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Slaughter v. Des Moines University College of Osteopathic Medicine

Supreme Court of Iowa

April 5, 2019


          Appeal from the Iowa District Court for Polk County, Jeffrey D. Farrell, Judge.

         Plaintiff appeals summary judgment dismissing claim that medical school failed to accommodate her mental disability and evidentiary ruling declining to impute confidential knowledge of psychotherapist to the school. AFFIRMED.

          John P. Roehrick of Roehrick Law Firm, P.C., Des Moines, and Bonnie J. Heggen, Ankeny, for appellant.

          Kelly R. Baier of Bradley & Riley PC, Cedar Rapids, and Melissa A. Carrington of Bradley & Riley PC, Iowa City, for appellee.


         In this appeal, we review an evidentiary ruling and summary judgment ending a lawsuit by a student who failed to meet academic requirements in medical school and sued the school for failing to accommodate her mental disability. The student was treated for depression by a staff psychotherapist during the school year but did not give consent to allow the psychotherapist to discuss her depression with the faculty. Nor did the student inform the academic decision-makers of her depression until mid-December, after she had failed a required class and performed poorly on other classes her first semester. Several accommodations were provided or offered, but she failed another required class the second semester and again performed badly on other courses. The medical school expelled her based on her failing grades and lack of academic promise.

         The student filed a complaint against the medical school with the Iowa Civil Rights Commission and then filed this district court action alleging the school failed to accommodate her mental disability. She filed an evidentiary motion to impute her psychotherapist's knowledge of her depression to the school's academic decision-makers. The district court applied statutory confidentiality requirements for mental health information to deny her motion, finding the student had not waived the privilege, and granted the school summary judgment on her failure-to-accommodate claim. We retained her appeal.

         For the reasons explained below, we hold the district court correctly declined to impute the psychotherapist's knowledge to the medical school's academic decision-makers. We also conclude based on the undisputed facts that the failure-to-accommodate claim failed as a matter of law. The student could not show the medical school denied any reasonable accommodation she requested or that any reasonable accommodation existed that would have allowed her to meet the school's academic standards. Accordingly, we affirm the district court's evidentiary ruling and summary judgment.

         I. Background Facts and Proceedings.

         In August 2014, Natalie Slaughter started her first year of medical school at Des Moines University College of Osteopathic Medicine (DMU). Almost immediately, she struggled academically. Slaughter soon came to the attention of the Academic Progress Committee (APC), a faculty committee that monitors student academic performance and conducts academic disciplinary hearings.

         Dr. Donald Matz, chair of the APC, repeatedly warned Slaughter regarding her subpar academic performance, sending her letters on August 25, September 9 and 19, and October 10 and 15. Dr. Matz specifically warned Slaughter that she was in jeopardy of failing one or more of her courses. In each letter, Dr. Matz encouraged Slaughter to seek assistance from her course director, faculty advisor, the Center for Academic Success and Enrichment (CASE), and DMU's student counseling center.

         On September 3, Slaughter completed a client intake form at the student counseling center. Slaughter indicated she was seeking help for "high anxiety and trouble falling asleep." During her intake appointment, Slaughter signed a document titled "Client Rights, Responsibilities, and Informed Consent." One of the client rights was "[t]o know that personal information cannot be disclosed to anyone, except for professional consultation or supervision, without your specific, written permission." Slaughter underwent weekly counseling sessions with Dr. Emily Sanders, a staff psychologist employed by DMU, from September 9 until June 2015. During these sessions, Slaughter discussed her history of depression and anxiety and often reported feeling worried and depressed because of her bad performance on tests. Slaughter did not give Dr. Sanders permission to discuss her case with DMU's faculty or administrators.

         Meanwhile, on September 10, Slaughter completed an intake form at CASE indicating she "would like to find a study strategy that works best for [her]." She did not disclose her depression on the intake form. CASE provided Slaughter with time management strategies, electronic study resources, and one-on-one tutoring. Slaughter claims she talked to someone at CASE about the depressive symptoms she was experiencing and how those symptoms affected her academics, though she could not remember the person's name. Slaughter also claims she discussed her depression with a student tutor from CASE.

         On September 20, Slaughter emailed her faculty advisor, Shelley Oren, about her unsuccessful performance on the second biochemistry test. Slaughter and Oren continued to communicate, both in person and by email, throughout the semester. Slaughter did not disclose her depression to Oren.

         On September 26, Dr. Matz met with Slaughter to discuss her poor performance in Gross Anatomy and Clinical Medicine. He gave Slaughter tips for labeling anatomical drawings to help her study for class. During this meeting, Dr. Matz encouraged Slaughter to utilize resources available at CASE.

         At the end of the fall semester, Slaughter failed her biochemistry course and performed badly in Gross Anatomy and Clinical Medicine. On December 16, Slaughter met with the APC to discuss ways to improve her academic performance and to discuss her academic status. During this meeting, Slaughter was asked to describe her study habits. Slaughter indicated she preferred to watch lectures online instead of attending class in person. Slaughter stated she studied six to eight hours per day, but she was an English undergraduate major and was uncomfortable taking multiple-choice tests. Slaughter did not tell the APC that she was experiencing depression. She stated that she was sick before her first biochemistry examination and that she had trouble sleeping the night before tests. During this meeting, Slaughter was told about the Extended Pathways to Success Program, a program that allows students who are struggling with DMU's traditional four-year program to take fewer courses each semester and complete their coursework in five years.

         The following day, Slaughter met with Oren to discuss the APC meeting and the Extended Pathways Program in more detail. During this meeting, Slaughter disclosed for the first time that she was experiencing depression and did not believe she could handle a fifth year of medical school. Slaughter and Oren dispute whether Slaughter had described her symptoms, such as difficulty falling asleep and nervousness, to Oren earlier in the semester. Slaughter declined Oren's request for permission to speak directly with Dr. Matz. Instead, Slaughter promptly that day emailed Dr. Matz disclosing her depression, stating,

[A]t the beginning of the semester I had some personal difficulties that I didn't entirely feel comfortable sharing in such a large setting. I have struggled with depression for a very long time, and at the beginning of the semester I had a horrible relapse of sorts. My normally well controlled disorder ended up severely affecting my life in ways it hasn't in many years. I was barely making it through the day without breaking down, and all the emotional energy it took for me to save face at school was so exhausting that by the time I would get home I had difficulty focusing on my coursework. I was extremely demoralized because of doing poorly it just ended up as this vicious cycle. There would be days where I couldn't get anything done and then I would get really behind, then crammed right before the test, do poorly, and then go right back into depression. I started seeing a therapist when I was about half of the way through biochem and as I have been working with her my mood has improved, making it easier for me to focus on school.

         Slaughter also expressed her preference not to enter the Extended Pathways to Success Program:

My fear is that stretching [the program] out in a longer period of time would be extremely detrimental for my mental health, I know I can handle this type of environment for another 3 semesters, but adding on a whole year would be devastating and I fear greatly that I would end up being severely depressed. I really want you to know that my resistance of going to the 5 year plan isn't out of stubbornness or pride, but out of self-preservation. I truly believe that this option would not be beneficial to me at all and instead would be harmful, because my issue is finding the tools that work best for me and getting my depression under control, which would be hindered.

         Dr. Matz responded to Slaughter's email within fifteen minutes, stating that he appreciated her sharing that information and that the APC "want[ed her] to succeed." Dr. Matz did not share Slaughter's email or any information about Slaughter's depression with the APC.

         On December 18, Dr. Matz wrote to Slaughter to inform her that the APC had decided to place her on academic probation. As a standard term of that probation, Slaughter was required to withdraw from her elective courses for the next semester so she could focus on her core classes. Dr. Matz again encouraged Slaughter to use the student counseling center and CASE, attend all classes, and enter the Extended Pathways to Success Program.

         On January 7, 2015, Slaughter met with Dr. Craig Canby, the Associate Dean for Academic Curriculum and Medical Programs, to discuss DMU's policies with regard to academic probation and academic dismissal and to develop an action plan for the upcoming semester. The action plan consisted of study strategies designed to help Slaughter learn course material. Dr. Canby was unaware of Slaughter's depression. Dr. Canby later stated that had he known, "[i]t would have changed the nature of [the] conversation," and he likely would have advised her to seek an accommodation or to take a medical leave of absence.

         Also in early January, Oren contacted Slaughter to see whether she would like to talk more about the Extended Pathways Program. Slaughter responded that she was "doing fine" and was "still planning on sticking with the 4 year plan." Oren met with Slaughter one-on-one several times during the second semester to discuss her progress, including meetings on January 7 and 30 and April 10. Oren told Slaughter that she could contact her at any time with questions.

         Slaughter continued to struggle academically throughout the second semester, although she ultimately passed the biochemistry course that she had failed first semester. Slaughter met with Dr. Matz in February to discuss her poor performance in her required physiology course. Dr. Matz explained the consequences of failing two courses in the first year, including possible dismissal from DMU.

         Slaughter failed physiology and performed poorly in other second semester courses. She ended the second semester with a GPA of 1.88, lower than her first semester GPA of 2.53. Under DMU policy, Slaughter was required to appear before the APC for a dismissal hearing for failing two of her required first-year courses. Slaughter attended the dismissal hearing with the APC on June 30. At Slaughter's request, Dr. Sanders appeared as her advisor. Slaughter discussed her academic performance as well as her use of the DMU resources. She expressed her preference to retake physiology over the summer instead of entering the Extended Pathways Program. Slaughter told the APC that she believed most of her struggles were due to her depression. Regardless, she argued there was an upward trend with her individual physiology test grades.

         On July 7, Slaughter was notified that the APC had voted to dismiss her from DMU due to her failing two required first-year courses and her lack of academic professional promise. Slaughter appealed the APC decision. On appeal, DMU concluded the APC complied with DMU's policies and due process and affirmed Slaughter's dismissal.

         Slaughter filed a complaint with the Iowa Civil Rights Commission, alleging disability discrimination in violation of the Iowa Civil Rights Act (ICRA). After obtaining a right-to-sue letter, she filed this three-count lawsuit under the ICRA against DMU, alleging discrimination, failure to accommodate, and retaliation based on her mental disability.

         After conducting discovery, DMU moved for summary judgment on all counts. DMU's motion stated, "The undisputed material facts demonstrate that DMU reasonably accommodated Slaughter throughout her enrollment at DMU. Accordingly, Slaughter cannot prove her failure to accommodate claim." DMU noted in its statement of undisputed facts,

The sole accommodations that Slaughter claims she proposed to DMU, but did not receive, are 1) the ability to watch classes online, in lieu of attending them in person, and 2) the ability to take electives while on academic probation.

         DMU supported its motion with sworn testimony (deposition excerpts and affidavits). Slaughter resisted and filed a cross-motion for partial summary judgment on her accommodation claim. She denied that the accommodations DMU identified were the sole accommodations she sought, but she did not identify what other accommodations she requested. In DMU's reply to Slaughter's resistance, it noted, "Slaughter has pointed to no evidence that she requested a reasonable accommodation that would have enabled her to meet the essential eligibility requirement of passing her required first-year courses." DMU continued,

Slaughter has pointed to no evidence that she could have been reasonably accommodated, but for DMU's alleged lack of good faith . . . . Instead, Slaughter states that "we will never know" whether she could have performed with reasonable accommodations. Such speculation is not sufficient to survive summary judgment.

         Slaughter also filed a "motion to determine admissibility [of evidence, ]" which sought a ruling that imputed Dr. Sanders's knowledge of Slaughter's depression to DM U.Slaughter argued that because Dr. Sanders is employed by DMU, her knowledge of Slaughter's depression should be imputed to the University as of September 2014 when their counseling sessions began-about three months before Slaughter first disclosed her depression to the academic decision-makers. DMU resisted.

         The district court determined that the psychotherapist-patient privilege applied to the communications between Slaughter and Dr. Sanders and that Slaughter had not waived the privilege. The district court concluded, "To the extent Dr. Sanders has knowledge of [Slaughter's] mental health condition pursuant to her role as a treatment provider, that knowledge cannot be imputed to DMU in its role as an academic institution." The district court also noted provisions in Iowa Code chapter 228 (2014) mandated confidentiality of mental health information. For those reasons, the district court denied Slaughter's evidentiary motion.

         At the hearing on the motions, Slaughter abandoned her discrimination claim (count I) and retaliation claim (count III). The district court granted summary judgment in favor of DMU dismissing those claims, and Slaughter does not appeal those rulings. With regard to Slaughter's failure-to-accommodate claim (count II), the district court concluded that DMU became aware of Slaughter's mental disability on December 17, 2014, when she informed Oren and Dr. Matz of her depression. The district court rejected Slaughter's claim that DMU failed to engage in good faith in an interactive process to accommodate her depression.

From the fall of 2014 until the time she was dismissed in the spring of 2015, DMU officials consistently communicated with plaintiff and sought methods to help her improve her academic performance. There was no breakdown in communications. Even viewed in the light most favorable to plaintiff, a reasonable fact finder could not find that DMU failed to act in good faith when engaging in an interactive process to accommodate plaintiff and assist her in satisfying DMU's academic standards despite her depression.

         The court also rejected Slaughter's argument that a reasonable accommodation "would have been discovered but for DMU's bad faith." The district court noted Slaughter "offers no evidence that DMU denied any reasonable accommodation she suggested" and that she explicitly conceded "there is no way of knowing whether she could have been successful in meeting DMU's academic standards had she been accommodated differently." The district court entered summary judgment dismissing count II, stating,

On this record, plaintiff has not suggested any accommodations which would have enabled her to pass her classes. Even viewed in the light most favorable to plaintiff, no reasonable factfinder could find that but for DMU's bad faith, plaintiff could have satisfied DMU's academic standards with a reasonable accommodation.

Slaughter appealed, and we retained her appeal.

         II. Standard of Review.

         We review rulings on the admissibility of allegedly privileged communications for abuse of discretion. State v. Anderson, 636 N.W.2d 26, 30 (Iowa 2001). We review rulings interpreting a statutory privilege for correction of errors at law. Id.; Fagen v. Grand View Univ., 861 N.W.2d 825, 829 (Iowa 2015).

         "We review summary judgment rulings for correction of errors at law." Deeds v. City of Marion, 914 N.W.2d 330, 339 (Iowa 2018). "Summary judgment is proper when the movant establishes there is no genuine issue of material fact and it is entitled to judgment as a matter of law." Id. (quoting Goodpaster v. Schwan's Home Serv., Inc., 849 N.W.2d 1, 6 (Iowa 2014)). "We view the record in the light most favorable to the nonmoving party." Id.

         III. Analysis.

         We first address whether the district court erred in denying Slaughter's motion for an evidentiary ruling imputing her psychotherapist's knowledge of her mental disability to DMU's academic decision-makers. We conclude the district court correctly applied the statutory confidentiality requirements for mental health treatment in Iowa Code chapter 228 to deny Slaughter's motion. We next address whether the district court erred in granting DMU's motion for summary judgment on Slaughter's failure-to-accommodate claim. We conclude the district court correctly granted summary judgment for DMU based on the undisputed facts. Slaughter is unable to identify any reasonable accommodation she requested that DMU refused. She cannot show that a reasonable accommodation existed that would have allowed her to meet DMU's academic standards.

         A. Slaughter's Motion to Impute Her Psychotherapist's Confidential Knowledge to DMU.

         It is undisputed that Dr. Sanders was employed by DMU as a staff psychologist in DMU's student counseling center when she treated Slaughter for depression beginning in September 2014. Slaughter argues that Dr. Sanders's knowledge of her depression learned while treating her must be imputed to DMU under principles of agency law.[1] See John Q. Hammons Hotels, Inc. v. Acorn Window Sys., Inc., 394 F.3d 607, 611 (8th Cir. 2005) ("It has long been held in Iowa that where information is imparted to an employee, acting within the scope of his employment, the knowledge of the employee is imputed to the employer under principles of agency law."). The district court rejected that argument, ruling that this general principle of agency law yields to the psychotherapist-patient privilege and statutory confidentiality for mental health treatment notwithstanding Dr. Sanders's status as an employee of DMU. This is a question of first impression in Iowa.[2]

         We begin by addressing the scope of the statutory restrictions on sharing mental health treatment information. We then address whether the statutory nondisclosure requirements trump the general principle of agency law imputing an employee's knowledge to the employer.

         1. Statutory prohibitions on disclosure of mental health information.

         The district court relied on two Iowa statutes protecting the privacy of mental health information: Iowa Code sections 622.10 and 228.2. We will address each in turn. Section 622.10 codifies the psychotherapist- patient privilege for evidentiary purposes and provides,

A . . . mental health professional, . . . who obtains information by reason of the person's employment . . . shall not be allowed, in giving testimony, to disclose any confidential communication properly entrusted to the person in the person's professional capacity, and necessary and proper to enable the person to discharge the functions of the person's office according to the usual course of practice or discipline.

Iowa Code § 622.10(1). The term "mental health professional" includes psychologists licensed under Iowa Code chapter 154B. Id. § 622.10(7). The parties agree that Dr. Sanders is a mental health professional within the meaning of section 622.10. "The privilege [of Iowa Code 622.10] extends to medical records that contain information which would be inadmissible at trial as oral testimony from the physician." State v. Eldrenkamp, 541 N.W.2d 877, 881 (Iowa 1995). The testimonial privilege in section 622.10 also limits discovery into physician-patient communications. Chung v. Legacy Corp., 548 N.W.2d 147, 151 (Iowa 1996).

         The purpose of the psychotherapist-patient "privilege is 'to promote free and full communication between a patient and his doctor so that the doctor will have the information necessary to competently diagnose and treat the patient.'" Fagen, 861 N.W.2d at 831-32 (quoting State v. Heemstra, 721 N.W.2d 549, 560-61 (Iowa 2006)). We construe section 622.10 liberally to carry out this purpose. Id. "We have repeatedly emphasized 'the importance of maintaining confidentiality in mental health treatment.'" In re A.M., 856 N.W.2d 365, 377 (Iowa 2014) (quoting State v. Thompson, 836 N.W.2d 470, 483 (Iowa 2013)). Indeed, "[t]he American Psychiatric Association has recognized that confidentiality is essential to effective treatment." Id. "[A] right as valuable as a psychotherapist privilege should not be deemed to be waived by implication except under the clearest of circumstances." Heemstra, 721 N.W.2d at 560.

         The district court ruled that section 622.10 applies to preclude imputing Dr. Sanders's knowledge gained treating Slaughter to DMU. We reach a different conclusion. "The physician-patient rule provided in section 622.10 is an evidentiary rule rather than a substantive right." Roosevelt Hotel Ltd. P'ship v. Sweeney, 394 N.W.2d 353, 355 (Iowa 1986). We have not applied section 622.10 outside of litigation to mandate confidentiality of physician-patient communications. See id. (noting "the medical profession's self-imposed standard of conduct, originating in the Hippocratic oath, that a physician not disclose a patient's confidences without the patient's consent, except as authorized or required by law"). Accordingly, we do not rely on section 622.10 here.

         The district court, however, properly relied on Iowa Code section 228.2, which more broadly restricts disclosure of mental health information.

Except as specifically authorized in [sections not relevant here], a mental health professional, data collector, or employee or agent of a mental health professional, of a data collector, or of or for a mental health facility shall not disclose or permit the disclosure of mental health information.

Iowa Code § 228.2(1). Chapter 228 permits certain limited disclosures. For example, a patient eighteen years or older may consent to the disclosure of mental health information. Id. § 228.3(1). Slaughter, however, did not give Dr. Sanders consent to divulge Slaughter's depression to DMU's academic decision-makers.

         Slaughter instead relies on another exception stating, "Mental health information relating to an individual may be disclosed to other providers of professional services or their employees or agents if and to the extent necessary to facilitate the provision of administrative and professional services to the individual." Id. § 228.5(4). Slaughter argues that section 228.5(4) required Dr. Sanders to disclose Slaughter's name and diagnosis to DMU's accommodation specialists so they could provide Slaughter with services.

         The district court correctly found this disclosure provision to be inapplicable. "Professional services" are defined to "mean[] diagnostic or treatment services for a mental or emotional condition provided by a mental health professional." Id. § 228.1(8). DMU's academic accommodation specialists are not mental health professionals who would diagnose or treat Slaughter's anxiety and depression. "Administrative information" relates to billing information but does not include the patient's diagnosis. Id. § 228.1(1). Section 228.5(4) would not allow Dr. Sanders to disclose Slaughter's depression to DMU's academic decision-makers. In addition, the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates confidentiality of mental health treatment. See generally Pub. L. No. 104-191, 110 Stat. 1936 (codified in scattered sections of 18, 26, 29, and 42 U.S.C.); Harrold-Jones v. Drury, 422 P.3d 568, 570-77 (Alaska 2018) (noting "cultural shift emphasizing medical privacy" and reviewing HIPPA requirements and interplay with state law); In re A.M., 856 N.W.2d at 379-80 (reviewing HIPAA privacy regulations); 45 C.F.R. pts. 160, 164 (2014) (HIPAA privacy regulations).

         The district court correctly concluded that Dr. Sanders was prohibited from divulging Slaughter's mental health information to DMU without a waiver from Slaughter, which she had not provided. Indeed, other courts have recognized a psychotherapist's tort liability for unauthorized disclosure of a patient's confidential information. See, e.g., Gracey v. Eaker, 837 So.2d 348, 353, 357 (Fla. 2002). The statutory protections against disclosure of mental health information do not depend on who pays the therapist's salary. The same confidentiality applies whether the therapist is in private practice or a university employee. A contrary holding would have a chilling effect on the willingness of students to open up to psychotherapists employed by their university.

         2. Exceptions to agency law principles generally imputing an ...

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