Dr. Tomas Rios was upset. He believed that some of his patients at Baylor St. Luke’s Medical Center had received unnecessary medical treatments in intensive care units at the Houston hospital, and one day in September 2015, he fired off three emails to colleagues expressing his frustration.

A month later, Rios was summoned to a meeting with his boss, but the purpose was not to discuss his concerns about patient care. Instead, he got a warning.

Dr. Victor Narcisse, a private-practice physician and member of the hospital’s medical executive committee, said that senior hospital officials had been in touch with him about Rios’ conduct, and they had made clear that they intended to “develop the evidence” to take punitive action against him. Narcisse compared the hospital’s plans for him to “an assassination,” according to a recording of the conversation. A transcript of the discussion was filed with Harris County District Court this week as part of a lawsuit by Rios against St. Luke’s.

“It’s like, forgive me, forgive the analogy, but when you have a conspiracy for an assassination, the No. 1 rule is you’ve got to get the guy that you were going after. And then none of the people who were involved get implicated,” Narcisse said.

“They’ve got to execute you,” he said a moment later. “Because if you stick around, they know that you’re going to, all these concerns that you have, you’re going to bring them to some regulatory person.”

Narcisse, the leader of Rios’ physician group at the time, suggested in the recording that Rios could avoid potentially career-ending discipline from St. Luke’s by resigning from the hospital staff.

But Rios did not resign, and within weeks, just as Narcisse said, Rios was told that a hospital committee had found him in serious violation of patient care standards, the first step toward disciplinary action. Two months later, Rios sued St. Luke’s for retaliation. In an amended complaint filed this week, Rios alleged that hospital personnel made false allegations about the way he practices medicine and sought to punish him after he expressed legitimate concerns.

St. Luke’s has denied in court filings that it retaliated against Rios, noting in one that he “has never been suspended or had his privileges revoked in any fashion.”

In a statement to reporters, Dr. David Berger, the hospital’s senior vice president and chief operating officer, said that the intensive care policies Rios began complaining about in 2015 have led to better outcomes across the hospital since their implementation four years ago.

“Dr. Tomas Rios is not a board-certified intensivist and not an expert in critical care medicine, and has actively opposed the intensivist process,” Berger said in the statement.

Regardless of whether Rios’ complaints about patient care were valid, the recording of a doctor describing the hospital’s plans to punish him raises new questions about the way St. Luke’s responds when its physicians and staff members voice concerns.

ProPublica and the Houston Chronicle reported in May that some St. Luke’s doctors complained internally in 2015 and 2016 about problems that led to poor outcomes in the hospital’s heart transplant program. Hospital leaders said they took steps to improve the program, but some physicians felt that their concerns were ignored.

And in a separate lawsuit filed in Harris County in July, the former administrative director of cardiovascular services at St. Luke’s said he was fired in 2017 “in retaliation for reporting violations of health and safety laws.” St. Luke’s, which has denied wrongdoing in court filings, declined to comment on the case. A hospital spokeswoman said by email, “We value the contributions that each staff member brings to improve patient care.”

Rios’ case also opens a window into St. Luke’s use of peer review, a confidential process intended to assess and discipline doctors accused of negligence or wrongdoing, but one that legal and health care experts say is sometimes manipulated by hospitals in order to punish outspoken physicians.

In a statement this week, a St. Luke’s spokeswoman said the hospital stands by the integrity of its peer-review process. Hospital officials said they couldn’t address the recorded conversation between Rios and Narcisse because they were not a party to it. Narcisse and Rios are not St. Luke’s employees, but rather independent physicians with privileges to practice at the hospital.

Narcisse, however, remains a member of the St. Luke’s medical executive committee, the primary body governing the hospital’s independent medical staff, and has performed other administrative duties. A hospital spokeswoman said Narcisse does not speak on behalf of the executive committee, and Narcisse did not respond to requests for comment.

Katharine Van Tassel, dean of San Francisco Law School and a co-author of law review articles on the subject of physician peer review and due process, said hospitals have broad discretion to discipline doctors for lapses in care. But in some circumstances, Van Tassel said, peer review has become “a tool to silence individuals from speaking out.”

“There appear to be little to no safeguards in place to avoid the improper use of hospital peer review to retaliate against physicians who are bringing up quality-of-care concerns,” she said.

In one such case in 2017, a Houston heart surgeon was awarded $6.4 million in damages after a Harris County jury found that Memorial Hermann Health System abused the peer review process in an effort to defame the surgeon and protect its business interests. The hospital is appealing the verdict.

“Believe it or not, hospital administrators do not always like to hear about problems with poor care,” said Dr. Lawrence Huntoon, the president of the American Health Legal Foundation. “And so, through the process of a sham peer review, they sometimes seek to kill the messenger rather than address the underlying problem.”

There is no doubt that Rios, 37, has been an outspoken physician, and his willingness to lodge complaints has earned him a reputation as a troublemaker in the Texas Medical Center. In 2014, a year before Rios started at St. Luke’s, UTHealth McGovern School of Medicine terminated his fellowship, saying he lacked the “clinical competencies” necessary to function in the program. Rios filed suit in that case as well, alleging that UT doctors acted based on false accusations after he filed a complaint about unsafe physician staffing levels on the night shift at Memorial Hermann hospital.

UTHealth denied his retaliation allegation, and the case was dismissed in 2017 on procedural grounds after going all the way to the Texas Supreme Court. As a result of the canceled fellowship, Rios had to complete a remedial plan with the Texas Medical Board in order to receive his permanent medical license in December 2014.

A month later, he started practicing full time at St. Luke’s, and he soon grew troubled by his experiences there. His concerns centered on a hospital program that deployed a “rapid response” team of critical care nurses to the bedsides of patients whose conditions appeared to be deteriorating. Similar programs have been implemented at hospitals around the country, with the goal of quickly assessing and treating patients before life-threatening events occur.

Rios, whose primary job is serving as the attending physician for hospitalized patients, started voicing concerns about the rapid response nursing team at St. Luke’s, which he said was routinely calling for intensive care doctors rather than consulting him first. As a result, Rios said he believes several of his patients were unnecessarily sent to the ICU, where some received what he considered needlessly aggressive medical treatment.

In his statement to reporters, Berger said the rapid response system has led to improved patient outcomes: “Baylor St. Luke’s experienced a 24 percent hospital-wide reduction in cardiac arrests since the Mobile ICU team was introduced in 2014, as well as a 10 percent improvement in ICU patient survival.”

Rios said in an interview that he doesn’t have a problem with the rapid response concept, but he believes a patient’s primary physician should be involved in the process, since they know the patient best. In one email to colleagues in September 2015, Rios questioned whether there was a financial motive behind the hospital’s policies, which he said made it easier to transfer patients to more expensive hospital beds and led to more costly treatments.

A month after sending that message, Rios was called to the meeting with Narcisse. Richard Law, an attorney for their physician group, Inpatient Consultants of Texas, also attended and said he was there to give Rios legal advice, according to an audio recording made by Rios without the knowledge of Law or Narcisse.

Rios provided ProPublica and the Chronicle with a copy of the the recording. In it, Narcisse is heard telling Rios that he’d had a series of phone calls “with a whole bunch of people who are going to deny that they ever had them with me,” including Dr. Mike Wilson, St. Luke’s chief of staff at the time, and Berger, then the hospital’s chief clinical officer.

Narcisse told Rios that hospital leaders had started compiling records of patient complaints that had been leveled against him — mostly related to his refusal to prescribe intravenous painkillers or other potentially addictive drugs — and that they planned to refer them to what was supposed to be an impartial panel of physicians, the process known as peer review.

Narcisse suggested that it instead would be a “kangaroo court” with a predetermined outcome and that hospital leaders were working “to develop the evidence to prove up the point.” He said the peer review committee would give Rios “a level-four adjudication,” the most severe finding the committee can bring against a doctor.

Both Narcisse and Law advised Rios to consider quitting to avoid punishment, and by the end of the conversation, Rios had agreed to do so. But he changed his mind the next day, he said, after learning that hospitals must report to the National Practitioner Data Bank — a repository of disciplinary actions against physicians — anytime a doctor resigns under the threat of investigation.

Law did not respond to a message seeking comment.

A few weeks later, Rios said he received a call from Wilson, who notified him that a peer review committee had met and reached the very conclusion Narcisse had warned about. The level-four finding indicated that the committee believed that Rios had provided seriously substandard care, putting patients in danger.

Rios did not record the conversation with Wilson, but a lawyer representing Rios at the time, Jim Edwards, confirmed his recollection of the call. Edwards said it was clear to him, since the peer review committee had reached its conclusion without giving Rios an opportunity to respond, that the hospital was not playing by the rules.

Wilson is no longer the chief of staff at St. Luke’s. Attempts to reach him by phone for comment were unsuccessful.

Rios filed his lawsuit two months after the call from Wilson. To date, the hospital has not taken formal disciplinary action against him, such as terminating his privileges, despite having found him in serious violation of patient care standards. He says he has been retaliated against in other ways.

In March, the physician group that employed Rios, Inpatient Consultants of Texas, also known as TeamHealth, suspended him and took him off the schedule at St. Luke’s after saying it had received complaints about him from hospital staff members.

Rios sued the group in April in Harris County District Court, alleging a breach of contract. The group has denied Rios’ allegations and is now countersuing, alleging it was Rios who violated the contract when he started his own practice in order to keep working at St. Luke’s following the suspension.

Meanwhile, Rios says he has continued to face disciplinary threats after expressing concerns about ICU care.

In one recent incident, a St. Luke’s peer review committee delivered another level-four finding against Rios, “a significant deviation from the standard of care,” because he interfered with a patient’s transfer to the ICU in May, according to a letter notifying Rios of the citation. Rios said he opposed the rapid response team’s decision in that instance because the patient and her family had said they did not want her to be reconnected to a ventilator, and because Rios did not believe her condition warranted it.

Rios did not share the patient’s name, but her relatives reached out to a reporter on his behalf. They confirmed that they opposed the decision to move her to ICU and felt their wishes were ignored by other physicians at the hospital. A St. Luke’s spokeswoman said federal patient privacy rules prevent the hospital from commenting on the case.

About a month after that incident, Rios was called into a meeting with Berger, St. Luke’s chief operating officer, and Gay Nord, the hospital’s president since October 2016, as well as Dr. William Granberry, now the chief of staff.

According to a recording of the meeting provided by Rios, Berger told Rios that “the peer review committee was extremely concerned about (his) interference with the process of the rapid response team.” Both Berger and Nord said they were unaware of Rios’ pending lawsuit related to the matter. Granberry told Rios that the rapid response program had led to improved outcomes for patients since 2014, and Berger warned that if Rios continued to get in the way of their work, he would be summarily suspended from the hospital.

Rios pushed back, according to the audio recording, saying that his primary focus has been the best interest of his patients. He cited two additional cases from that month in which the rapid response team called in intensivists, who then moved his patients to critical care units without consulting him. Those patients, Rios told the executives, “suffered untoward events.”

“What I can tell is that I will continue to advocate for my patients,” Rios said, according to the recording. “I don’t play politics. My No. 1 priority has always been my patients and will continue to always be my patients, above politics, above money, above anything else. If I feel that rapid response or critical care or whomever is jeopardizing my patient care, then I will act accordingly.”

Berger responded: “And the hospital will act accordingly.”

Rios’ lawsuit is scheduled for trial in December.