Regarding "The Cost of Courage," (Oct. 26-29):

It was with a combination of bemusement and alarm that I read the Post-Gazette series on disruptive physicians and your Nov. 3 editorial "The Hospital Canker." I spent the greater part of my 50 years of legal practice working with many respected physicians who serve as medical staff leaders in nonprofit community hospitals dealing with a small number of physicians who were incapable of working cooperatively with nurses and other physicians. I also co-authored an article on this subject in 1985 that has been cited by many courts.

I found it bewildering that a small and unrepresentative number of physicians, many of whom had exhausted (unsuccessfully) their appeals in the court system, now find an ear in the PG.

While I am not familiar with the facts of the individual cases that staff writer Steve Twedt chose, it has been my experience that physicians are not typically disciplined for coming forward with concerns about quality. In cases involving physician disruptive behavior with others, including patients, corrective actions occur only when the physicians' manner of expressing themselves is abusive and affects the quality of patient care. A nurse who has been the target of a slap or loud profanity is likely to fear working with that physician again; nursing morale and quality suffer.

The vast majority of physicians practice competently and relate professionally to other members of the health-care team. However, there are a few who do not and cannot. In my experience, a claim of whistle-blowing is too often an afterthought, an excuse for abusive conduct.

For example, in the case of Wieters vs. Roper Hospital (one of the physicians profiled in the articles), the 4th U.S. Circuit Court of Appeals in February 2003 did not find that a claim of whistle-blowing justified "paroxysms of rage." While we don't know details beyond those described in the court's opinion, this case is typical of the reported cases on disruptive conduct. If someone in your family were a nurse who was subjected to angry outbursts by a physician, it is unlikely that you would turn the other cheek because the doctor later claimed to be a courageous whistle-blower.

The handful of physicians whose behavior crosses the line of decency usually retain aggressive legal counsel and are aggressive themselves. They often attack the people who were willing to come forward -- nurses who filed incident reports, and medical staff leaders who risk losing their referral patterns. The leaders take time to testify in the rigorous internal hearings that must be given to physicians, and then again in a court suit. They gain nothing for doing so and often are made defendants in a suit by the physician.

The examples used in the articles were extreme and the statements one-sided. In most of the court cases, the physicians did not prevail because they were not truly "whistle-blowers." Portraying the disruptive practitioner as a crusader for quality is simply not supported by the experience of those in the trenches or judges to whom we all look for objectivity.

I have been honored and privileged to work with some of the very best medical staff leaders and hospital boards in all parts of the country. Those leaders are committed not only to high quality standards but to creating and maintaining an environment in which all individuals -- physicians, other health-care professionals and patients -- are treated with courtesy, respect and dignity.

The Health Care Quality Improvement Act of 1986 was passed by Congress to restore the balance needed to protect physicians who perform the thankless task of hospital peer review because there was a risk that no physician would be willing to put his or her assets on the line when faced in the past with the threat of antitrust or other liability.

Today, the retaliatory theory du jour is the whistle-blower strategy. A court must be convinced that a reasonable hospital would have taken action in light of the evidence in the record before it rules against a physician -- hardly an unfair standard! (The act had nothing to do with whistle-blowers.) And, it has had the effect of increasing peer review that does protect patients.

Were any of those nurses or physicians who spoke out at great personal cost featured in your article to balance the picture? Unfortunately, no.

-- Eric W. Springer is of counsel at Horty, Springer & Mattern, a Downtown law firm focused on health care.