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A Failure to Protect the Public

Originally published in Forum Magazine

Originally published in Volume 21, Number 1 of the Federation Forum Magazine.

It was one of those heart wrenching, wake-you-up-in-the-middle-of-the-night stories that haunted me long after it vanished from newspaper headlines.

Jessica Santillan was a 17-year old girl from Mexico whose family reportedly paid a smuggler to bring her to the United States for a life-saving heart and lung transplant. The young woman died after organs with the wrong blood type were implanted by doctors at Duke University Medical Center. I kept wondering how something like that could happen at a prestigious hospital with some of the most highly skilled physicians in the country. It was also a hospital that trains doctors.

Unfortunately, the tragedy was not an isolated incident. A source at a Tennessee hospital told about a doctor who had mental problems and allegedly drugged his wife and child and threatened to do the same to my source. The physician had come from Texas before landing at the Tennessee hospital and apparently had gotten into trouble there. No one at the Tennessee hospital knew he was hiding a troubled past when they hired him. When they checked his background, nothing turned up in the National Practitioner Databank. After Tennessee officials learned of the doctor’s alleged mental instability and his reported drugging of family members, one would think they would report him to the databank so that his past will be documented. It was never reported.

Dr. Pamela Johnson arrived as a resident at Duke in 1989. She joined the faculty four years later and had a promising career, but in 1997, the head of OB/GYN for Duke told Johnson that she would have to leave if she didn’t improve her surgical skills. She had a high complication rate, he told her, and he asked her to stop doing surgeries. At least three patients had filed claims for malpractice including a woman who said Dr. Johnson nipped her intestine during a tubal ligation. That alleged slip of the scalpel put the patient in the hospital for ten days and resulted in a colostomy. The case was settled for an undisclosed amount.

There was also pressure from Duke’s Risk Management office to fire Dr. Johnson to avoid paying a higher malpractice premium for the department. Nevertheless Duke kept her on until 2000 when they terminated her privilege, but instead of reporting Dr. Johnson to the databank, Duke gave her letters of recommendation. Those letters and the medical center’s failure to report her to the databank enabled Dr. Johnson to land a job at a Virginia hospital for five months, and then move on to a New Mexico hospital. It wasn’t until the death of a patient at that New Mexico hospital that hospital administrators launched an internal investigation and learned of her troubles at Duke. Dr. Johnson resigned from the New Mexico hospital before the investigation was complete.

Eventually, the New Mexico Medical Board suspended her license when they realized she had lied on her license application about being fired from Duke. Ultimately, though, it didn’t matter. The New Mexico Board forgot to report it to the databank. She moved to Michigan and got a license to practice. She now lives near Houston and is waiting approval for a license to practice in Texas.

Officials in the tiny Arkansas town of Stuttgart, about an hour from Little Rock, knew about Dr. Jeffrey Levitt’s troubled past in Maryland that included drug use and sex with patients. The medical board in that state had suspended his license for three years and reported him to the databank, but Stuttgart, which was losing its only OB/GYN to retirement, was so desperate for a replacement that they overlooked Dr. Levitt’s history. Despite warnings from the retiring physician for hospital administrators to think long and hard about hiring him, officials saw it as a chance to lure a big city doctor. The mayor and others successfully pleaded with the Arkansas Medical Board to give him a temporary license so that he could practice at the town’s only hospital.

Within three months, Stuttgart officials were looking for Dr. Levitt’s replacement. A female patient claimed that he made a pass at her. There were also rumors that he was an alcoholic, an allegation he denied. Levitt returned to Maryland which had given back his suspended license a year early. There were new allegations of sex with patients and drug use and he left acupuncture needles in a woman after he claimed he forgot she was there. His Maryland license was suspended again in 2000. However, he is eligible to reapply this year.

For Dr. Joseph Hays, having active licenses in several states helped hide his history of run-ins with the law. When Dr. Hays, a family practitioner, was charged six years ago with fondling female patients in Tennessee, he simply moved to South Carolina. Because he had kept his South Carolina license current, he could start practicing there without any new applications or background checks, and he did so until he was convicted in Tennessee. He continues to have a license in Tennessee, but he is restricted to practice in an administrative role in a male prison. He has surrendered his South Carolina license.

There was a doctor in Loudon County, Va., who performed colonoscopies and was taking the pain killers that he was supposed to give the patients. He was taking the medicine out of the syringe and replacing it with saline, and patients were waking up in the middle of procedure. When the hospital found out, it finally took action and the Virginia Board suspended him, but the doctor has his license back now. He could turn up in Virginia. He can turn up in Texas. He can turn up anywhere.

I do not think anybody would argue with giving a doctor a second chance. However, a female psychiatrist had alcohol issues on 13 different occasions over a period of years, and 13 times they gave her another chance. Her argument was that she didn’t treat patients physically, so couldn’t harm them. That surely is open to debate. She has since been suspended for life but told me that if she stays clean for 18 months, they will give her license back. Evidently, one can always come back and get a license if somebody is willing to give it.

There is more. One source told me how a hospital became a dumping ground for doctors no longer wanted. Another source discussed the federal tracking system and its loopholes. I reviewed the records of every doctor disciplined in DC, Maryland and Virginia for the past five years to see if they had licenses in other states, and I reviewed all medical board disciplinary records to see if there were other patterns. The result of that research is the series “Special Treatment Disciplining Doctors.”

Between 1999 and 2004, nearly a thousand physicians were disciplined in one state, moved at least once more and were punished again for a separate infraction. Among doctors’ licenses in D.C., Virginia and Maryland were about two dozen migrating doctors who got in trouble in one jurisdiction and moved to another to keep practicing. Many hospitals limit doctor discipline to less than 30 days, because longer sanctions must be reported to the databank. More than half of all hospitals have never reported a disciplinary action to the databank. I believe the number is 54%. No fine or penalty has ever been imposed on medical boards or hospitals for not reporting problem doctors to the databank, even though federal law requires that they be penalized for not doing so. The names of doctors are sometimes removed from malpractice settlements, in fact, to keep them out of the databank because only those named in the final settlement have to be reported.

Doctors are given repeated chances to practice despite well-documented drug and alcohol problems. Many are never reported to the databank including one California physician who has been caught twice stealing drugs from hospitals where he worked and using them himself while on the job. The medical board’s answer was to place him in rehab - and rehab again when he relapsed - and to let him keep practicing.

That solution has been repeated by medical boards around the country. More than two dozen doctors with substance abuse problems known to the District of Columbia’s Medical Board have not been disciplined even though six lost their licenses in other states. Vice President Dick Cheney’s doctor misused prescription drugs for five years, but continued to practice in D.C. The District’s Medical Board said it didn’t know about his drug use, but even after it found out, it waited six months before suspending his license. Fourteen D.C. doctors went unpunished by the Board, even though they were disciplined in Maryland and Virginia for sexual misconduct, criminal convictions or questionable medical care. The methods used to investigate and punish bad doctors are deeply flawed. The system is ineffective and the public often suffers because of it. Yet one source hinted that improvements are not in the offing. “We just expect people to be honest,” the source said, “particularly doctors and medical boards.”