Bring the peer review action in the following ways:

1. Cut the physician's support staff. This generates inefficiency and disharmony in the remaining staff. It also lays the basis for the following.

2. Place a 'mole' in the office staff to collect a list of alleged wrongdoing, including the most trivial rumors and innuendoes. It is not the validity of these allegations, but the volume of the list, which matters. The target physician will be unable to address all the items if it is long, and the community will be more likely to believe it. It is preferable to use an outsider, newly hired, as the mole. Once the target physician is gone, fire the mole.

3. Include the Chief of Staff and two other adversarial physicians in the scheme. They can actually be kept ignorant of the true motives behind the attack. All physicians are busy and might accept data from authoritative figures, without carefully confirming their validity. Tell these doctors, for example, that the target has serious problems, which cannot be revealed without "hurting" him or her, implying personal failings, which must be kept confidential.

Hospitals which have this process well greased will usually have the same doctors "elected " to key positions year after year. They will maintain a clique of insiders who can be relied on to be supportive.

4. Begin a rumor campaign. Leak allegations to the entire medical staff and community at large. This can be done very cryptically. Any secretary who must type up corporate documents may unwittingly serve the purpose.

5. Restrict the physician's access to records. This will hamper efficiency and prevent proof of competency.

6. Use the most severe punishment (especially summary suspension) at the very outset of the review process. This will emotionally damage the target physician and his/her family, creating a shock effect. It also promotes the community's doubts about the physician's competence and character. This trauma may be all it takes to scare the physician out of town. A hasty departure only further damages the target's credibility, so that he/she will be presumed guilty. The immunity provided by the 1986 law prevents any scrutiny of the decision.

7. Limit the target physician's access to allegations, and keep them as vague as possible. The broader and more nebulous the charge, the harder it is to address it. Make the list as long as possible, even adding half-truths, frivolous allegations, rumors, and outright lies. The target will hardly have time even to read the list, and might succumb without a fight. The sheer length and vagueness of the list assures failure of the target to refute all the charges.

One added advantage to a massive list is that any physician asked to review the cases will also be overwhelmed and be more likely to accept the hospital's version of the cases.

8. Prevent the target from obtaining privileges at other institutions. Then, spread rumors to the staff about the rejections by other institutions. This maneuver also keeps the target broken financially, unable to sustain legal aid.

9. Set up hearings so that only a few key insiders know what is happening. By this point, the whole hospital staff may have ostracized the target physician, if the rumors are sufficiently scandalous.

10. To help implement the plan, hire an aggressive law firm that favors corporate interests. Hospitals that routinely practice these schemes seem to use the same law firm.

11. Break the physician financially. Keep the list of allegations and the list of witnesses as long as possible. This will prolong the legal nightmare for the target, producing massive legal fees. The hospital can easily outlast the targeted physician in a protracted legal battle.

Clearly such dealings are not isolated incidents. It may well be that this systematic attack on individual physicians is being formulated by law firms that cater to aggressive hospitals, particularly those hospitals with monopolistic aims. The hospital's success in such attacks is almost guaranteed by the new federal law. Even when the hospital committee flagrantly denies due process to the physician, there is no longer a mechanism for exposing such practices. The 1986 law provides a degree of immunity that effectively veils their proceedings. Our best initial recourse is public awareness. If you have had a similar experience, or any insights into hospital-privilege battles, I would be pleased to hear from you.

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