Appellant, Dr. Siri Hongsathavij, was a member of the medical staff of respondent, Queen of Angels/Hollywood Presbyterian Medical Center (the Medical Center). After Dr. Hongsathavij was removed from the Medical Center's emergency room "call panel" (which did not affect his staff privileges at the Medical Center), he had a court-ordered hearing before a hospital judicial review committee (JRC), composed of peer physicians
From October 1990 through approximately January 1991, Dr. Hongsathavij was on the call panel of the Medical Center for OB/GYN physicians who served, among others, pregnant patients coming through the emergency room of the Medical Center. The call panel was a rotating list of doctors available to treat patients in the emergency room. Dr. Hongsathavij earned approximately $17,000 a month from the call panel alone. Los Angeles County (the County) had contracted with the Medical Center to provide obstetrical and newborn care for eligible County patients who could not be placed in a County hospital due to a lack of available space. The County also had contracted with Dr. Hongsathavij to provide prenatal, obstetrical and newborn services to patients whose care was then paid for by the County. Many but not all of the patients who entered the Medical Center's emergency room were County patients.
The Medical Center had only one call panel. There was no separate list of physicians on call to cover the emergency room for non-County patients, as distinguished from County patients. The call panel functioned so that physicians were always compensated. In 90 percent of the cases, payment came either from insurance, from the County (for County patients), or from retroactively authorized Medi-Cal payments. In the remaining 10 percent of cases, the Medical Center itself compensated the doctor at Medi-Cal rates. Physicians at the Medical Center, other than Dr. Hongsathavij, generally understood or agreed that their emergency room services entailed treatment of all walk-in patients, including both County and non-County patients. Many were expressly informed that they had to see non-County patients to participate on the call panel. Some physicians considered treatment of all patients to be a moral obligation and thought it ethically improper to determine payment status before delivering a baby. Others were initially reluctant to treat non-County emergency room walk-ins, but were told it was a requirement if they wanted to be on the call panel.
The Incident and Removal From the Call Panel
On January 23, 1991, a patient in premature labor arrived in the emergency room of the Medical Center. The patient was 29 years old, had no prenatal care, had active vaginal bleeding, and admitted a history of drug abuse during her first trimester of pregnancy. The emergency room doctor contacted Dr. Hongsathavij, who admitted the patient to the hospital and had her transferred from the emergency room to the labor and delivery floor. She was admitted to the labor and delivery floor, but Dr. Hongsathavij refused to treat the patient because he discovered she was not a County-referred patient.
After Dr. Hongsathavij refused to treat the patient, Medical Center administrator Ronald Dahlgren requested Dr. Boyd Cooper to take the patient under his care. Dr. Cooper was at home and not then on call, but agreed to come to the Medical Center and treat the patient. Before Dr. Cooper accepted the patient, he contacted Dr. Hongsathavij and admonished him about his obligation to treat the patient. Dr. Hongsathavij told Dr. Cooper that he did not want to treat the patient because he did not have medical malpractice insurance. Dr. Cooper stated that he had to have insurance because he was on the hospital staff, and Dr. Hongsathavij replied, "Well, I'm still not going to take the patient." The Medical Center administrator also that day admonished Dr. Hongsathavij that he had to accept non-County patients. However, he still refused to care for that pregnant patient, and Dr. Cooper delivered her infant later the same day.
Dr. Hongsathavij was subsequently removed from the Medical Center's emergency call panel by the Medical Center's administrator. Dr. Hongsathavij filed a mandamus action in superior court seeking reinstatement. In June of 1993, the superior court granted the petition for a writ of mandate, ordered the Medical Center to reinstate Dr. Hongsathavij on what it termed "the County's admission and referral list," provided he otherwise qualified,
The Charges Against Dr. Hongsathavij
The Medical Center asked its medical staff's medical executive committee (MEC) to conduct the court-mandated hearing, pursuant to the medical staff's bylaws. The MEC impaneled a JRC by appointing five physicians from its ranks, but it refused to issue notice of charges and thus declined to prosecute the case against Dr. Hongsathavij. To comply with the court-ordered hearing, the Medical Center's administrative risk management staff, on behalf of the Medical Center's governing body (i.e., its board of directors), assumed the task of issuing a notice of charges and representing the Medical Center at the hearing.
The six charges against Dr. Hongsathavij were as follows: (1) abandonment of a patient; (2) failure to evaluate and stabilize the patient, subjecting himself and the hospital to "COBRA" violations;
Evidence at the JRC Hearing
On the issue of Dr. Hongsathavij's acceptance and then abandonment of the patient, Dr. Hongsathavij acknowledged at the hearing that after talking with the emergency room physician, he accepted as a patient the pregnant woman in question and then had her transferred to labor and delivery. An emergency room doctor cannot admit patients to the hospital; only attending physicians admit patients. But for rare exceptions, the Medical Center does not transfer a patient from the emergency room to the labor and delivery floor (i.e., does not admit a patient) unless and until a physician with staff privileges accepts the patient into his care. According to Dr. Jacob Fookary, an emergency medicine specialist at the Medical Center, the standard of care and the standard of practice in the Medical Center was that once a patient is accepted by a physician, the patient becomes that physician's patient and is under that physician's care and responsibility.
According to Dr. Cooper, once Dr. Hongsathavij accepted the pregnant woman in question as a patient, Dr. Hongsathavij became responsible for her care. Even when a physician has made a mistake about the patient's identity, the physician's duty to treat the patient remains until another doctor has assumed responsibility for the patient. Dr. Cooper, as well as Dr. Hongsathavij's two expert witnesses — Dr. Louis Acosta (an emergency room physician) and Dr. William Hummer, agreed that the refusal to care for a patient whom a physician arranges to admit constitutes abandonment. Dr. Hummer concluded that the patient in question had not been abandoned. This conclusion was based on the assumption that Dr. Hongsathavij had not accepted the patient because he had not yet offered her any treatment and on the theory that Dr. Hongsathavij had no obligation to a patient he did not want to accept. Dr. Hummer, however, was unaware that Dr. Hongsathavij had previously acknowledged that he had in fact accepted the woman in question as a patient for treatment.
Dr. Acosta also acknowledged that, as indicated by the emergency room chart, Dr. Hongsathavij had agreed to undertake the care of the patient, but then did not issue any orders for her care or treatment. In fact, Dr. Hongsathavij told the nursing director on duty, Nurse Mary Cox, that he "did not want to take care of the patient [and] that his insurance would not allow him to do so." She considered the patient "high-risk" and was concerned about the patient's blood pressure and the fact that she had no treatment orders and
The medical experts at the JRC hearing — Drs. Cooper, Fakoory and Acosta — agreed that the patient in question was a high-risk patient. Dr. Cooper also explained that the patient had ruptured membranes, which alone presented the potential for infection and harm, and required the presence and care of an obstetrician. The patient's history of no prenatal care, vaginal bleeding, premature rupture of membranes, premature labor, low amniotic fluid and drug abuse indicated a high-risk patient. Even though there was no immediate need for a physician's attention when the patient arrived in labor and delivery and the patient's vital signs were stable, a physician's care was still needed.
Dr. Hummer agreed that the patient's baby tested positive for drugs, indicating the patient's recent drug usage. Dr. Hummer then acknowledged that, based upon the Medical Center's rules and regulations regarding high-risk cases and records showing the patient's drug abuse, the patient's history of drug abuse indeed constituted a high-risk factor. Dr. Acosta admitted that "the patient was never taken care of or examined or no orders were written" by Dr. Hongsathavij. It was uncontroverted at the hearing that Dr. Hongsathavij did not offer the patient in question any treatment after he accepted her as his patient.
Testimony at the hearing by expert witness Paul Viviano, a hospital administrator, further established that federal COBRA laws require that physicians not delay examination or treatment in an emergency by inquiring as to the patient's ability to pay for health care. COBRA defines an emergency condition to include a pregnant woman having contractions where a transfer to another facility would pose a threat to the woman or the baby. COBRA imposes a duty upon the physician to stabilize the emergency condition. In the case of a pregnant woman, the duty to stabilize requires delivery of the baby, including delivery of the placenta. Until the emergency condition is stabilized and the baby and placenta delivered, no inquiry can be made into the patient's ability to pay for medical services. COBRA violations can result in substantial fines to both the physician and the hospital, and a hospital could lose the ability to participate in Medicare and Medi-Cal programs.
Dr. Hummer testified that Dr. Hongsathavij had no duty to evaluate and stabilize the patient. However, this conclusion was based upon Dr. Hummer's opinion that the patient "certainly was not in any type of dire or emergency straits by the time she got up to the labor and delivery area." Dr. Hummer later admitted that the patient in question met COBRA criteria of an emergency patient because she was a pregnant woman having contractions, she had certain risk factors, and Dr. Hongsathavij had provided no treatment to her.
Although Dr. Hongsathavij concluded the patient did not present an emergency, he did not make this opinion in the context of COBRA laws. Dr. Hongsathavij based his opinion on the fact that he had been advised the patient's vital signs were stable. Dr. Hongsathavij nonetheless admitted she was a high-risk pregnant patient who was not "within normal limits."
Testimony at the JRC hearing also addressed the issue of Dr. Hongsathavij's malpractice insurance. On January 23, 1991, Dr. Hongsathavij told three people he did not have insurance to cover him in the emergency room context. He told Nurse Cox that his malpractice insurance would not allow him to treat patients admitted from the emergency room or to care for the patient in question. Nurse Cox then promptly spoke with the Medical Center administrator, Mr. Dahlgren, who in turn contacted Dr. Hongsathavij and was told by him that his malpractice insurance prohibited him from treating patients coming through the emergency room. Dalghren told Dr. Hongsathavij at that time that until he had emergency room malpractice insurance, he could not serve on the call panel. Dr. Hongsathavij also told Dr. Cooper that he had no insurance. The following month's call panel was then revised by Dahlgren to eliminate Dr. Hongsathavij from the list. This action had no effect on Dr. Hongsathavij's medical staff privileges at the Medical Center.
At the JRC hearing, Dr. Hongsathavij denied he told Dahlgren that his malpractice insurance did not cover patients coming through the emergency room. Rather, Dr. Hongsathavij claimed he told Dahlgren that he was "in a high-risk category with my malpractice insurance, and my insurance wouldn't be happy if I'm taking more risk than I [am] supposed to."
On February 26, 1991, Dr. Hongsathavij wrote a letter to Dalhgren requesting reinstatement to the "County" call panel and asserting he had insurance which covered all areas of the hospital. Dr. Hongsathavij did not provide the Medical Center administrator with a certificate of insurance or other evidence reflecting malpractice insurance which would have covered him for treatment of non-County patients in the emergency room context. Not until the JRC hearing did Dr. Hongsathavij present a letter from PIT, dated December 13, 1993, indicating he did in fact have an insurance policy in effect covering his emergency room work on the same date he told Dalghren, Dr. Cooper and Nurse Cox that he did not have insurance.
On September 6, 1994, the JRC issued its written statement of decision. The JRC found, in pertinent part, as follows: that there was "no evidence" that Dr. Hongsathavij was "informed of, agreed to, or was contractually required" to treat non-County patients; that the patient in question "was in no immediate danger and no medical emergency existed"; that the Medical Center met its responsibilities to provide care to the patient; and that although he may have led Dahlgren to believe to the contrary, there was "no evidence" Dr. Hongsathavij lacked malpractice insurance, which he did indeed have at the time of his suspension from the call panel.
From those findings, the JRC concluded that no abandonment of a patient had occurred, that no violation of COBRA had occurred, and that Dr. Hongsathavij did not fail to provide documentation of medical malpractice insurance coverage. The JRC made no findings specifically addressing the definition of abandonment under COBRA. The Medical Center appealed the
On February 16, 1995, Dr. Hongsathavij again filed a petition for a writ of mandamus, seeking reinstatement on the call panel. The superior court held a hearing and then issued a statement of decision and an order denying the petition. This appeal followed.
I. The standard of review.
Further instructive on the proper role of the superior court in such a context is Huang v. Board of Directors (1990) 220 Cal.App.3d 1286 [270 Cal.Rptr. 41]. In Huang, the governing body on appeal overruled the judicial review committee's decision in favor of the complaining physician and issued its own decision against the physician. The superior court looked only
Accordingly, the superior court cannot focus exclusively on the decision of the judicial review committee, or there would be no purpose for the bylaw provision which permits review of that decision by the hospital's governing body, which then issues the final administrative decision in the matter. A review which does not exclude the governing body's determination is also consistent with the requirement that "in cases arising from private hospital boards ... abuse of discretion is established if the [superior] court determines that the findings are not supported by substantial evidence in the light of the whole record." (Code Civ. Proc., § 1094.5, subd. (d), italics added.)
As to the function of the Court of Appeal, our function in this context is the same as the superior court's, which was the same as the hospital's governing body. "Like the trial court, we also review the administrative
Moreover, an appellate court must uphold administrative findings unless the findings are so lacking in evidentiary support as to render them unreasonable. (Oskooi v. Fountain Valley Regional Hospital (1996) 42 Cal.App.4th 233, 243 [49 Cal.Rptr.2d 769]; Gaenslen v. Board of Directors, supra, 185 Cal. App.3d at p. 572.) A reviewing court will not uphold a finding based on evidence which is inherently improbable (Schaffield v. Abboud (1993) 15 Cal.App.4th 1133, 1142 [19 Cal.Rptr.2d 205]), or a finding based upon evidence which is irrelevant to the issues. (Broadway, Laguna etc. Assn. v. Board of Permit Appeals (1967) 66 Cal.2d 767, 773 [59 Cal.Rptr. 146, 427 P.2d 810]; City and County of San Francisco v. Board of Permit Appeals (1989) 207 Cal.App.3d 1099, 1109-1110 [255 Cal.Rptr. 307].) Therefore, even if a finding is supported by evidence, if that evidence is irrelevant to the charge, the decision must be reversed for insufficient evidence. (Broadway, Laguna etc. Assn. v. Board of Permit Appeals, supra, 66 Cal.2d at p. 773; City and County of San Francisco v. Board of Permit Appeals, supra, 207 Cal. App.3d at pp. 1109-1110.) Finally, we note that the opinion testimony of expert witnesses does not constitute substantial evidence when it is based upon conclusions or assumptions not supported by evidence in the record. (Pacific Gas & Electric Co. v. Zuckerman (1987) 189 Cal.App.3d 1113, 1135 [234 Cal.Rptr. 630]; see Roddenberry v. Roddenberry (1996) 44 Cal.App.4th 634, 651 [51 Cal.Rptr.2d 907].)
II. The Appeal Board did not improperly substitute its own judgment, as substantial evidence supports its reversal of the JRC's conclusion.
A review of the entire record indicates there was sufficient evidence to support the decision of the Appeal Board of the Medical Center, which described the findings of the JRC as so lacking in evidentiary support as to render them unreasonable. As discussed below, substantial evidence supports the conclusion that in large part the findings of the JRC were simply nonresponsive to the specific charges and thus not supported by the evidence.
A. Abandonment of the patient
A physician cannot just walk away from a patient after accepting the patient for treatment. A physician cannot withdraw treatment from a patient without due notice and an ample opportunity afforded to secure the presence of another medical attendant. (Payton v. Weaver (1982) 131 Cal.App.3d 38, 45 [182 Cal.Rptr. 225].) In the absence of the patient's consent, the physician must notify the patient he is withdrawing and allow ample opportunity to secure the presence of another physician. (See BAJI No. 6.05 (8th ed.).) Dr. Hongsathavij does not contest the validity of such well-accepted principles.
Here, Dr. Hongsathavij admitted the emergency room patient in question to the hospital and had her transferred to the labor and delivery floor. Significantly, there is no evidence either that the patient requested or consented to Dr. Hongsathavij's subsequent cessation of treatment, or that Dr. Hongsathavij gave the patient notice he would not treat her. Though there was some evidence he indicated to one of the nurses that he would "stand by," Dr. Hongsathavij never called a substitute physician and was, in fact, unaware of who had ultimately contacted Dr. Cooper to care for the patient. This was patient abandonment.
Dr. Hongsathavij attempts to defend such conduct with technical notions of mistake of fact and contract analysis. We are unpersuaded. Dr. Hongsathavij asserts both he and the emergency room physician were under a mutual mistake of fact that the patient was a County patient when Dr. Hongsathavij agreed to accept her, and that Dr. Hongsathavij acted appropriately when he learned otherwise. However, the mutual mistake purportedly relied upon by Dr. Hongsathavij was a mistake between two physicians,
Nor was it of any consequence to the abandonment charge that Dr. Cooper arrived at the Medical Center in approximately 45 minutes, or that the patient — whom Dr. Hongsathavij admitted was a high-risk patient — was not in need of immediate attention from a physician. All parties concerned should consider themselves fortunate there were no mishaps or untoward occurrences for this patient or her baby.
B. COBRA violations
COBRA thus compels a physician either to transfer the high-risk pregnant woman or to provide "such treatment as may be required to stabilize the medical condition." (42 U.S.C. § 1395dd(b)(1)(A).) "To stabilize" is a term, again defined in COBRA, which in the emergency context of a pregnant woman with contractions means "to deliver (including the placenta)." (42 U.S.C. § 1395dd(e)(3)(A).) Therefore, a physician violates COBRA when he refuses to treat a pregnant woman having contractions (by definition, an emergency) through delivery of her baby (including the placenta). (See Burditt v. U.S. Dept. of Health and Human Services, supra, 934 F.2d at p. 1376 [$20,000 penalty against physician affirmed].)
In the present case, the facts elicited by Dr. Hongsathavij on the COBRA issue were essentially irrelevant. One of his expert witnesses, Dr. Acosta,
The JRC then relied upon such irrelevant testimony in addressing the COBRA issue. The following findings by the JRC were thus of no consequence: that the patient was in no immediate danger; that the patient received nursing care throughout her hospitalization and was appropriately treated at the Medical Center during her entire time there after admission; and that the Medical Center met its responsibilities to provide care to the patient. The JRC's conclusion that no COBRA violation occurred was based on facts irrelevant to that issue. That the Medical Center in essence bailed Dr. Hongsathavij out of a potentially disastrous situation and that fortunately nothing untoward befell the patient do not establish the absence of a COBRA violation.
Moreover, Dr. Hongsathavij's contention that he was not subject to the requirements of COBRA because he was purportedly not on call for non-County patients flies in the face of the very purpose and function of COBRA. As previously noted, COBRA was designed to prohibit physicians from limiting their care of emergency patients (contractually or otherwise) to only those with financial resources to pay or to those who could indemnify for any malpractice claims. Dr. Hongsathavij was thus not at liberty under COBRA to accept an emergency room patient and then reject that patient who had no means to pay for his services and no means of indemnity for any malpractice.
Accordingly, the JRC's findings on the COBRA issue were not relevant. Substantial evidence supports the Appeal Board's decision to reverse the decision of the JRC, and the superior court's ruling was proper as a matter of law.
C. The malpractice insurance issue
First, it is uncontested that the medical staff bylaws provide for the automatic suspension of privileges of a physician for lack of malpractice insurance, and that such privileges remain suspended until evidence is provided to the MEC that the physician has secured appropriate professional liability insurance. Although in the present case on-call status and not staff privileges was the issue, the requirement that Dr. Hongsathavij provide proof of coverage was eminently reasonable under the circumstances of evidence of his denial of having appropriate coverage.
Second, three people — Nurse Cox, Dahlgren and Dr. Cooper — testified Dr. Hongsathavij told them on three separate occasions that he did not have insurance to cover the emergency room. Even Dr. Hongsathavij admitted he told Dahlgren that he was "in a high-risk category with my malpractice insurance, and my insurance wouldn't be happy if I'm taking more risk than I[am] supposed to." Thus the JRC's conclusion that there was "no evidence" Dr. Hongsathavij lacked insurance is a blatant error and contradicted by the evidence.
Third, although on February 26, 1991, Dr. Hongsathavij wrote a letter to Dahlgren requesting reinstatement to what he referred to as the "County" call panel and claimed he had insurance which covered all areas of the hospital, he offered no documentation reflecting malpractice insurance to cover his non-County emergency room work. Not until the JRC hearing approximately two years later did Dr. Hongsathavij present a letter from PIT indicating he did have an appropriate insurance policy in effect at the time, approximately three years earlier, when he had told Nurse Cox, Dahlgren and Dr. Cooper that he did not have insurance. But this belated letter had no probative value on the issue of Dr. Hongsathavij's failure to present documentary evidence to the Medical Center in 1991, several months after removal from the call panel, as he was required to do.
Again there was substantial evidence in support of the conclusion that the JRC's findings on this matter were so lacking in evidentiary support as to be unreasonable.
III. Dr. Hongsathavij was not denied a fair procedure.
Dr. Hongsathavij assumes bias by the Medical Center. However, bias in an administrative hearing context can never be implied, and the mere suggestion or appearance of bias is not sufficient. (Gill v. Mercy Hospital (1988) 199 Cal.App.3d 889, 911 [245 Cal.Rptr. 304].) It is also well established that a party is not denied an impartial adjudicator merely because an administrative entity performs both the functions of prosecutor and judge. (Griggs v. Board of Trustees (1964) 61 Cal.2d 93, 98 [37 Cal.Rptr. 194, 389 P.2d 722].) Overlapping investigatory, prosecutorial and adjudicatory functions do not necessarily deny a fair hearing and are common before most administrative boards. (Rhee v. El Camino Hospital Dist. (1988) 201 Cal.App.3d 477, 490 [247 Cal.Rptr. 244]; Smith v. Vallejo General Hospital (1985) 170 Cal.App.3d 450, 459 [216 Cal.Rptr. 189]; Hohreiter v. Garrison (1947) 81 Cal.App.2d 384, 392 [184 P.2d 323].) By the very nature of an internal administrative peer review process, a hospital or one of its representatives is likely to be involved in the initiation and prosecution of charges, including any appeal process.
Nor was there any bias or "practical probability of unfairness" (Applebaum v. Board of Directors (1980) 104 Cal.App.3d 648, 659 [163 Cal.Rptr. 831]) since none of the people involved in the process had any overlapping memberships in both the adjudicatory body and the reviewing appeal board. (See Rhee v. El Camino Hospital Dist., supra, 201 Cal. App.3d at p. 491; Anton v. San Antonio Community Hospital (1982) 132 Cal.App.3d 638, 648 [183 Cal.Rptr. 423].) As the trial court below also aptly recognized, it was the administrator (not the governing body itself) which initially imposed the action giving rise to the hearing, and the risk management department (not the governing body) prosecuted the hearing. The governing body did not become actively involved until it assumed an appellate role. Moreover, where an administrative body has a duty to act, and is the only entity capable
In essence, Dr. Hongsathavij's position is that if the governing body believes an action against a physician is necessary, and if the medical staff disagrees, then the medical staff gets to make the final decision, since the governing body is tainted by its initial position on the matter. Such a proposition establishing medical staff sovereignty is untenable. Ultimate responsibility is not with the medical staff, but with the governing body of the hospital.
Certain policy considerations must be borne in mind. Hospital governing body members have fiduciary duties as directors and under certain circumstances have exposure to personal liability. (See Corp. Code, §§ 309 [corporations, generally], 5231 [nonprofit benefit corporations], 7231 [nonprofit mutual benefit corporations], and 9241 [nonprofit religious corporations].) A hospital itself may be responsible for negligently failing to ensure the competency of its medical staff and the adequacy of medical care rendered to patients at its facility. (Elam v. College Park Hospital (1982) 132 Cal.App.3d 332, 346 [183 Cal.Rptr. 156].) A hospital has a duty to ensure the competence of the medical staff by appropriately overseeing the peer review process. (Id. at pp. 338, 341-342, 347.) Hospital assets are on the line, and the hospital's governing body must remain empowered to render a final medical practice decision which could affect those assets. A hospital's governing body must be permitted to align its authority with its responsibility and to render the final decision in the hospital administrative context.
IV. The Medical Center had a right to appeal the decision of the JRC.
Dr. Hongsathavij accurately observes that the medical staff bylaws only provide that either the member physician or the MEC may request an appellate review of a JRC decision. He thus asserts the Medical Center improperly appealed the matter to its own board. For whatever reason, the medical staff bylaws provide no specific right of the Medical Center to appeal for actions initiated by the governing body. Nonetheless, we find the review sought by the Medical Center in the present case did not constitute a material deviation from the bylaws.
The Medical Center's medical staff bylaws apparently did not envision a situation, as occurred here, where the superior court directed the hospital to
The order under review is affirmed.
Nott, J., and Zebrowski, J., concurred.
Hospitals are required by law to have a medical staff association which oversees physicians who are given staff privileges to admit patients and practice medicine in the hospital. A hospital's medical staff is a separate legal entity, an unincorporated association, which is required to be self-governing and independently responsible from the hospital for its own duties and for policing its member physicians. (Health & Saf. Code, §§ 1250, subd. (a), 32128; Cal. Code Regs., tit. 22, § 70701, subd. (a)(1)(D), (a)(1)(F); Bus. & Prof. Code, § 2282; see Anton v. San Antonio Community Hosp. (1977) 19 Cal.3d 802, 809-810 [140 Cal.Rptr. 442, 567 P.2d 1162].) A medical staff and its MEC operate under bylaws created by the medical staff. (Cal. Code Regs., tit. 22, § 70703, subd. (b).)