diagnosis and therapy for the disruptive physician. Physician Exec. 2002 Jan-Feb;28(1):54-8. PMID: 11806231 (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no): An article written by three authors, of whom Susan Lapenta is an associate of Horty and Springer.

Linney Barbara J. Confronting the disruptive physician. Physician Exec. 1997 Sep-Oct;23(7):55-8. PMID: 10170424 (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no): Linney is the only author who concedes what has been my suspicion for years, namely, that hospitals and hospital-personnel treat physicians like children. The indicative quotation, from a referenced and quoted interview of a hospital-consultant named Greeley , follows:

Repeated acts that are deemed hostile or disruptive should be dealt with through a program that mimics the 'progressive discipline' that is often reserved for children. Such progressive discipline could (but should rarely) lead to the revocation of medical staff appointment and clinical privileges. In the event such occurs, the effected practitioner should be entitled to an appropriate fair hearing procedure as documented in hospital/medical staff policies or procedures."[2]

As is customary, Linney cites other opinion-pieces but no scientific evidence to support the alleged deleterious influence of disruptive behavior.

Pfifferling John-Henry. The disruptive physician. A quality of professional life factor. Physician Exec. 1999 Mar-Apr;25(2):56-61. PMID: 10351731 (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no): An article similar to Pfifferlings article in Fam Pract Manag, above.

Rosenstein Allan H, Russell H, Lauve R. Disruptive physician behavior contributes to nursing shortage. Study links bad behavior by doctors to nurses leaving the profession. Physician Exec. 2002 Nov-Dec;28(6):8-11. PMID: 12448134 (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no): Rosenstein enlists the alliance of two other authors in an opinion-piece on his prior thesis (see Rosensteins article, above), blaming disruptive physicians for the nursing shortage.

Sotile Wayne M., Sotile Mary O. The angry physician 1: The temper-tantruming physician, Physician Executive. 1996;22(8):30-34. (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no): Sotile, author of these four self-help titles gives advice on how to manage anger but the advice is useless in managing the justifiable outrage aroused by unreasoning, yet sanctimonious, hospital-hierarchies.

Sotile Wayne M., Sotile Mary O. The angry physician 2: Managing yourself while managing others. Physician Executive. 1996; 22(9):39-42.2: Youssi MD. JCAHO standards help address disruptive physician behavior. Physician Exec. 2002 Nov-Dec;28(6):12-3. PMID: 12448135 (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no)

Sotile Wayne M, Sotile Mary O. How to shape positive relationships in medical practices and hospitals. Physician Exec. 1999 Jul-Aug;25(4):57-61. PMID: 10557487 (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no)

Sotile Wayne M, Sotile Mary O. Part 2, Conflict management. How to shape positive relationships in medical practices and hospitals. Physician Exec. 1999 Sep-Oct;25(5):51-5. PMID: 10558284 (EU HS online, PDF only; UF Nemours yes; SF HS yes; SC HS no)

Hollowell Edward E. The disruptive physician. Southern Hospitals. 1984 May-Jun;52(3):69-70. PMID: 10266775 (MCOG yes; SF HS yes; UF HS not that issue; EU HS missing only that volume; SC HS no): Makes the cogent point, little observed today, In most instances, summary suspension is not...a proper procedure for the hospital in disruptive physician cases.

Hollowell Edward E. The disruptive physician: handle with care. Trustee. 1978 Jun;31(6):11-3, 15, 17. PMID: 10307838 (UF HS yes; GS 1947 onward; KSU 1988 forward; MERA 1990-93 only; EU HS online, not that volume; SC business no 1988 forward; SC HS no; MCOG no) : Runs through mostly the same list of court-cases as other court-oriented authors, above, to affirm the arbitrary, unreasonable and capricious will and whim of hospitals governing bodies to destroy the careers of physicians and adds a few cases that other authors didnt mention.

Heading: Disruptive-Physician Books not yet seen

Neff Kent . Understanding and managing physicians with disruptive behavior. In: Ransom SB, et al., editors. Enhancing physician performance: advanced principles of medical management. Tampa (FL): American College of Physician Executives. 2000. p. 45-72. (EU no; FUs no; USC HS no; USC no; UCLA no; GSU no)

Heading: Disruptive-Physician Periodicals not yet seen

Barnsteiner JH, Madigan C, Spray TL. Instituting a disruptive conduct policy for medical staff. Am Assoc Clin Nurs. 2001;12(3):378-382. (EU no; GA no)

DeWitt K. Practical points on private nursing. Am J Nurs. 1900;14-17. ( CN North Indian Creek Road 1964 forward; EU no;)

Purtell DJ. How to deal with the disruptive physician. Hosp Med Staff. 1981 Jan;10(1):10-4. PMID: 10249746 (GS 1972-1985; SF HS yes; SC Richland Memorial Hospital, Bull Street; was in Hall Psychiatric, not now; EU HS no; other FUs no; MCOG no)

Veltman L. The disruptive physician: the risk manager's role. J Healthc Risk Manag. 1995 Spring;15(2):11-6. PMID: 10155807 (SC HS no; EU HS no; FUs no; MCOG no)

Griffith RL. The malcontent or disruptive physician: some practical problems. J Qual Assur. 1989 Jun-Jul;11(3):12-3. PMID: 10293975 (UF Nemours only but not that volume; other FUs not; SC HS no; EU no; MCOG)

Wilkerson M. Disruptive physician metamorphosis. North Carolina Physician Health Program. 2001;4-5.

Disruptive physicians in the OR direct threat to patient care. OR Manager. 1987 Aug;3(8):1, 6-7. PMID: 10324475 (UF Naval Hospital, JAX only; MCOG no; VSU not that volume: after 1995 only; EU no; Clarkson U not that volume)

Benzer DG, Miller MM. The disruptive-abusive physician: a new look at an old problem. Wisc Med J. 1995;94(8):455-460. (UF HS volumes 58-95 (1959-1996) and volume 96 (issues 1-8) (1997); SF HS only volumes 71-73 (1972-1973) and volumes 77-82 (1978-1983); EU no)

Healthcare-team periodicals

Bates David W MD, MSc, Gawande Atul A MD MPH, Error in Medicine: What Have We Learned? Annals of Internal Medicine. 2000 May 2;132:763-767

Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311-1316.

Jellinck Michael S. Recognition and management of discord within house staff teams. JAMA. 1986 August 8;256(6):754-755

Kefalides Paul T MD. The Invisible Hand of the Government in Medical Education. Annals of Internal Medicine. 2000 April 18;132(8):686-8

Shine Kenneth I. MD. Health Care Quality and How to Achieve It. Academic Medicine. 2002;77(1):91-99

Wu Albert W. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ. 2000 March 18;320(7237):726-727

Other references:

AMACEJA (The American Medical Association Council on Ethical and Judicial Affairs), Kirk Johnson, AMA General Counsel. Code of Medical Ethics, Current Opinions with Annotations. 2000-1 Edition

Friendly Henry. Some Kind of Hearing. 123 University of Pennsylvania Law Review. 1267-1317 (1975)

Morris Herbert. Persons and Punishment. Monist. 1968 October;52(4):475-94

Tulgan Henry, Cohen Shepard N, Kinne Kevin. How a teaching hospital implemented its termination policies for disruptive residents. Academic Medicine. 2001 November 76(11):1107-1112

Twedt Steve. (access via www. google.com under Steve Twedt)

Walton Douglas N. The Witch Hunt as a Structure of Argumentation. Argumentation. 1996 Aug;10(3):389-407

White Susan J. Statistical errors in papers in the British Journal of Psychiatry. British Journal of Psychiatry. 1979 Oct;135:336-342)

Caselaw:

McElhinney v. Booth Memorial Hospital , 544 SW2d 216 (KY 1976)

Miller v. Eisenhower Medical Center , 614 P2d 258 ( Cal. 1980)

Rosner v. Eden Township Hospital District, 375 P2d 431, 434 (CA 1962)