Clinical Case for Discussion:    You are the Medical Director of a freestanding surgery center.  A surgeon at the facility has a serious perioperative complication which leads to a bad outcome.  You believe that his management was below the standard of care.  What do you do?

Discussion:    You put on your best Dirty Harry sneer and say, “Punk, we don’t want your kind in these parts no more.”  Then you wake up from your daydream, and deal with the reality of an unpleasant responsibility.  Playing policeman with your surgical colleague’s privileges is not on any anesthesiologist’s Top Ten list.

There is a growing trend of surgical cases moving away from hospitals to freestanding facilities.   Each of these outposts must have medical leadership.  Anesthesiologists are ideally suited for Medical Director jobs, because of their training and expertise in perioperative patient care.  In addition, duties include quality assurance (QA) monitoring, setting policies and procedures, preoperative consultation regarding appropriateness of particular patients for the facility, and medical staff credentialing.

The phrase “Standard of Care” is defined as “the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances.”  When a physician is suspected of practicing below the standard of care, the facility he or she is practicing at may initiate an investigation of his or her clinical practice.  In addition, if there was an adverse patient outcome, the medical malpractice system may initiate legal action to investigate the physician’s role in the adverse outcome.

This column will discuss only the investigation of the physician by the medical facility, and will not address the workings of the medical malpractice system.

When an adverse patient outcome occurs, the QA system at a surgery center begins with telephone calls to the Medical Director to inform him or her of the event, followed by written incident reports to document the details of what occurred.  The Medical Director is responsible for screening for:

(1) errors in the system which contributed to the patient’s outcome,

(2) errors in judgment, or

(3) practice below the standard of care.

Goals are to:

a)  improve any system problem which lead to the complication,

b)  identify  educational opportunities to prevent future incidents, and

c) identify if an individual may have practiced below the standard of care.  The medical-legal system defines standard of care as what a reasonably competent practitioner of that specialty would do in the same setting.

What will you do as Medical Director if after careful review of the medical records and incident reports, you believe the surgeon’s management was below the standard of care?   Each facility you work at, including a hospital or any surgery center, has a document called the Medical Staff Bylaws.  Most physicians throw their copy into a file cabinet and never read it.  In a case like we are examining today, the Bylaws are the road map for what to do next.  A typical Bylaw pathway might be as follows:   (Reference:  Bylaws of the Waverley Surgery Center in Palo Alto, California.)

(1) Investigation.  The QA committee, with representatives of all specialties, reviews the case.   (At  different institutions, this committee may have  a different name,  such as the Medical Advisory Committee, or the Medical Care Evaluation Committee.)   They may appoint an Ad Hoc Investigation Committee of relevant specialties to gather facts and circumstances.  The Investigation Committee will report back to the QA committee with their consensus.

(2) Interview.  The physician is interviewed by the QA committee.

(3) Actions.  The QA committee may:   a) take no action,  b) issue a warning,  c) recommend a term of probation,  d) recommend a reduction or suspension of privileges, or  e) recommend suspension or revoking of medical staff membership.

(4) Request for a hearing.  The physician may appeal and request a hearing following suspension or revoking of privileges.  An Ad Hoc Hearing Committee composed of unbiased members of the medical staff not previously involved in the investigation is chosen.  The physician is physically present for the hearing, and may have an attorney present.  The meeting is tape recorded, and all evidence is heard.  The majority decision of the Hearing Committee is usually final.  A system for appeals exists.

(5) Any suspension or revocation of privileges must be reported to the Medical Board of California, and the National Practitioner Data Bank.  Being reported to these two is a very big deal.  In the surgeon’s future, every application to every hospital or surgery center, and every medical license renewal would have to include this information.

Despite the obvious perks of stretch limousines, penthouse suites, and groupies,  the Medical Director job comes with some serious responsibilities.  Investigating another physician’s practice is difficult, time-consuming, and can be emotionally taxing for everyone involved.  Ignoring potentially substandard care is a mistake, however, that can result in further mishaps and the possibility of further patient harm in the future.

Dirty Harry exists for doctors too, but it is a system, not an individual, that does the dirty work. The Quality Assurance investigative system is a chore and and obligation for a Medical Director, but it’s an important and essential chore.


Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book cover image below:


Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ FargoThe Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.



Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.



allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.


By W. Brown

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

I read this in hardcopy and loved it. A good well balanced novel. Characters and a story that I enjoyed and remember more than a month later. Got the book on a Saturday, and stayed up late on Monday to finish it. I rarely am so gripped by a book that I make the time to finish it that quickly.

It has some nice and unexpected plot twists, and an unusual mix of characters.

You’ll enjoy it.


Fun read. I could not put it down, November 18, 2014



This review is from: The Doctor and Mr. Dylan (Paperback)

Fun read. I could not put it down. Loved knowing a bay area doctor wrote this novel.

Five Stars, November 20, 2014


Kim (Portola Valley, CA USA)

This review is from: The Doctor and Mr. Dylan (Paperback)

Fun read, well written and highly recommend!

Learn more about Rick Novak’s fiction writing at


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