Enforcing Neutral Medical-Clearance Policies as a Legitimate Non-Discriminatory Basis: Sixth Circuit Affirms Summary Judgment and Highlights Proof Requirements for Hostile Environment and Retaliation

Case: Ahmed Elzein v. Ascension Genesys Hospital, No. 24-1917 (6th Cir. Oct. 22, 2025) (not recommended for publication)

Panel: Readler, Murphy, and Bloomekatz, JJ. (opinion by Bloomekatz, J.)

Introduction

This unpublished Sixth Circuit decision addresses the intersection of hospital workforce policies, residency training agreements, and federal anti-discrimination statutes. Dr. Ahmed Elzein, a first-year internal medicine resident at Ascension Genesys Hospital, experienced a mental-health-related hospitalization after colleagues observed concerning behavior. Upon discharge, he was subject to a Resident Training Agreement requiring medical clearance by either his private physician or the hospital’s employee health department before returning to duty if an illness caused an absence longer than two days. He did not complete that clearance process despite repeated reminders. The hospital ultimately opted not to renew his one-year residency agreement.

Dr. Elzein sued under the Americans with Disabilities Act (ADA) and Title VII of the Civil Rights Act, alleging disability discrimination; race, national origin, and religious harassment; and retaliation. He also asserted a state-law false imprisonment claim, contending he was forcibly taken to the emergency department. The district court granted summary judgment to the hospital on the federal claims and declined supplemental jurisdiction over the state claim. The Sixth Circuit affirmed across the board.

While designated “not for publication” and thus non-precedential within the circuit, the opinion is instructive on three recurring themes:

Strict, evenhanded enforcement of return-to-work medical-clearance policies can constitute a legitimate, non-discriminatory reason for nonrenewal or termination absent concrete evidence of pretext.
Hostile work environment claims require proof not only of severe or pervasive harassment but also that the employer knew or should have known and failed to take prompt, appropriate remedial action. Failure to develop this element can be dispositive.
Retaliation claims must include some evidence of causal connection between protected activity and the adverse action; reciting elements and pivoting to pretext without causal evidence will not suffice.

Summary of the Opinion

The Sixth Circuit reviewed de novo the grant of summary judgment. On the ADA discrimination claim, the court assumed arguendo that a prima facie case existed but held that Dr. Elzein failed at the pretext stage. Ascension’s stated reason for nonrenewal—his failure to obtain proper return-to-work medical clearance after an absence exceeding two days—had a factual basis and actually motivated the decision. The record showed he: (1) provided an inaccurate reason (“cold-like symptoms”) to the health department; (2) tendered a discharge note signed by a social worker, not his treating physician; and (3) never obtained clearance from either his treating physician or the hospital’s occupational health physician despite multiple reminders and a final warning.

On the Title VII hostile work environment claims (race/national origin; religion), the court did not reach whether the alleged conduct was severe or pervasive. It affirmed on the fifth element—employer notice and failure to act—because the record reflected the hospital investigated the reported harassment and the plaintiff failed to contest that element in the district court or on appeal.

On the Title VII retaliation claim, the court held that the plaintiff failed to make out a prima facie case due to lack of any evidence of causation between his protected complaint and the nonrenewal. Even if a prima facie case were assumed, the claim would fail for the same pretext reasons as the ADA claim.

Finally, with all federal claims resolved, the court found no abuse of discretion in the district court’s decision to decline supplemental jurisdiction over the state-law false imprisonment claim under 28 U.S.C. § 1367(c)(3).

Analysis

Precedents Cited and How They Shaped the Outcome

McDonnell Douglas Corp. v. Green, 411 U.S. 792 (1973): The court applied the familiar burden-shifting framework for circumstantial evidence claims under both the ADA and Title VII. After assuming a prima facie case, it focused on the employer’s legitimate reason and the plaintiff’s failure to show pretext.
Hrdlicka v. General Motors, LLC, 63 F.4th 555 (6th Cir. 2023): Provided the ADA prima facie elements, including disability status, qualification, adverse action, employer knowledge, and replacement/position remaining open. The court bypassed debate on this step and moved to pretext, consistent with circuit practice.
Chen v. Dow Chemical Co., 580 F.3d 394 (6th Cir. 2009): Framed the common pathways to prove pretext (no basis in fact; did not actually motivate; insufficient to motivate). The court concluded the hospital’s rationale had a firm factual basis and actually motivated the nonrenewal.
Williams v. AT&T Mobility Services LLC, 847 F.3d 384 (6th Cir. 2017), and Miles v. Southern Central Human Resource Agency, Inc., 946 F.3d 883 (6th Cir. 2020): Reinforced that there is no single formula to prove pretext; plaintiffs must still produce evidence creating a reasonable inference of discrimination. The court found none here.
Williams v. CSX Transportation Co., 643 F.3d 502 (6th Cir. 2011), and Hafford v. Seidner, 183 F.3d 506 (6th Cir. 1999): Established the elements of racial/national origin and religious hostile environment claims, respectively, including the essential fifth element that the employer knew or should have known of the harassment and failed to act. This element was dispositive.
Hawkins v. Anheuser-Busch, Inc., 517 F.3d 321 (6th Cir. 2008): Emphasized employers’ duty to take prompt and appropriate corrective action when on notice of harassment. The hospital’s investigation met this standard on the undisputed record.
Redlin v. Grosse Pointe Public School System, 921 F.3d 599 (6th Cir. 2019), and Wyatt v. Nissan North America, Inc., 999 F.3d 400 (6th Cir. 2021): Provided the Title VII retaliation framework and elements, including the causal connection requirement. The court found that the plaintiff offered no evidence to satisfy causation.
Upshaw v. Ford Motor Co., 576 F.3d 576 (6th Cir. 2009), and A.C. ex rel. J.C. v. Shelby County Board of Education, 711 F.3d 687 (6th Cir. 2013): Clarified that while causation at the prima facie stage is a “minimal” burden, some evidence must permit a reasonable inference of a causal link. The plaintiff provided none.
Musson Theatrical, Inc. v. Federal Express Corp., 89 F.3d 1244 (6th Cir. 1996), and 28 U.S.C. § 1367(c)(3): Support the frequent practice of declining supplemental jurisdiction after dismissal of all federal claims. Affirmed here as a proper exercise of discretion.

Legal Reasoning

1. ADA Disability Discrimination (Nonrenewal)

Applying McDonnell Douglas, the panel moved directly to the employer’s reason and pretext. Ascension’s proffered rationale was straightforward: Dr. Elzein did not meet the Resident Training Agreement’s condition precedent for returning to work following an illness-based absence exceeding two days—namely, medical clearance via (a) his private/treating physician or (b) the hospital’s employee health department. Although an employee health physician initially cleared him after a negative COVID-19 test, that clearance was revoked when it emerged that he had provided an inaccurate reason for his absence (“cold-like symptoms”) and lacked appropriate clinician signoff (the Havenwyck note was signed by a social worker). Repeated reminders over several months culminated in a written notice that nonrenewal would follow absent proper clearance within 14 days; none was forthcoming.

The court held that these undisputed facts precluded a finding of pretext. There was a clear factual basis for the decision, it actually motivated the nonrenewal, and nothing in the record suggested the stated reason was insufficient to motivate the action. The plaintiff’s contention that he was held to “more stringent requirements” failed because the record established he had a choice: obtain clearance either from his treating physician or from the hospital’s occupational health physician, Dr. Vosburgh. He declined both. Significantly, he did not argue that compliance would have been futile due to discriminatory animus.

2. Title VII Hostile Work Environment (Race/National Origin; Religion)

The court identified the contested allegations, including a comment telling the plaintiff to “go back to where [he] came from” while he was praying, and another resident’s statement using a racial slur. Without deciding whether these remarks, considered together, were sufficiently severe or pervasive, the panel affirmed on the fifth element: employer notice coupled with failure to take prompt and appropriate corrective action.

The district court found that the hospital promptly investigated the reported harassment, and the plaintiff failed to contest that element below, which the district court treated as a concession. On appeal, the plaintiff again did not brief the “notice and failure to act” element, focusing solely on severity/pervasiveness. The Sixth Circuit affirmed on that ground, emphasizing that even strong evidence of harassment cannot substitute for proof that the employer knew or should have known and failed to act.

3. Title VII Retaliation

The court again applied McDonnell Douglas. It was undisputed that the plaintiff engaged in protected activity by reporting harassment, the employer knew of the report, and nonrenewal was an adverse action. But the plaintiff failed to offer evidence supporting the fourth element—a causal connection between his protected activity and the nonrenewal. At the prima facie stage, causation is a minimal burden, yet it is not automatically satisfied by assertion alone. The plaintiff did not point to temporal proximity, comparator evidence, statements, or any pattern suggesting retaliatory motive.

Even if a prima facie case were assumed, the claim would fail at pretext for the reasons stated under the ADA: the employer’s reason was well-documented and undisputed, and no evidence suggested retaliation was the real motivation.

4. State-Law False Imprisonment and Supplemental Jurisdiction

The plaintiff alleged he was forcibly escorted to the emergency department on the day of the incident. The hospital’s witnesses stated he ultimately agreed to go after consultation with a psychologist and his mentor. The district court declined supplemental jurisdiction over this purely state-law claim after disposing of all federal claims. The Sixth Circuit affirmed that decision as a standard exercise of discretion under 28 U.S.C. § 1367(c)(3), noting the plaintiff offered no reason to retain the state claim in federal court once the federal claims were dismissed.

Impact and Practical Significance

A. Employment and Residency Programs

Employers, including graduate medical education programs, may enforce neutral, written return-to-work medical-clearance policies. When absences exceed a stated duration, requiring clearance from a treating physician or occupational health is a legitimate business requirement—especially in patient-facing roles.
Where the employee’s noncompliance with such policies is undisputed and repeatedly documented, plaintiffs face an uphill battle to show pretext under the ADA or to establish retaliatory causation under Title VII.
Nonrenewal decisions in time-limited training programs are treated as adverse employment actions; employers should document neutral reasons for nonrenewal as carefully as terminations.

B. Hostile Environment Litigation

Even if evidence could support a finding of severe or pervasive harassment, plaintiffs must prove the employer knew or should have known and failed to take prompt and appropriate corrective action. Evidence of a prompt investigation can defeat this element.
Failure to develop the “notice/failure-to-act” element in briefing can be dispositive. This decision underscores the importance of fully addressing each element on summary judgment and on appeal.

C. Retaliation Claims

“Minimal” causation does not mean “no” causation. Plaintiffs should marshal some evidence of linkage—temporal proximity, suspicious timing, pattern of antagonism, shifting explanations, or statements—before proceeding to pretext.
When the employer has a time-stamped, consistent reason that predates or is independent of the protected activity (here, noncompliance with clearance requirements lasting months), causation is particularly difficult to establish.

D. Hospital Compliance and Risk Management

Document both the policy architecture (Resident Training Agreement language) and each enforcement step (initial clearance, revocation basis, reminders, leave placement, final warning, nonrenewal memo). Such documentation carries heavy weight at summary judgment.
When investigating harassment, promptly log complaints, interviews, and outcomes; that record can satisfy the “prompt and appropriate corrective action” requirement and defeat vicarious liability in co-worker harassment cases.
Be clear that employees may choose among acceptable clearance avenues (treating physician vs. occupational health). Offering a choice reduces exposure to claims that the employer imposed “more stringent” or targeted requirements.

Complex Concepts Simplified

McDonnell Douglas burden-shifting: A three-step method for cases relying on circumstantial evidence. Step 1: The employee makes a “prima facie” showing of discrimination. Step 2: The employer articulates a legitimate, non-discriminatory (or non-retaliatory) reason. Step 3: The employee proves that reason is pretext—a mask for unlawful motive.
Pretext (Chen v. Dow): The employee may show the employer’s reason (a) had no factual basis, (b) did not actually motivate the decision, or (c) was insufficient to motivate the decision. Documentary consistency and undisputed policy violations usually defeat pretext.
Hostile work environment: Requires proof that harassment was severe or pervasive enough to alter employment conditions, plus proof that the employer knew or should have known and failed to act (for co-worker harassment). A prompt investigation often suffices as appropriate remedial action.
Retaliation causation: Even at the low prima facie threshold, some evidence must connect protected activity to the adverse action. Mere assertion or element-recitation is insufficient.
Supplemental jurisdiction: Federal courts may—but need not—hear state-law claims related to federal claims. Once all federal claims are dismissed, courts commonly decline the state claims so they may proceed, if at all, in state court.
Adverse employment action via nonrenewal: In fixed-term positions like residencies, nonrenewal can qualify as an adverse action under the ADA and Title VII, but employers can still prevail by showing legitimate, non-discriminatory reasons and no pretext.

Conclusion

The Sixth Circuit’s decision in Elzein reinforces several practical litigation and compliance lessons. First, an employer’s consistent and evenhanded enforcement of a return-to-work medical-clearance policy—especially when paired with undisputed employee noncompliance—constitutes a strong, legitimate, non-discriminatory basis for nonrenewal or termination in ADA and Title VII cases. Second, hostile environment claims fail without evidence that the employer knew or should have known of the harassment and then failed to act; plaintiffs must fully develop this element, not merely argue severity/pervasiveness. Third, retaliation claims require at least some evidence of causation at the prima facie stage; recitation of elements and pivoting straight to pretext will not suffice when the employer’s legitimate reason is well-documented.

Although unpublished and non-precedential, the opinion provides a clear roadmap for employers in healthcare and other safety-sensitive sectors: draft clear clearance requirements; document enforcement; investigate reported harassment promptly; and communicate options for compliance. For employees and their counsel, it underscores the need to present concrete evidence on each element—especially employer knowledge/failure to act in harassment claims and causation in retaliation claims—and to confront the employer’s stated reason with specific, record-based pretext evidence.