This case involves difficult facts, and while it may have come to the correct result, it is not clear that the resident was treated fairly. The difficulty arises from the special nature of medical residencies and medical schools when presented with a claim for medical or physical disability. Some medical education programs blur the lines between administration decisionmaking and medical evaluation, requiring, as in this case, that the student or resident be medically evaluated by an administrator or teacher in the program. This denies the individual any semblance of privacy and raises significant issues about the impartiality of the review.
In this case, the plaintiff, Shaboon, developed acute psychiatric problems, probably related to overwork and stress. When the residency director noticed that she was tired and not functioning as well as in the past, he requested that Dr. Toni Dollinger, the Chief Resident in psychiatry at the Health Science Center, examined her. Dollinger's notes from the exam state that Shaboon was very tense, guarded, and moderately depressed. Shaboon discussed the morning incident and stated that she was not recording her patient interactions on charts. Shaboon reportedly was having trouble sleeping and could not manage her patients and interns. She was not violent or suicidal. Dollinger testified in deposition that Shaboon was not thinking rationally, but was capable of making an informed decision about seeking hospitalization. Dollinger concluded that Shaboon satisfied the criteria for involuntary hospitalization. She urged Shaboon to check into a mental hospital voluntarily, and threatened to fill out involuntary commitment paperwork if Shaboon did not.
Plaintiff voluntarily went to a mental hospital for evaluation. Dr. Christopher Ticknor examined her and found that upon admission she was "fully oriented to person, place, date, and time, and that she was not a danger to herself or to others." Ticknor found that Shaboon was suffering from major depression, and that she was suffering from severe psychosocial stressors and obsessive ruminations about her professional performance. He found that she was "psychologically and physically exhausted and ha[d] deprived herself of sleep, normal appetite and relaxation . . . ." Ticknor concluded that "[h]ospitalization is indicated because of the severity of the patient's depression and the paralyzing nature of her obsessive-compulsive disorder." Plaintiff staying the hospital for a week, then left against Dr. Ticknor's recommendation, but did not immediately return to work or ask for time off. When she returned to work 5 days later, Duncan, the residency director, said she was absent without leave and required her to produce a psychiatric report confirming that she could resume treating patients. Dr. Eileen Smith then evaluated Shaboon. Shaboon had stopped taking psychiatric medications that Ticknor had prescribed for her because they made her sick. Smith told Duncan that Shaboon was not ready to return to work. Ticknor confirmed this to Duncan. With Shaboon's consent, Duncan received copies of psychiatric records from Ticknor and Smith. According to records from Ticknor's hospital, Shaboon told doctors that her father sexually abused her when she was a child.
When she returned to the residency, she was not allowed to see patients, and Duncan requested that the hospital terminate her privileges, which would also fire her from the residency since she was an employee of the hospital. At Duncan's suggestion, Shaboon met with doctors on the Hospital District Physicians Advocacy Committee ("Advocacy Committee"), which assists disciplined physicians in Hospital District proceedings. The committee members, themselves psychiatrists, asked to see Shaboon's psychiatric records and talk to her psychiatrist at the time, Dr. Malathi Koli. Shaboon offered only to give them Koli's opinion on her medical fitness and to receive written questions for Koli. She stated in her deposition that she did not want doctors in the hospital to know about her childhood sexual abuse. Duncan also asked to speak to Koli, but Shaboon offered him the same limited disclosure. She hospital privileges were terminated and she was dismissed from the residency for failure to carry out her duties and for not cooperating with efforts to help her with her psychiatric problems. There was also an allegation that she threatened the children of one of the professors, although this complaint had questionable documentation.
Shaboon filed suit in 1994, alleging a wide variety of claims against virtually every person involved in these events. In a series of rulings, the district court dismissed most of the claims and most of the defendants. Duncan, Dollinger, and the Health Science Center are the remaining defendants. Duncan and Dollinger, as state employees running a state program, asserted qualified immunity. Shaboon countered Dollinger's motion with the testimony of her expert, psychiatry professor Dr. Daniel Creson. Creson reviewed Dollinger's treatment records and deposition testimony, and opined that no reasonable doctor would have committed Shaboon on August 3. Creson also said that it was unacceptable for a psychiatrist to threaten involuntary commitment if she knew that involuntary commitment was impracticable. The court denied Dollinger's summary judgment motion, holding that Creson's testimony created a fact issue on Dollinger's qualified immunity under Texas law. The hospital raised an 11th Amendment defense to plaintiff's ADA claim.
The core of plaintiff's non-ADA claims is that she was denied a liberty interest in her continued education without appropriate due process. Unfortunately, liberty interests are very limited for students. The controlling case is Board of Curators of University of Missouri v. Horowitz, 435 U.S. 78, 98 S.Ct. 948 (1978). In Horowitz, the United States Supreme Court found that a medical student's dismissal was academic even though the school warned her to improve her personal hygiene and attendance as well as her academic performance. "Personal hygiene and timeliness may be as important factors in a school's determination of whether a student will make a good medical doctor as the student's ability to take a case history or diagnose and illness." Based on this, the court here found:
"Here, the undisputed facts indicate that the Health Science Center dismissed Shaboon for reasons related to her fitness to perform as a doctor. Shaboon received several negative evaluations and was suffering from mental problems on or after August 3. She departed Villa Rosa against Ticknor's recommendation and stopped taking medication. Smith and Ticknor indicated that Shaboon was not ready to treat patients. No psychiatrist ever cleared Shaboon to return to work, and Shaboon missed clinical rotations as a result. Although Shaboon's intransigence might suggest that her dismissal was disciplinary, her refusal to acknowledge and deal with her problems furnished a sound academic basis for her dismissal. As a matter of law, therefore, Shaboon was not entitled to any type of hearing and cannot claim that Dr. Duncan violated a liberty interest in her residency. ... Nevertheless, Shaboon received sufficient procedural protection even if her dismissal was solely for disciplinary reasons. ... Shaboon was informed that her residency was in jeopardy and of her deficient performance. She had several opportunities to comply with the official requests for a review of her psychiatric records and to explain why she should not be dismissed. She was allowed to have her attorney represent her in a meeting with Duncan and Park. Thus, Shaboon received sufficient process as a matter of law even if her dismissal was disciplinary." (citations omitted)
"We reject for the same reasons Shaboon's claim that Duncan violated a liberty interest in her clinical privileges at the Hospital District. Under the Hospital District bylaws, Shaboon had limited privileges 'to treat patients under the supervision of the Active and Courtesy staff.' These privileges were part of her educational program and were not distinct from her residency. She lost the privileges for the same academic problems that caused her to lose her residency, and so she had no right to a hearing. Even if the dismissal was disciplinary, she received adequate process from agents of the Hospital District. Shaboon therefore received all the process she was entitled to for her lost residency and clinical privileges."
The court dismissed the remaining complaints against Duncan, then turned to the complaints against Dollinger. The most interesting of these was the complaint that her threat to commit plaintiff was medical malpractice. The court found that the standards for Texas official immunity would apply if Dollinger was 1) performing discretionary duties; 2) in good faith; and 3) while acting within the scope of her authority. The Texas good faith element is "substantially" the same as the federal "objective legal reasonableness" test:
"[T]he test is one of objective legal reasonableness, without regard to whether the government official involved acted with subjective good faith. '[W]e look to whether a reasonable official could have believed his or her conduct to be lawful in light of clearly established law and the information possessed by the official at the time the conduct occurred.' Thus, qualified immunity protects "all but the plainly incompetent or those who knowingly violate the law.' Dollinger is thus entitled to immunity 'even if [she] acted negligently.' To survive summary judgment, Shaboon had to show that "no reasonable person in [Dollinger's] position could have thought the facts were such that they justified [her] acts." (citations omitted)
The district court found a fact issue on Dollinger's qualified immunity defense because she allegedly used "questionable tactics" to convince Shaboon to go voluntarily to Villa Rosa. Dollinger's alleged threat to commit Shaboon was only questionable, however, if no reasonable doctor could have concluded that Shaboon satisfied the standards for involuntary commitment. Under Texas law a person can be committed if she is 1) mentally ill; 2) suffering severe and abnormal mental or physical distress; 3) experiencing substantial mental or physical deterioration of her ability to function independently; and 4) unable to make a rational and informed decision as to whether to submit to treatment. Dollinger testified that although Shaboon could make informed decisions, Shaboon was not thinking rationally on August 3 and satisfied the criteria for involuntary commitment. While Creson disagreed after reviewing depositions and Shaboon's records, this would at best a fact question as to the interpretation of the data. While this would be enough to prevent summary judgment in a medical malpractice case, it is not enough to resist a claim of qualified immunity:
"We conclude that a reasonable jury could not find that Dollinger failed to act with objective legal reasonableness. There is no doubt that Shaboon was suffering from some degree of mental illness on August 3. Ticknor's examination indicates that Shaboon was depriving herself of sleep, normal appetite, and relaxation. He wrote that she was physically exhausted and was suffering from major depression. He also wrote that she needed hospitalization for her paralyzing obsessive-compulsive disorder. Ticknor's examination indicates that a reasonable doctor could have found that Shaboon satisfied the criteria for involuntary commitment. ... Furthermore, Creson's testimony actually suggests that Dollinger was at most negligent. His affidavit stated only that Dollinger 'violated the standard of care' and 'breached the duty of care.' These are terms of negligence. Creson testified that he had 'no information' that Dollinger consciously intended to harm Shaboon or was consciously indifferent to Shaboon's rights and safety. Although Dollinger's subjective beliefs are not at issue, Creson is effectively testifying that the circumstances did not indicate that she acted in bad faith. Chambers establishes that Dollinger is immune from claims that she acted negligently. Thus, Creson's testimony and affidavit are not sufficient to create a fact issue on Dollinger's immunity."
The court did not dismiss the 11th Amendment defense to the ADA claim against the hospital, but remanded it to district court for further fact finding. This is an important case that reviews the legal status of medical residents and should be mandatory reading for anyone providing legal advice to such programs.
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