Two surgeons say St. John’s Medical Center is denying one of them practicing privileges for political purposes, something the hospital denies.
“It’s so blatant, what is happening here,” said Dr. Catherine Durboraw, an oculoplastic surgeon. “What the people of Jackson need to understand is that limits their choice for health care. When St. John’s makes a decision like that, they’re saying to you, ‘We’re not going to give you choice. You can only have the Big Mac. We’re not going to have a Burger King. We’re not going to have a Five Guys.’ And that matters because until we start having choice, it’s just like anything else. Choice makes us better.”
Durboraw and her partner, Dr. Laura Cooper, a plastic surgeon whose specialty is breast reconstructions, preapplied for hospital credentials in August 2016. Though Durboraw eventually received her credentials in March, Cooper never did. Her application was closed, but not denied, in August.
“I’ve never had any problems getting privileges at any facility,” said Cooper, who moved to Jackson in July 2016. “Whether it was Atlanta, where I did my fellowship, or in Tennessee, where I went into private practice, or in Idaho Falls.”
Durboraw and Cooper believe Cooper wasn’t granted privileges to protect Dr. John Payne, a plastic surgeon who works for St. John’s Physician Services. Payne declined interview requests.
Marc Domsky, St. John’s chief of staff, denied the accusations that politics are at play but would not comment on the specifics of Cooper’s or Durboraw’s credentialing process, saying the hospital could be sued because applications for privileges are confidential by law.
“In this respectful atmosphere it is disappointing that complaints about any particular applications have been aired in a public forum rather than brought to the medical staff, where they can be specifically addressed in a productive manner,” Domsky said.
In a routine case, Domsky said, the preapplication process takes anywhere from a week to a month. After the medical staff office verifies materials an in-depth evaluation by the credentials committee occurs. If the applicant is licensed in Wyoming the process usually takes between three and six months.
The hospital sees roughly between 15 and 20 new applicants for privileges a year and hovers around 180 credentialed staff members, including about 20 credentialed nurse practitioners and physician assistants.
If an application is denied, the applicants are entitled to a fair hearing process. Domsky said that he couldn’t remember the last time a formal application was rejected and that it would take something “very egregious.”
“We think our process is thoughtful and fair,” Domsky said. “And maybe there are some people that don’t. And that’s OK, too. That’s all.”
The two Center for Aesthetics surgeons say the credentialing process was out of the ordinary.
“It took an extraordinarily extended long time to get through the process,” Durboraw said. “Every step of the way we felt like there were hurdles that we were being asked to jump over that we normally wouldn’t have had from other facilities.”
An initial phone call
Roughly half an hour after Durboraw and Cooper preapplied for courtesy staff privileges at St. John’s, Payne called Rick Starkey, the administrator at Teton Outpatient Services. Payne told Starkey that the two women would never have St. John’s privileges because there was no need for them and he already provided similar services.
Starkey confirmed the call. Durboraw and Cooper are now both credentialed at Teton Outpatient Services.
After learning of Payne’s initial call, Durboraw’s husband and office manager, Dan Carl, called Payne, upset, and told him the two doctors would fight for privileges “up to and including litigation.” There were later conversations about the call with St. John’s CEO Paul Beaupre.
As chief of surgery Payne is a member of the Medical Executive Committee, the group in charge of credentialing new doctors with final approval by the board of trustees. Other members of the committee include departmental representatives, the CEO, the chief nursing officer and a liaison from the board of trustees. The Center for Aesthetics was notified in December 2016 that Payne would be recused from Cooper’s credentialing process.
Payne’s reaction surprised Durboraw.
“I was totally blindsided,” she said. “Because our thought was, you know, we aren’t competing with Payne. We’re already here.”
“I think they’re protecting their hospital employee, which would be Dr. Payne,” Cooper said. “I think that’s what it really all boils down to. This is very political.”
Durboraw echoed that sentiment.
“It’s very simple,” Durboraw said. “Because they have one person on their staff who feels very threatened by [Cooper’s] presence. And I think he’s concerned about his job. If I had to be really honest about it, I think he’s concerned about the longevity of his job.”
Cooper and Durboraw say that if they both had practicing privileges at St. John’s, they could increase elective surgery volumes there and bring new expertise to the valley. Beaupre said a dip in elective surgery volumes affected revenue expectations for the hospital this fall.
In 2017 the two surgeons combined did 55 cases with Jackson-area ZIP codes, 20 of which were performed out of state.
“So when St. John’s blocks elective surgeons who are completely qualified, competent, local physicians — when they bar them from operating at their facility — they are basically just hurting themselves,” Durboraw said. “They benefit from having the highest quality, the most reputable surgeons on their staff. That’s how they are going to become profitable.”
Domsky disputed the idea that more surgeons mean more surgeries.
“That doesn’t always happen that way,” he said. ‘There’s a limit to the amount of patients that come through here, a limit to the population of Teton County and the surrounding areas and the amount of tourists that come through.”
Revenue aside, Cooper and Durboraw say the lack of patient choice is their primary concern. Holly Carter, a patient of Cooper’s from Tennessee, wrote to the News&Guide this summer about the importance of doctor choice.
“Why would a community hospital deny its citizens access to a skilled female plastic surgeon as talented as Dr. Cooper?” Carter wrote. “Intrinsic knowledge of a woman’s thoughts regarding her body is an essential attribute for a plastic surgeon performing aesthetic or reconstructive surgery. ... The citizens of Jackson deserve the best medical services available and access to her superior skills.”
“That’s the heart of the matter here,” Cooper said. “By closing my application what they’re doing is limiting patients’ choice and their access to a provider. I’m board certified in general surgery, board certified in plastic surgery, I’ve done years of training, and for them to not allow me to practice in this area is limiting patients’ access to care.”
Competition is healthy, the surgeons say.
“When I have competition I become better at what I do,” Durboraw said. “I’m a better provider; I’m more attentive to my patients. That’s what creates a healthy health care environment, having more than one of us around.”
‘Fly by night’
Cooper and Durboraw have practicing privileges elsewhere, including Eastern Idaho Regional Medical Center and Mountain View’s Creekside Ambulatory Surgery Center over Teton Pass in Idaho. Throughout the credentialing process, they say this was seen as a liability and used as an excuse by St. John’s.
“They don’t ask me if I spent time in Jackson,” Durboraw said. “No surgeon credentialed in Idaho Falls has a stipulation or requirement that they aren’t allowed to have a satellite clinic in an outlying area.”
Throughout the process Cooper was asked to be on what’s called active staff to obtain privileges. Cooper wanted to be on courtesy staff, a designation for applicants who want privileges and meet the general qualifications for staff membership but do not maintain full-time practice requirements. More differences between active and courtesy staff are explained in the hospital’s medical staff bylaws. Cooper felt caught in a bind: She has a home in Jackson and spends three to four nights in the area each week but has patients in Idaho that she felt she couldn’t give up if she wanted to maintain her skills.
Many specialized surgeons in rural areas have a geographically large practice region to keep their surgery volumes up without concentrating caseloads in one location. There are other doctors in the same boat who have been granted courtesy staff privileges at St. John’s. Some, like opthalmologist Dr. Jamie Monroe, perform surgeries but don't live here full-time.
Durboraw pointed out that doctors in big cities might have satellite clinics on opposite sides of large cities with long commutes between facilities. Many local patients go out of the region for elective surgeries, Durboraw said, so they, too, could end up in the emergency room without a doctor nearby. The same goes for tourists.
“So the idea that somehow we are really encumbering the ER and the surgeons — that doesn’t hold any water either,” she said.
Cooper agreed and took issue with being called “fly by night” during her application process.
“For someone to use that terminology to describe my practice or the care of my patients is somewhat offensive,” she said. “It’s just frustrating. I know that I do good work, and I know that my patients respect and appreciate that.”
In March the surgeons set up a meeting with Beaupre to discuss the courtesy versus active staff issue. Then, in May and June, there were some snafus with paperwork, signatures and communication between Cooper, Durboraw and the hospital.
A coverage plan in place
After a Medical Executive Committee meeting on July 11, Cooper agreed to become active staff as long as surgeries could be scheduled far in advance. She also created a schedule for being on call. The medical committee then came back with an additional request, asking Cooper to create a plan for her patients in the eventuality that her cases were to return to the operating room. However, this plan was also rejected. Cooper said she has a 1-in-300 take-back rate to the operating table since starting in private practice 7 1/2 years ago.
Cooper agreed to stay in Jackson for 48 hours after surgery and not leave the region for two weeks after an operation.
She was then instructed to ask the three general surgeons employed by St. John’s for coverage, which she did through phone or email. They all denied her request. At that point, Cooper and the Center for Aesthetics offered to pay surgeons for coverage after their own surgeries — an uncommon offer, they say, and one that was never discussed.
Cooper was then encouraged to reach out to Payne directly, which she did to set up a meeting. When it appeared a meeting might take place at the time, emails show that Domsky later discouraged the interaction and said it wouldn’t be “constructive.”
Cooper then secured call coverage by another surgeon, not employed by St. John’s. The medical committee didn’t accept this coverage. That surgeon was contacted by the News&Guide to confirm his willingness to offer coverage but did not return repeated calls. Paperwork shows this offer to cover any patient admission or urgent and emergent surgical care if Cooper was out of the area was signed Aug. 1 — the same month Cooper’s file was closed.
So what was the problem?
“I would hope that the decisions made by all the members of the MEC when we are sitting down and discussing a topic at the meeting, and we have to make a decision that ultimately is going to affect the care of patients in our community, that that decision is made looking out for the best care of the patients in our community without bias or political agendas,” Domsky said, speaking generally. “That is my goal, and that is the goal as a medical staff here.”
Domsky repeated he couldn’t get into specifics of Cooper’s case or explain point by point why her coverage plans were denied.
“At this point I feel like I’ve done everything I can do,” Cooper said. “It’s a waiting game, and it’s letting the community know that there’s somebody who is extremely well trained who wants to be able to provide these services in the Jackson area and not have to take them to another state for their procedure. But I can’t, because my hands are tied.”
Domsky said that the Medical Executive Committee is “continuously open to dialogue.”
“Just because an application is closed does not mean that someone can’t apply again,” Domsky said. “Absolutely not. In no shape or form.”
This version of the article was edited to correct the paragraph about Dr. Jamie Monroe, who has courtesy staff privileges at St. John's. She said she does not fly out the same day after performing a surgery; she usually stays at least one night in her Jackson Hole home to follow up with patients. — Ed.