A spectacular failure of a state medical board

One of the greatest mysteries I’ve encountered since I started following the case of Stanislaw Burzynski is how he’s managed to keep practicing for 36 years after he first began treating patients with his concoction of peptides purportedly isolated from blood and urine that he dubbed “antineoplastons” (ANPs) because of their alleged ability to inhibit the growth of cancer. This is not an issue that is by any means unique to Burzynski; I’ve discussed other cases like this, such as Rolando Arafiles, who used his business relationship with the local sheriff to fend off the Texas Medical Board (TMB); Mark Geier, who was only recently stripped of his license to practice in several states; Rashid Buttar, who went so far as to use his political influence to alter the law in North Carolina to be more quack friendly, and an oncologist who administered chemotherapy to patients who didn’t have cancer and defrauded Medicare for tens of millions of dollars. It’s a general problem. However, as far as doctors who should have been shut down a long time ago, Burzynski takes the cake.

Unfortunately, a recent tragic case of a neurosurgeon in Texas shines a fair amount of light on why Burzynski has been able to get away with it for so long. The Texas Medical Board is quite ineffective, but it’s only part of the problem. If you want to see how bad protections against bad doctors can be, check out this story about a neurosurgeon in Texas who was as incompetent as any surgeon I’ve ever heard of, to the point that he perpetrated what we derisively refer to as “clean kills” in the OR. See the anatomy of a tragedy in the form of doctor named Christopher Duntsch. As the story relates at the outset, Dr. Duntsch graduated from the neurosurgery program at the Department of Neurosurgery at the University of Tennessee Health Science Center and came to Dallas to start a neurosurgery practice. Before the TMB finally acted, he had been responsible killing two patients and leaving four paralyzed. As a word to non-medical people before I go on. It is very rare that I will say that a doctor killed a patient, but in this case there appears to be little doubt: If the story as described is accurate, Dr. Duntsch killed those two patients. You’ll see what I mean if you read the story, and you’ll see what I mean as I wade into the story more. Worse, this is not a case where there weren’t complaints. As the story describes, surgeons who scrubbed with Dr. Dunstch or who had to clean up the mess after his surgical misadventures were so horrified that they broke the wall of silence that all too often prevents surgeons from reporting fellow surgeons to the state medical board:

Physicians who complained about Duntsch to the Texas Medical Board and to the hospitals he worked at described his practice in superlative terms. They used phrases like “the worst surgeon I’ve ever seen.” One doctor I spoke with, brought in to repair one of Duntsch’s spinal fusion cases, remarked that it seemed Duntsch had learned everything perfectly just so he could do the opposite. Another doctor compared Duntsch to Hannibal Lecter three times in eight minutes.

And:

But the real tragedy of the Christopher Duntsch story is how preventable it was. Over the course of 2012 and 2013, even as the Texas Medical Board and the hospitals he worked with received repeated complaints from a half-dozen doctors and lawyers begging them to take action, Duntsch continued to practice medicine. Doctors brought in to clean up his surgeries decried his “surgical misadventures,” according to hospital records. His mistakes were obvious and well-documented. And still it took the Texas Medical Board more than a year to stop Duntsch—a year in which he kept bringing into the operating room patients who ended up seriously injured or dead.

In Duntsch’s case, we see the weakness of Texas’ unregulated system of health care, a system built to protect doctors and hospitals. And a system in which there’s no way to know for sure if your doctor is dangerous.

The incidents described in this story are shocking. The two patients he killed died because he cut their vertebral arteries. Now, don’t get me wrong. That is a potential complication of spine surgery. The vertebral arteries run right next to the spine. The incompetence comes from Dr. Duntsch’s apparent failure to recognize that’s what he did and a pattern of causing this sort of complication way too frequently. Worse, as described in the article, he didn’t appear to know how to recognize or deal with the complication when it did happen, something that’s part of the basic training of any neurosurgeon or orthopedic surgeon who does spine surgery. It would be as though I, as a breast surgeon, didn’t know how to deal with an injury to the axillary artery while doing an axillary dissection and, worse, when I did produce such an injury beyond my ability fo fix, didn’t call a vascular surgeon, leading to the the patient either bleeding to death or losing her arm. True, that’s an intentionally extreme example, but this guy is a neurosurgeon. Not only can people die if he cuts a vertebral artery and doesn’t fix it, those who survive can end up paralyzed. In Dr. Duntsch’s case, several of his patients did, in fact, end up paralyzed for various reasons, among them iatrogenic injuries to the vertebral artery due to surgical misadventure. To show you that, I’m going to skip around a bit in the article. Take a look at how the first patient died at Baylor Regional Medical Center of Plano:

Kellie Martin and her husband, Don, went to see Duntsch, who suggested a procedure called a microlaminectomy, in which part of the spine is removed to relieve pressure on the nerves.

“He sounded impressive,” Don said. “He talked impressive. He was very eloquent in stating the causes and the need for the procedure. He felt confident. We felt confident too.”

Kellie Martin went into surgery on March 12, 2012. It was supposed to be a simple procedure, which is, perhaps, why Baylor didn’t put anyone in the operating room to supervise Duntsch. Don Martin, who was waiting outside, was told the operation wouldn’t take more than 45 minutes. Forty-five minutes passed, then an hour, two hours, with no word.

Don was a lieutenant with the Garland Police Department, and had spent enough time in hospitals to know this delay wasn’t a good sign. He went to the operating room and asked to speak to the doctor. When Duntsch came out, he told Don there had been “some complications,” and that Kellie would have to stay the night, but that the operation had gone fine.

Duntsch went back into the operating room and left Don waiting. He waited until they told him his wife had been sent to the intensive care unit. Then he waited for several more hours until the nurses came out to tell him and his daughters that Kellie Martin was dead.

So egregious was the death that the Collin County medical examiner listed the cause of death as “therapeutic misadventure” because the cause of death had been an injured vertebral artery. You just don’t see coroners putting that sort of phrase on a death certificate. In any case, after Kellie Martin’s death, Dr. Duntsch either resigned or was forced out, but there was no black mark on his record. He got privileges at another hospital, Dallas Medical Center. Now look at how the second patient died:

In the second [operation], while doing a cervical fusion on a woman named Floella Brown, Duntsch “removed a bone from an area that was not required by any clinical or anatomical standards, resulting in injury to the vertebral artery,” according to Texas Medical Board records. Brown was later found unresponsive in her hospital room and staff couldn’t contact Duntsch for 90 minutes, according to those records. Brown had suffered excessive blood loss and a stroke, according to the agency. By the time she was transferred to UT Southwestern Medical Center later that day, she was brain dead.

Cutting vertebral articles was not the only error to which Dr. Duntsch was prone. Brown was just one of three cases on three consecutive days that Dr. Duntsch did, the second. The third was a woman named Mary Efurd. She was told that the case went fine, although she woke up in horrible pain, worse pain than she had been in before surgery, and barely able to move her legs. Another neurosurgeon at Dallas Medical Center, Dr. Robert Henderson, was asked to operate to fix the problem after a postoperative CT showed that the metal spinal fusion hardware that is normally screwed into the vertebrae to keep them from moving while the fusion heals were in the back muscles, inches from where they needed to be. They weren’t holding anything together. Dr. Henderson was shocked at what he saw. As recorded in the article, Dr. Henderson said, “He had amputated a nerve root. “It was just gone. And in its place is where he had placed the fusion. He’d made multiple screw holes on the left everywhere but where he had needed to be. On the right side, there was a screw through a portion of the S1 nerve root.”

So bad was this that Dr. Henderson thought that Dr. Duntsch must be an impostor, because to him no one with an MD and a PhD who had managed to graduate from a respected neurosurgery residency could possibly be that bad. So Dr. Henderson contacted the University of Tennessee and even sent a picture. The residency program reported that Dr. Duntsch had finished it. Meanwhile, as the complaints to the TMB rolled in, made in increasingly desperate tones, Dr. Duntsch kept operating, not only cutting vertebral arteries, but forging ahead with new, previously unheard-of complications of spinal surgery, such as paralyzed vocal cords.

There were further incidents, too, the last of which reminded me of Stanislaw Burzynski. Remember University General Hospital? I pointed out that Stanislaw Burzynski and some of his cronies apparently managed to get clinical privileges there. That’s where they treated Fabio Lanzoni’s sister as she died. At the time, I wondered about any hospital that would grant clinical privileges to a doctor like Burzynski, who isn’t even board-certified or board-eligible in internal medicine, and his employees at the Burzynski Clinic, and quite rightly too, in my not-so-humble opinion. Alarmingly, Dr. Randall Kirby, who was a neurosurgeon at Plano when Dr. Duntsch plunged into his first surgical misadventures and was one of the earliest surgeons to raise the alarm about Dr. Duntsch, received an invitation from University General Hospital to meet its new neurosurgeon. That neurosurgeon was—you guessed it!—Dr. Duntsch. Dr. Kirby immediately called the owner of UGH to warn him that UGH had a big problem. This is what happened:

According to Kirby, the hospital owner told him that Duntsch had privileges to do only minimally invasive surgeries.

It was a minimally invasive surgery, Kirby said, that killed Kellie Martin.

Two weeks later, on June 14, 2013, Kirby got a call to come to University General to do a recovery surgery on one of Duntsch’s patients. The surgery had gone so badly, Kirby later wrote to the Medical Board, that the rest of the OR team had to physically restrain Duntsch from continuing. For two days the patient, Jeffrey Glidewell, lay unattended in the ICU while Duntsch made excuses to the family. Finally the family fired him. When Kirby saw Glidewell, he later wrote the Medical Board, he was “horrified.” The incision, he wrote, was cut into Glidewell’s throat “two or three inches lower and an inch midline from where it should have been oriented … saliva and pus were coming out of the wound.”

Duntsch, it turned out, had, as with other patients, cut into Glidewell’s vertebral artery; an MRI found that he had also left a sponge festering in the soft tissue of Glidewell’s throat.

Likely the reason for the saliva and pus coming out of the wound was because the surgical sponge probably eroded into the esophagus. Either that, or Dr. Duntsch had cut the esophagus as well, which is certainly possible.

This case is disturbing on so many levels that it’s hard to know where to begin. First of all, as someone involved in training residents myself, I can’t help but discuss one thing that the article glossed over: How the hell did the Department of Neurosurgery at the University of Tennessee let Dr. Duntsch finish its program, thus presenting him as qualified and well-trained as a neurosurgeon? Every surgical residency program occasionally admits a resident who reveals himself over time to be incompetent to the point of being untrainable. We surgeons who are affiliated with residency training programs have all at one time or another seen the resident with “hands of stone” or the resident who “can’t operate his way out of a paper bag.” We’ve all seen the occasional resident who seems to have zero surgical judgment or even worse, as I’ve sometimes heard it called, “negative surgical judgment,” which I like to characterize as the unerring ability to choose in any given clinical scenario exactly the wrong course of action. Indeed, at least a couple of surgeons who reported him described Dr. Duntsch in terms similar to negative surgical judgment, bemoaning his seemingly uncanny ability to choose exactly the wrong course of action in any given situation in the operating room. Surely, the residency director and the faculty at UT must have known that Dr. Duntsch was so bad, although it was brought up in the comments that it’s possible that Dr. Duntsch was an okay surgeon during residency but then something, such as drug or alcohol abuse, happened. Even so, this happened so soon after Dr. Duntsch finished residency that it’s hard to believe there weren’t some fairly obvious indications of problems when he was still a resident. Of course, one problem these days with residency programs is that they are afraid to get rid of trainees who are clearly not making it; specifically, they are afraid of being sued. Enormous amounts of caution and, above all, documentation are needed before a residency director will fire an incompetent resident.

Then there’s Texas itself. The article is a truly depressing read in that it shows how the very law in Texas is written to facilitate incidents of this sort. For example:

One might think that if a doctor had paralyzed one patient and had another die in the course of a month, it would be someone’s job to figure out why. But as in many other areas in Texas—benzene pollution from hydraulic fracturing sites; ammonium nitrate pileups at fertilizer plants—Martin’s death and Summers’ paralysis fell into a regulatory no man’s land. Once Duntsch left Baylor, he was no longer the hospital’s problem. The only entity that could stop Duntsch from seeing more patients was the Texas Medical Board.

But the board is limited in its ability to investigate malpractice. For one thing, it can open a case only if it receives a written complaint—akin to a police department that forbids its officers from investigating criminal activity they witness. With the exception of pain management clinics and anesthesiologists, the board doesn’t have the authority to inspect a doctor, or to start an investigation on its own.

It’s further explained this way:

But the Medical Board wasn’t designed to be an aggressive enforcer. It was mostly designed to monitor doctors’ licenses and make sure the state’s medical practitioners are keeping up with professional standards. The board’s mandate, spelled out in the Medical Practice Act, recognizes a doctor’s license as a hard-won, valuable credential. Doctors’ rights are to be protected at every step of the process. The board can’t revoke a license without overwhelming evidence, and investigations can take months, with months or years of costly hearings dragging on afterward. The protections make some sense. The Legislature doesn’t want the Medical Board taking a doctor’s license—and livelihood—unnecessarily or based on flimsy or frivolous claims. But the result is that unless a doctor is caught dealing drugs or sexually assaulting patients—or is convicted of a felony—it is difficult to get his or her license revoked.

This is basically the problems with state medical boards in other states, but on steroids, and amplified by other protections that are weak, such as the cap on pain and suffering damages in medical malpractice lawsuits and laws that make it very difficult to sue hospitals. Indeed, the attitude is completely wrong. It is a high privilege to be a physician; the state in essence trusts us to do things to other people that no other person can do. For example, as a surgeon, I am given the power to rearrange people’s anatomy for therapeutic intent. If anyone else besides a surgeon does what surgeons routinely do, it would be assault and battery. I like to think that that privilege is earned. To me, if that privilege is abused mechanisms need to be in place to rapidly stop that abuse. Patients must come first, not the privilege of physicians. Certainly, there do need to be legal protections for doctors against frivolous complaints; physicians are not immune from professional rivalries and enemies looking to hurt them by going after their license. (Hell, I’ve had someone—and I’m pretty sure I know who it was—try to do just that to me to get back at me for my posts about Stanislaw Burzynski, but fortunately my state’s medical board recognized it for the nonsense that it was.) However, Texas goes way too far in the opposite direction, protecting doctors over patients. The case of Dr. Duntsch is a particularly spectacular example of that.

I also think I now know why Burzynski has been able to keep his license in Texas for 36 years and why he’s managed to get admitting privileges at University General Hospital.