In this antitrust conspiracy action, Linda Boczar, M.D., appeals from a judgment notwithstanding the verdict for defendant Manatee Hospitals & Health Systems, Inc.1 We reverse.

Dr. Linda Boczar practiced obstetrics and gynecology ("ob/gyn") in Sarasota, Florida. Defendant-appellee Manatee Hospitals & Health Systems, Inc. ("Manatee" or "the hospital") operated Manatee Memorial Hospital, for profit, in nearby Bradenton, Florida. In 1988, Manatee's chief executive officer, Richard Kaleba, recruited Boczar to join Manatee's obstetrics staff. Kaleba thought Boczar would bring new patients and revenue to Manatee. Boczar applied for staff privileges at Manatee and opened an office in Bradenton.

When Manatee's credentials committee met to decide whether Boczar should join the staff, some incumbent staff obstetricians opposed granting Boczar privileges. The credentials committee recommended against granting Boczar privileges, but the executive committee and board of directors overrode the credentials committee's recommendation. Manatee granted Boczar staff privileges in June 1988.

Shortly into Boczar's tenure at Manatee, problems arose between Boczar and the hospital and its staff. These clashes included differences over Manatee's "call" scheduling procedures, excessive patient referrals, emergency room ("ER") staff members' diagnostic judgments, and anesthesia services.

Beginning in August, 1988, the Manatee executive committee began a series of "peer review" proceedings against Boczar for alleged infractions of professional standards and reported these proceedings to Florida's medical licensing agency, the Department of Professional Review (DPR).2 These proceedings ended in suspensions of Boczar's staff privileges. In December 1988, Boczar resigned. Manatee reported to DPR that Boczar had resigned due to a "quality of care issue." DPR sent the report to all Florida hospitals and began its own investigation.

Boczar sued Manatee, four named physicians,3 and "unnamed conspirators." Boczar's complaint included a claim that defendants conspired to restrain trade in violation of the Sherman Act, 15 U.S.C. § 1 et seq. Her Sherman Act claim went to trial. The jury found none of the four named physicians liable, but did find the hospital liable. The jury awarded Boczar $150,000 in damages, to be trebled under the anti-trust laws. Manatee moved for JNOV.

The district court granted JNOV for Manatee. In the light of the jury verdict in favor of the four physician defendants, the district court thought that Boczar had failed to show that the hospital conspired with anyone.4 The district court also granted Manatee's motion for a new trial in case JNOV was reversed.

Boczar brought this appeal. She contends she is entitled to reinstatement of the jury's verdict. We agree.

This appeal presents no significant dispute about the law. This case is about evidence and the facts the evidence can support. We review judgments n.o.v. de novo. We must view the evidence in the light most favorable to Dr. Boczar; and if the evidence substantially supports the jury's verdict, we must reverse the JNOV. Watts v. Great Atlantic and Pacific Tea Co., 842 F.2d 307, 309-311 (11th Cir.1988).5

a. Evidence of Conspiracy to Restrain Trade

Dr. Boczar presented sufficient evidence that the hospital conspired with others to restrain her practice of medicine.6 We have said that plaintiff physicians may properly rely on circumstantial evidence--"evidence of irrational conduct that would create an inference of conspiracy"--to prove a Sherman Act conspiracy claim. See Bolt v. Halifax Hosp. Med. Ctr., 891 F.2d 810, 819 (11th Cir.1990) (holding that hospitals may be found liable for conspiring with members of medical staff, and that evidence of pretextual, sham peer review proceedings presented jury question whether hospitals conspired with peer review committees in violation of Sherman Act).

Viewed in the light most favorable to her, Dr. Boczar's evidence: (1) showed that the "conspiracy alleged is ... one that would inure to the defendants' economic benefit;" (2) "tend[ed] to exclude the possibility that the alleged co-conspirators acted independently and in a manner consistent with rational business objectives;" and, (3) showed the conspiracy had an "anti-competitive effect." See id. at 819-20. The jury could have inferred the existence of an unlawful combination or conspiracy between the hospital and members of its staff or peer review committees. See id.; cf. Todorov v. DCH Healthcare Auth., 921 F.2d 1438, 1457 (11th Cir.1991) (affirming summary judgment for defendants where physician failed to disprove that hospital acted unilaterally to promote its independent, competitive interest).

(1) Evidence of Economic Benefit

Like the defendant in Bolt, cf. 891 F.2d at 820, Manatee Hospital argues that it recruited Boczar to bring in patients and revenue and so had no economic reason to take away her privileges. But we think that a jury could reasonably find from the evidence that, although the hospital had recruited Boczar for rational business reasons, the hospital later came to view Dr. Boczar's practice, through no real fault of hers, as inconsistent with its interests.

When Dr. Boczar joined its staff, Manatee Hospital had suffered defections by members of its ob/gyn staff and feared still more ob/gyn departures to a competing hospital. More than half of the remaining ob/gyn specialists, Dr. Boczar's most direct competitors,7 openly opposed granting Dr. Boczar and her group privileges on the stated basis of the commuting distance between Sarasota and Bradenton and their accounts of Dr. Boczar's interpersonal disputes at her Sarasota hospital. There was evidence that Dr. Boczar's approach to her practice was not typical of Manatee ob/gyn physicians. For example, she performed significantly fewer C-section deliveries and charged a flat rate for all deliveries, Caesarean or natural. Boczar's prices were significantly lower than those of competing Manatee physicians. Given these special facts about this hospital and these doctors, the jury reasonably could infer that the hospital came to think that it would be better to lose Boczar and the revenue she generated than to keep her on staff and risk additional dissatisfaction and defections among her competitors on the Manatee ob/gyn staff.8

Most important, Dr. Boczar brought to the direct attention of Mr. Kaleba, the hospital's chief, a number of serious hospital deficiencies. Boczar detailed and documented her observations in writing. These charged deficiencies included excessive and unnecessary gynecological referrals, allegedly serious misdiagnoses by ER physicians, and sub-standard anesthesia services.9 Because of the sub-standard anesthesia capabilities at Manatee, Dr. Boczar stopped performing deliveries and surgery at Manatee for all except her on-call patients. Dr. Boczar got little response to her criticisms. One month later, Dr. Boczar began to encounter a series of serious allegations about the quality of her own patient care.

The jury could reasonably have thought that Dr. Boczar's illumination of patient care problems increased the risk that the hospital--a for-profit institution--would incur costs and liabilities based on those deficiencies. In these circumstances, the jury could also infer that the hospital and its staff had economic reasons not only to try to remove Boczar, but to discredit her and damage her reputation.10

We conclude that one reasonable view of the evidence supports a finding that the hospital had an economic motive to conspire to restrain Boczar's practice. The jury could believe that the hospital would benefit economically by securing its pre-existing ob/gyn staff and revenues and also by avoiding or delaying costs caused by Dr. Boczar's complaints about patient care.

(2) Evidence Tending to Exclude Possibility of Legitimate Action

The hospital argues that its acts were legitimate peer review actions taken to address Boczar's alleged unavailability or slow response time when she was called to care for patients. Dr. Boczar introduced evidence, however, from which a jury reasonably could believe that the hospital consciously joined with members of its staff, including one or more un-named defendants, either to manufacture or to exaggerate these incidents. Fabricating damaging incidents or purposeful overreacting would be conduct that no reasonable medical practitioner or hospital could believe to be part of legitimate peer review.

The peer review proceeding charging Boczar with abandoning one of "her" patients who had come to the emergency room ultimately resulted in Dr. Boczar's resignation and suspension. One reasonable view of the evidence suggests that the incident was contrived. Jurors might reasonably have thought that the hospital, through its agents and with the cooperation of the staff physicians involved, drafted an affidavit which gives the false impression that Mossman appeared at the emergency room complaining of abdominal pain and asking to be treated by "her physician," Dr. Boczar.11

Dr. Boczar testified that when a member of the emergency room staff called her about Ms. Mossman, Dr. Boczar told the caller that Mossman was no longer her patient and so should see the ob/gyn doctor on call at that time. Dr. Watsky reported the incident to the hospital's executive committee, of which Watsky was a member. The executive committee then brought a meritless patient abandonment charge against Dr. Boczar, summarily suspended her, and reported the Mossman incident to DPR.

Mossman's testimony at trial, plus a second Mossman affidavit detailing the incident, supported Dr. Boczar's version of the facts. Mossman testified at trial that she told emergency room personnel that she had no current gynecologist. She also testified that she did not call Dr. Boczar before going to the emergency room, nor expected to be treated by Dr. Boczar for her illness, "because she wasn't my doctor." Mossman said that she had expected to be treated by the emergency room physician. In addition, Mossman testified that the hospital later called her and had her come to the hospital and sign the misleading affidavit without telling her of its contents or implications. A jury might reasonably have determined that the hospital and Dr. Watsky acted in concert in this incident and that the peer review proceeding was pretextual. Thus, the jury may have properly inferred an unlawful conspiracy.12

(3) Anti-Competitive Effect

That the hospital's actions had the effect of restraining trade is also supported by sufficient evidence. By causing Dr. Boczar's departure, Manatee effectively ended Dr. Boczar's ability to compete and to practice in Bradenton and burdened her ability to compete generally.

b. Conclusion

For the above reasons, we conclude that there was evidence from which the jury could reasonably infer that the hospital conspired with members of its medical staff and peer review committees, including un-named co-conspirators, to restrain trade in violation of the Sherman Act. It was error to grant the motion for JNOV.

Our review of dispositions of motions for a new trial is "rigorous if the motion is granted rather than denied ... and if the basis for the motion was ... the weight of the evidence." Watts, 842 F.2d at 310-311. In this case, "the trial involved simple issues and highly disputed facts, and ... lacked 'pernicious occurrences' such as prejudicial comments by counsel or introduction of possibly inflammatory evidence." Id. And our review of the record convinces us that the jury verdict was not against the "great weight" of the evidence. See id. Therefore, the conditional grant of a new trial was an abuse of discretion; and we must reverse the grant of a new trial and reinstate the verdict. Id.III. Conclusion

The orders of the district court granting judgment notwithstanding the verdict and conditionally granting the motion for a new trial are VACATED, and the case is REMANDED with instructions to reinstate the jury verdict and for further proceedings consistent with this opinion.

VACATED and REMANDED.