United States District Court, M.D. Pennsylvania
SARAVANAN RAMALINGAM, M.D., Plaintiff.
ROBERT PACKER HOSPITAL, et al., Defendants.
Matthew W. Brann United States District Judge.
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.
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
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.
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. 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.
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.
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.
Ramalingam did not graduate in June 2015, and parties sharply
differ as to why.
to Defendants, Dr. Ramalingam began to exhibit deficiencies
in his competence and professionalism. RPH faculty noted gaps
his medical knowledge,  clinical experience,  operative skills,
ability to orally communicate and give
presentations. 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.” Dr. Cagir specifically described Dr.
Ramalingam as lacking “intellectual honesty”
because Dr. Ramalingam could not accept his own
according to Dr. Ramalingam, his performance remained
exemplary as other physicians rated him highly on periodic
evaluations of his work and assessment of his communication
skills. 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. 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.
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. 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.
VanderMeer communicated the RPC's decision to Dr.
Ramalingam, 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
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
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.
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
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
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. This Court denied Defendants' motion
presently move for summary judgment on all counts of Dr.
Ramalingam's complaint. 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
Standard of Review
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.” 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.” 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. When deciding whether to grant
summary judgment, a court should draw all reasonable
inferences in favor of the non-moving party.
Health Care Quality Improvement Act
argue that they are entitled to immunity under the HCQIA for
all of Dr. Ramalingam's state law claims.
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.” Professional
review bodies include health care entities and committees
formed within such entities to review the performance of
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.
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.
although courts may decide whether HCQIA immunity applies as
a matter of law once the record becomes sufficiently
developed,  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. Record evidence suggests
that the committee was concerned with Dr. Ramalingam's
alleged “inability to demonstrate learning from poor
outcomes, ”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. 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
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. 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. 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.
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.
Count I: Breach of Contract
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
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 ...