Surgeon Koehler would return; Martha's Vineyard Hospital says he's not needed

By Nelson Sigelman
Published: February 5, 2009

Surgeon Richard Koehler resigned from the Martha's Vineyard Hospital (MVH) medical staff seven years ago in a swirl of controversy generated during a very public battle with the hospital administration. Now in private practice in Plymouth, Dr. Koehler wants to re-establish a surgical practice on the Island.

Dr. Richard Koehler spoke at a hospital forum held in February 2002, soon after he resigned.
File photo by Steve Rodgers

But, Dr. Koehler says, Martha's Vineyard hospital has unfairly denied him even the opportunity to apply for medical staff privileges. Without staff privileges he cannot admit patients or use hospital operating suites.

Dr. Koehler, who specializes in laparoscopic surgery and operates at Jordan Hospital in Plymouth, detailed his complaints, including accusations of hospital wrongdoing, in a December 16, 2008, seven-page letter to the office of Massachusetts attorney general Martha Coakley. The letter was provided to The Martha's Vineyard Times without the knowledge of Dr. Koehler.

Dr. Koehler wrote that the hospital's actions constitute "violations of laws regarding fair trade and commerce" and are "certainly not in the best interest of the healthcare delivery to the people of Martha's Vineyard."

Alluding to his past clashes with the administration, he wrote, "These actions by the hospital are unreasonable, unfounded, and in my opinion are based solely upon a singular discriminatory retaliation against me for political and personal reasons."

Upheaval and resignation

Since the upheavals of the 1990s, news from the hospital has been mostly good, including the successful community campaign to raise $42 million to construct a new hospital building, the hiring of new physicians, industry awards for quality care, the hospital's affiliation with Partners Healthcare, and generally positive year-end financial reports for the hospital and Windemere, the Island's only nursing home.

It was a much different story in the winter of 2001/2002. The hospital and Windemere were awash in red ink, and contract talks between Kevin Burchill, hospital CEO at the time, and union representatives for 35 permanent hospital staff nurses had turned contentious.

Dr. Koehler was a hospital staff surgeon, and his wife at the time, Kathleen Koehler, was a highly respected gastroenterologist and member of the hospital board in private practice.

It was at that time that continuing friction between the tough-talking Mr. Burchill and the self-assured Dr. Koehler reached a head. The catalyst was a series of written communications from the hospital administration to Dr. Koehler concerning administrative procedures.

In a letter to the editor published in The Martha's Vineyard Times on Jan. 10, 2002, Dr. Koehler announced his resignation, effective July 8, 2002, and he and his wife's departure from the Island. News of the resignation and Dr. Koehler's continuing public and private criticism of the hospital leadership fueled a storm of public protest from Koehler supporters.

Critics accused Mr. Burchill of bullying behavior and excessive concern with the hospital's bottom line. His supporters credited him with leading the hospital out of bankruptcy, a new focus on the quality of medical care, and securing critical care access designation from the federal government, gaining the hospital thousands of dollars in added Medicare reimbursements.

The turmoil played out in letters to the editors of both Island newspapers and an unprecedented public forum called to discuss hospital issues that attracted approximately 300 people, many of them vocal supporters of Dr. Koehler.

That March, Mr. Burchill announced his departure, and the hospital trustees elected Mr. Ferguson chairman, ushering in a new era.

In the months that followed, the board named chief financial officer Tim Walsh the new CEO, began hiring new doctors, and planning for a new building. The turmoil that had enveloped the hospital receded.

That summer, the hospital hired Dr. Pieter M. Pil, who had recently completed his surgical residency training at Harvard Medical School and Brigham and Women's Hospital, and Dr. Denise Fraser, a surgeon in the department of surgery, and the director of the breast health program at Roger Williams Medical Center in Providence.

One year later, in summer 2003, Doctors Richard and Kathleen Koehler, then on the staff of the Springfield Hospital in Vermont, spoke with hospital officials about returning to the Vineyard to practice.

In brief comments at the time, Mr. Walsh said the hospital did not need a new surgeon and was looking for primary care doctors.

Plan for coverage

In an interview with The Martha's Vineyard Times Friday, Tim Walsh, the MVH chief executive officer, and surgeon Pieter M. Pil, hospital chief of staff, said the hospital follows its medical needs plan to identify areas where physicians are needed. Both men agreed that there is no need to add a general surgeon to the medical staff. Both said Mr. Koehler's past issues with an earlier hospital administration are not relevant.

"Time has moved on," said Dr. Pil. "It is not the same administration."

Mr. Walsh said any decision to grant staff privileges begins with a staffing plan, created at the suggestion of John Ferguson, CEO of Hackensack University Medical Center in New Jersey, soon after he was named chairman of the hospital board of trustees in 2002.

The original plan identified pressing needs in the areas of family medicine and internal medicine, but concluded that in other areas, such as pediatrics and general surgery, the hospital is well covered.

In the past, most of the Island's primary care physicians and specialists were in private practice. They rented office space in the hospital but operated independently.

Mr. Walsh said the cost of moving to the Island and beginning a private practice made it difficult to attract physicians. Six years ago, the hospital changed the model, in order to attract and keep the five primary care physicians called for in the staffing plan, and it began to hire doctors.

Unlike most rural hospitals, Martha's Vineyard provides specialties and added coverage that the Island population alone could not support under a private practice model, Mr. Walsh explained. For example, the numbers of births alone do not call for a full-time obstetrics department but, "It is something we think we have to do."

The hospital employs two general surgeons and two anesthesiologists. Although the volume of surgeries is not enough to support two full-time general surgeons, it provides the Vineyard with full-time surgical call coverage, a critical element when the trauma team is alerted to assemble for an emergency.

Mr. Walsh said that level of medical care is rare for a hospital that serves a population the Island's size. "I think our success is that we have been able to be a pretty sophisticated rural hospital," he said. "But if you manage the resource well, you can do a lot with it."

It all rests, according to the chief executive, on a fragile financial equation that would not be successful if the hospital freely granted privileges, as it did in the past.

"The staffing plan is really the key component," said Dr. Pil. "And we have not identified the need for a third surgeon."

In demand

Dr. Pil said the hospital receives many requests for hospital privileges, particularly in the summer. "A lot of people want to be credentialed here, because they have a house here," he said.

It is not unusual for a visiting physician to ask to use the hospital's resources, in order to treat a family member or a friend. Some people do not seem to understand, Dr. Pil said, that "this is a real hospital with real people; it is not a summer camp."

The hospital's credentialing process begins with a discussion between the physician seeking privileges and Jay Ferriter, director of physician practice management. Based on the hospital's identified needs, the conversation proceeds or stops there.

A physician may ask to join the staff in one of five categories: active staff, associate staff, community affiliate, replacement staff, or honorary staff. Each category entails a different set of hospital privileges.

The administration then checks the physician's medical credentials. The head of the respective hospital department contacts references, former employers, and co-workers. All hospital physicians must be board-certified.

The hospital medical executive committee, including physicians who are voting members and attended by Mr. Walsh and a board member, then review applications in detail. The committee forwards a recommendation to the hospital board, which has the final say.

Dr. Pil said people do not normally apply for hospital privileges unless they know there is an opening.

"These are not unique things, other hospitals have staffing plans, they have credentialing," said Dr. Pil. He said the hospital is following its own procedures. "I think he [Dr. Koehler] needs to follow the rules that we have, just like everybody else has to follow the rules. If he wants to apply to be on the replacement staff we will welcome his application. Richard is a fine surgeon, but he is not talking about that. He wants to be on the active staff."

No competition

In a telephone conversation Monday, Dr. Koehler said he would not comment on the letter he sent to the office of the attorney general. Last week, the attorney general's office acknowledged receipt of Dr. Koehler's letter, which he described as confidential. Dr. Koehler said he wrote the attorney general's office in response to a telephone request from the office that he do so. The attorney general's office would not confirm Dr. Koehler's claim that he had been asked to submit his complaint.

Dr. Koehler offered guarded comments on his efforts to regain active staff hospital privileges. "Ever since I left, and to this day, there are many, many patients on the Island who express a desire that I would be back on the hospital staff and a desire to get surgery by me at the hospital," he said. "The same surgery I was doing for the eight years before."

Dr. Koehler joined the staff at Jordan Hospital following a stint at the Springfield Hospital in Vermont. His former Island connection was strengthened when he began a romantic relationship with singer-songwriter Carly Simon of West Tisbury.

When he is not on call, Dr. Koehler, who maintains a residence in Plymouth, is on the Vineyard. "Very often when I am on the Island I run into former patients or their friends who express a desire that I was back on staff at the hospital," said Dr. Koehler. He insisted that his request for staff privileges is a response to a demand from Vineyarders.

Dr. Koehler said it is unprecedented for a hospital to refuse to provide a physician with an application to apply for staff privileges. "Most hospitals, provided the hospital does not have to finance the practice, would be happy to have as many general surgeons and orthopedic surgeons as wanted to apply on staff," he said.

Unlike the Martha's Vineyard Hospital, which recruits and pays the salaries of its physicians, Jordan Hospital relies on a private practice model. "As long as they are not paying for those surgeons, the more that are there the more the hospital makes," Dr. Koehler said.

Arguing his case, Dr. Koehler estimated he has treated approximately 100 Vineyard patients at Jordan Hospital. He said the money he now generates could be money collected by Martha's Vineyard Hospital if he were operating there, and at no cost to the hospital.

Dr. Koehler said he would not be in competition with the hospital's two staff surgeons, because much of the surgery he has done at Jordan Hospital would not presently be performed at Martha's Vineyard Hospital. "I have always been a supporter of the hospital staff - the nursing staff are fantastic and it sounds like the surgery department is fantastic - and what I want to do is to be able to offer something to the hospital staff and to the population of the Island that is something we were doing there before and I think I am in a very good position to offer those services," he said.

Dr. Koehler said he was never told that he was free to apply for a status other than active. "If they are suggesting that the only reason they are not sending me an application is because I am asking for the wrong type of privileging, then that is news to me," said Dr. Koehler.