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Ramalingam v. Robert Packer Hospital

United States District Court, M.D. Pennsylvania

August 21, 2019

ROBERT PACKER HOSPITAL, et al., Defendants.


          Matthew W. Brann United States District Judge.

         Defendants Robert Packer Hospital/Guthrie Healthcare System Auxiliary, Robert Packer Hospital, Dr. Thomas VanderMeer and Dr. Burt Cagir have moved for summary judgment against Plaintiff Dr. Saravanan Ramalingam. For the following reasons, that motion is granted in part and denied in part.

         I. BACKGROUND [1]

         Dr. Ramalingam graduated from Stanley Medical College in India and eventually became certified in general surgery by India's National Board of Examiners. He later emigrated to the United States and sought to become board-certified under American standards. To become board-certified in the United States, Dr. Ramalingam needed to complete a general surgery residency.

         Robert Packer Hospital (“RPH”) in Sayre, Pennsylvania, offered Dr. Ramalingam a place in its general surgery residency program. Such residency programs are subject to requirements promulgated by the American Board of Surgery (“ABS”) and the Accreditation Council for Graduate Medical Education (“ACGME”). Due to his extensive prior experience and training, the ABS gave Dr. Ramalingam permission to enter RPH's five-year residency program as a fourth year resident - i.e., as a “Post Grad Year Four” (“PGY-4”) resident. Because of his PGY-4 status, Dr. Ramalingam was scheduled to graduate in October of 2015.

         Dr. Ramalingam commenced his general surgery residency in October 2013. In early 2014, Defendant Thomas VanderMeer, M.D., the Director of RPH's Residency Program, advised Dr. Ramalingam to apply for a post-residency fellowship. Such a fellowship, however, would have to commence in July 2015 - three months before Dr. Ramalingam was scheduled to graduate from the general surgery residency program. In early 2014, Dr. VanderMeer contacted the ABS and requested that Dr. Ramalingam be allowed to graduate in June 2015 rather than October 2015. The ABS agreed so long as Dr. Ramalingam achieved a requisite score on a qualifying examination and demonstrated the necessary clinical skills for a PGY-4 as attested to by Dr. VanderMeer.[2] Dr. Ramalingam exceeded the minimum score required and Dr. VanderMeer authored a letter attesting to Dr. Ramalingam's clinical skills. The ABS then approved the June 2015 graduation date.

         Dr. Ramalingam's early graduation should have been approved by the ACGME. ACGME requires surgical residents to complete 750 procedures over the length of their residencies, which typically last five years. Because Dr. Ramalingam entered RPH's program as a PGY-4, he would have to squeeze requirements designed to be completed over a five-year period into two years. Consequently, Dr. Ramalingam asked Dr. VanderMeer to contact ACGME to obtain a waiver for the 750-procedure requirement. Dr. VanderMeer and RPH's residency coordinator assured Dr. Ramalingam that they would. However, Defendants did not contact ACGME at the time they contacted ABS; they waited until February 2015 to do so.

         Meanwhile, believing that he would be able to graduate in June 2015, Dr. Ramalingam applied to various hepatobiliary and pancreatic (“HBP”) surgery fellowship programs. He was ultimately accepted into such a program at Dalhousie University in Nova Scotia, Canada. That fellowship would have started in July 2015, given that Dr. Ramalingam was set to graduate in June 2015.

         But Dr. Ramalingam did not graduate in June 2015, and parties sharply differ as to why.

         According to Defendants, Dr. Ramalingam began to exhibit deficiencies in his competence and professionalism. RPH faculty noted gaps his medical knowledge, [3] clinical experience, [4] operative skills, [5] and ability to orally communicate and give presentations.[6] Dr. VanderMeer and Burt Cagir, M.D., Assistant Director of the RPH General Surgery Residency Program, wrote in their biannual resident review that they harbored “significant concerns about [Dr. Ramalingam's] ability to learn from his practice and to seek out high quality medical literature in order to improve his practice.”[7] Dr. Cagir specifically described Dr. Ramalingam as lacking “intellectual honesty” because Dr. Ramalingam could not accept his own mistakes.[8]

         But according to Dr. Ramalingam, his performance remained exemplary as other physicians rated him highly on periodic evaluations of his work[9] and assessment of his communication skills.[10] Dr. Ramalingam contends that Dr. VanderMeer and Dr. Cagir's efforts to undercut Dr. Ramalingam's professional competency arose from either personal animus or Dr. Ramalingam's perceived misalignment in internal hospital politics. For example, Dr. Ramalingam participated in two peer review conferences, where he presented on two cases involving one of Dr. VanderMeer's patients. According to Dr. Ramalingam, Dr. VanderMeer wanted Dr. Ramalingam to present the cases in a manner critical of a certain general surgeon with whom Dr. VanderMeer had a conflict.[11] Dr. Ramalingam, however, explains that he reported the cases objectively and substantiated his explanations with medical literature-a course of action that Dr. Ramalingam says earned him Dr. VanderMeer's reproach when Dr. VanderMeer called Dr. Ramalingam “intellectually dishonest.”[12]

         In March 2015, RPH's Resident Promotion Committee (“RPC”), a faculty committee of surgeons who evaluate resident performance, convened and decided that Dr. Ramalingam was not prepared to graduate in 2015.[13] The committee noted that Dr. Ramalingam did not complete ACGME's 750-procedure requirement and did not complete rotations in pediatric surgery, endoscopy, thoracic surgery, and plastic surgery.

         Dr. VanderMeer communicated the RPC's decision to Dr. Ramalingam, [14]identified the areas of Dr. Ramalingam's practice that concerned the committee, and provided Dr. Ramalingam with a draft remediation plan to improve his perceived deficiencies. As a result of the RPC's decision, Dr. Ramalingam contacted Dr. Michele Molinari, the fellowship director at Dalhousie University, and arranged a later start date for his HPB fellowship.[15]

         Dr. VanderMeer also decided to e-mail Dr. Molinari, explaining that Dr. Ramalingam would not graduate in time to start the fellowship in July 2015, at least in part because he did not achieve a minimum case volume. Dr. Molinari ultimately decided to revoke Dr. Ramalingam's fellowship offer, at least in part because Dr. Ramalingam would not graduate in June 2015.

         Dr. Ramalingam appealed the RPC's decision by filing a grievance with the Impartial Fair Procedure Review Panel, and the panel upheld the RPC's decision not to graduate Dr. Ramalingam in June 2015.

         At some point, Dr. Ramalingam began to correspond directly with ACGME. In May 2015, ACGME told Dr. Ramalingam that he need not complete the 750-procedure requirement to graduate. This announcement, however, came after Dr. Molinari withdrew the fellowship offer.

         Dr. Ramalingam ultimately graduated from RPH's surgical residency program in September 2015 after completing Defendants' remediation program. He explains that because Defendants' wrongful actions deprived him of his HPB fellowship, he has been unable to secure the type of full-time employment he otherwise may have been able to obtain.

         Dr. Ramalingam later filed a four-count complaint in this Court. In Count I, he alleges that Defendants breached their contract with him by, inter alia, not seeking a waiver of the 750-procedure requirement from ACGME. In Count II, a promissory estoppel claim, he alleges that Defendants made “multiple representations, promises, and assurances” to him, which he reasonably relied on to his detriment. In Count III, he alleges that Defendants' actions amounted to tortious interference with his contractual relationship with Dalhousie University - i.e., with his HPB fellowship there. In Count IV, he alleges that Defendants' actions amounted to tortious interference with prospective business relations - i.e., with job offers he could have sought had he successfully completed the HPB fellowship at Dalhousie University. Defendants moved to dismiss Count II, Count III, and Dr. Ramalingam's claim for punitive damages for failure to state a claim upon which relief may be granted.[16] This Court denied Defendants' motion to dismiss.[17]

         Defendants presently move for summary judgment on all counts of Dr. Ramalingam's complaint.[18] Defendants argue that they are entitled to immunity under the Health Care Quality Improvement Act (HCQIA), or alternatively, that Dr. Ramalingam has failed to substantiate each of his causes of action.[19]


         A. Standard of Review

         Summary judgment is granted when “the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.”[20] A dispute is “genuine if a reasonable trier-of-fact could find in favor of the non-movant, ” and “material if it could affect the outcome of the case.”[21] To defeat a motion for summary judgment, then, the nonmoving party must point to evidence in the record that would allow a jury to rule in that party's favor.[22] When deciding whether to grant summary judgment, a court should draw all reasonable inferences in favor of the non-moving party.[23]

         B. Health Care Quality Improvement Act

         Defendants argue that they are entitled to immunity under the HCQIA for all of Dr. Ramalingam's state law claims.[24]

         Congress passed the HCQIA to immunize professional review bodies from state law claims for money damages in an effort “to improve the quality of medical care by encouraging physicians to identify and discipline physicians who are incompetent or who engage in unprofessional behavior.”[25] Professional review bodies include health care entities and committees formed within such entities to review the performance of other physicians.[26]

         For an individual or entity to enjoy HCQIA's immunity, the challenged decision must have been made as part of a “professional review action, ” defined as:

[A]n action or recommendation of a professional review body which is taken or made in the conduct of professional review activity, which is based on the competence or professional conduct of an individual physician (which conduct affects or could affect adversely the health or welfare of a patient or patients), and which affects (or may affect) adversely the clinical privileges, or membership in a professional society, of the physician.[27]

         However, if the challenged decision was primarily based on “any other matter that does not related to the competence or professional conduct of a physician, ” - i.e. if the peer review action was pretextual - it cannot be considered a “professional review action” and accordingly, the challenged decision lies outside of the HCQIA's immunizing umbrella.[28]

         Here, although courts may decide whether HCQIA immunity applies as a matter of law once the record becomes sufficiently developed, [29] determining whether Defendants' decision not to graduate Dr. Ramalingam early qualifies as a professional review action must be decided by the jury. On the one hand, a jury could credit evidence favorable to Defendants and conclude that the RPC was convened and decided to hold Dr. Ramalingam back because of his professional incompetence-that is, clinical concerns related to Dr. Ramalingam treatment of patients.[30] Record evidence suggests that the committee was concerned with Dr. Ramalingam's alleged “inability to demonstrate learning from poor outcomes, ”[31]which, according to Dr. VanderMeer, manifested in one particular instance when Dr. Ramalingam failed to diagnose an obvious case of necrotizing fasciitis and failed to recognize his own mistake in the diagnosis' delay.[32] In sum, if a jury concludes that Defendants held Dr. Ramalingam back because of his competence or professional conduct, the HCQIA's immunity might apply, assuming other statutory requirements are met.[33]

         On the other hand, a jury could credit evidence favorable to Dr. Ramalingam and find that the RPC was convened and ultimately decided to hold Dr. Ramalingam back primarily to protect the general surgery program and Dr. VanderMeer's position as program director.[34] Record evidence suggests that although Dr. VanderMeer admitted he could graduate Dr. Ramalingam without satisfying ACGM's 750 caseload requirement, Dr. VanderMeer feared that such an action would lead ACGME to “red flag” or sanction the program.[35] A jury could infer, then, that what motivated Dr. VanderMeer to hold Dr. Ramalingam back was to protect RPH's accreditation with ACGME, rather than to address Dr. Ramalingam's competence or professional conduct. If a jury so concludes, Defendants cannot seek shelter under the HCQIA.

         Accordingly, because the jury must decide who to believe, the Court cannot at this time decide the applicability of the HCQIA, and summary judgment on this basis must be denied.

         C. Count I: Breach of Contract

         Defendants argue that Dr. Ramalingam's breach of contract claim must fail because Dr. Ramalingam does not attach a contract to his complaint, does not set forth specific contractual terms, does not identify which of those terms were breached, and any damages flowing from the alleged breach were unforeseeable.[36]

         To prevail on his breach of contract claim under Pennsylvania law, Dr. Ramalingam must establish “(1) the existence of a contract, including its essential terms, (2) a breach of a duty ...

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