The June Southern California Physician article "Hospitals and Medical Staffs: Solid Cooperation or Fragile Teamwork?" observed that the majority of medical staffs and hospital administrations get along through mutual cooperation. On the contrary, in many cases, the apparent surface calm in these relationships is not an accurate indication of the true state of affairs.

Physicians today face many challenges because of the conditions within the healthcare delivery system. As a consequence, time given to the affairs of the medical staff has taken a backseat to the survival of their practices. Since physicians are paying less attention to medical staff issues, hospital administrations have acquired too much power. We must be aware of what is happening to correct the situation and to fulfill our role as patient advocates and diagnosticians of hospital ailments.

The conflicts most recently occurring at Community Memorial Hospital in Ventura and the Western Medical Center Santa Ana are just the tip of the iceberg in what is occurring not only in California, but also across the country. It is a stretch, we believe, to state that the "vast majority" of hospitals and medical staffs function pretty well. Unfortunately, we find that physicians who say everything is just fine typically reveal--upon close questioning--the situation is not that rosy.

Ask the physicians who state everything is fine if they have independent medical staff legal counsel. Ask who pays that attorney. And then ask if their attorney also represents hospitals. Too often, the "independent" legal counsel for the medical staff does extensive work for hospitals from which he/she derives significant income. Or their counsel is paid by the hospital. Clearly, those situations compromise the ability of the attorney to advocate vigorously for the medical staff.

Ask the medical staff leaders who drafts amendments to the medical staff bylaws. Very often, the hospital attorney drafts the amendments. In areas where the authority of the medical staff comes in conflict with the mission of the hospital, an attorney who represents hospitals views the world from a different perspective than truly independent medical staff legal counsel. When legal issues arise contesting the rights and responsibilities of the medical staff, independent legal counsel selected and paid by the medical staff is an imperative.

Finally, how many medical staffs actually adhere to the principles of self-governance as articulated by the California Medical Association and the American Medical Association or even know what those principles are? To be true advocates for patients, we must adhere to these principles. This necessitates medical staff bylaws consistent with these policies and principles.

How can we find our courage and our voice? Is there hope? We can answer a resounding, "Yes!"

There is good news regarding the SLAPP (Strategic Lawsuit Against Public Participation) against Michael Fitzgibbons, MD. "SLAPPers" do not sue to achieve a litigation outcome; rather, they file to silence their opposition. Generally, the mere filing of the suit--or just the threat of the suit--accomplishes that purpose. Equally important, the SLAPP also sends a message to others that they can be sued for speaking up.

Integrated Healthcare Holdings Inc., purchasers of four Tenet hospitals in Orange County, filed a SLAPP against Dr. Fitzgibbons when he expressed concerns about the hospital's financial status and condition. The appellate court unanimously ruled in Dr. Fitzgibbons' favor, dismissing the lawsuit by stating that his speech was protected by California's anti-SLAPP legislation. Tom Curtis, attorney for Dr. Fitzgibbons, did a superb job at the oral argument convincing the court that IHHI was attempting to chill the speech of physicians who speak out on issues affecting patient care.

However, this is not the only instance of attempting to chill patient advocacy by physicians. In 2003, a series in the Pittsburgh Post-Gazette, titled "The Cost of Courage," described cases across the country where hospitals, many times with the complicity of medical staff leadership, destroyed the careers of physicians who spoke out on quality of care issues. (See www.post-gazette.com/pg/03299/234499.stm.)

One mechanism of silencing physicians is through a perversion of the peer review system, typically meant to resolve quality problems in a confidential, professional manner. Sham peer reviews are now weapons to destroy the careers of targeted physicians. Sham peer review is characterized by a disciplinary action, often imposed summarily. Physicians who speak out on behalf of their patients are often labeled as "disruptive."

Concomitant with the rise of sham peer review is the recrudescence of economic credentialing, exclusive credentialing, "codes of conduct" and "conflict of interest guidelines" imposed on the medical staff.

Conflicts of interest arise when physicians with significant hospital contracts assume medical staff leadership positions. Such conflicts of interest, either perceived or real, are impediments to active advocacy for the medical staff by the contracted physicians. Indeed, some medical staffs are now prohibiting individuals with significant contracts from running for elective office within the medical staff. Medical staff bylaws must have clear declaration of interest statements so that the membership knows exactly for whom they are voting.

We disagree with William Monnig, MD, who is chair of the AMA Organized Medical Staff Section. He stated in the article that it's time to "back off from confrontation." As physicians, we would say instead, "We have not yet begun to fight!" This fierce advocacy for our patients is and ultimately must be our responsibility as physicians.

The word cooperation is a term that is bandied about without defining what it means. It always seems to mean the unilateral compliance of the medical staff with the hospital. If that is the hospital's definition, then "backing off from confrontation" would betray our longstanding ethical requirement to advocate for patients.

Now is not the time for polite deception. The public demands improved hospital safety and quality of care. These goals require medical staff involvement in all hospital policies that affect patient care, safety and the function of the medical staff (see Title XXII and the standards of the Joint Commission on the Accreditation of Healthcare Organizations).

SB 1325, the California Medical Association-sponsored bill, codified as Business and Professions Code 2282.5, states it well: "The Legislature finds and declares that providing quality medical care in hospitals depends on the mutual accountability, interdependence, and responsibility, of the medical staff and the hospital governing body for the proper performance of their respective obligations."

We believe that the proper medical staff-hospital relationship is one of true partnership, with the medical staff fulfilling the mandates of law, accreditation standards and ethical traditions. Since the medical staff is to be responsible for oversight of hospital quality, we must be involved in resource allocation decisions at the highest levels of governance. These financial issues are at the very heart of our responsibility to provide quality healthcare to patients.

To prevent a recurrence of the Fitzgibbons situation, there must be clear anti-retaliation provisions in the medical staff bylaws to protect the medical staff's lawful duty to advocate for patients.

It has been said that the best way to predict the future is to create it. The future of quality medical care in the hospital depends on the medical staff creating the environment whereby staff members can fulfill their role as fiduciaries for patients. Then we will measure up to our calling as physicians.

Howard L. Lang, MD, past president of CMA and past chair of AMA OMSS

John Luster, MD, chair of family practice at St. Joseph's Hospital in Orange and Medical Staff Executive Committee at Chapman Medical Center in Orange

Tom Badin, MD, OMSS delegate for CMA and AMA and member at large on the Medical Staff Executive Committee for Western Medical Center Santa Ana

Michael Fitzgibbons, MD, past chief of staff for Western Medical Center Santa Ana and OCMA board member