In the last post, I mentioned that there was a pattern regarding the University of California and its tolerance of anything that might threaten its funding streams. To reiterate my own experience: as a resident, I had been asked by the residency program director that if a patient refused a surgery based on what I had told him, "don’t you realize that you would be responsible?" In context, (see my Sunday, June 16, 2002 post) I thought that was a pretty clear, though misguided, warning not to tell patients the risks of anesthesia.

Such a rhetorical question was not, apparently, clear enough for UC Irvine. According to the LA times, Dr. Sean Cao, at the time the only UCI transplant surgeon, actually wrote an email regarding talking to potential transplant patients. Dr. Cao apparently distributed a confidential memo that stated "Anyone who spreads the rumors [that he was turning down organs] ," would be subject to discipline for "professional misconduct" and held "liable, especially if the patients … find out something and decide to take legal action."

The thing is that these "rumors" were apparently true. In 2003, UCI performed just 8 liver transplants, as opposed to the minimum of 18 required by the state to maintain certification, or the minimum of 12 transplants required by the feds. Only 16.2% of patients who had joined the waiting list between July 1998 and June 2001 had received a liver three years later, as opposed to the nationwide average of 42% of patients who got a liver within three years. In any case, I find it interesting that UCI, in the person of Dr. Cao, threatened staff in writing with "liability" if "patients … find out something and decide to take legal action." Wow. Simply wow.

In my last post (the one just below this one) I mentioned how remarkable it was that none of the UCI empoyees happened to mention to "transplant" patients that there was no transplant surgeon generaly available from July 2004 onwards. (Dr. Cao left the program, and was not replaced, so UCI had no full-time transplant surgeon. Transplant candidates were not notified, however.) I think that this memo might indicate the source of the problem. After all, what sort of highly educated, trained, and mobile professionals would stay with the program after getting those sorts of email threats? For that matter, what sort of people would stay working at UCI after the long string of scandals? Answer to both questions: the sort of people who are working there right now. Related answer to both questions: largely the sort of people who will be there as the next scandal occurs. I think that says a lot.

I’ve noticed, as have you if you’ve been reading this site, that the last few posts seem to revolve around the University of California. That’s not really what I had in mind when I wrote my June 16, 2002 post; I originally thought I was being a little bit more universal, and writing about residency / training programs in general. However, the title of the blog is "trying to make sense of (some of) it all," and perhaps this blog has helped me understand a little bit more of what I was writing about.

It’s become pretty obvious to me, after re-reading some of my posts on this blog, that there may be a problem at the University of California in particular. That became more evident lately when it emerged in a series of stories spearheaded by Charles Ornstein and Alan Zarembo of the LA Times that, over at least the last two years, the University of California, Irvine has been involved the worst crisis in medical ethics since the Tuskeegee Experiments. I’m going to replicate the gist of the news stories here, even though I don’t have any new information of my own to add.

According to these stories, since at least July 2004, the University of California has been running a sham liver transplant program, in which UCI:

recruited patients with liver disease
told patients that they were on the list for liver transplants
obtained federal funding for running a liver transplant program
presumably charged insurance companies for pre-transplant evaluations
… and didn’t actually have a full-time liver transplant surgeon available.

[the original version of this post stated that UCI didn't have a transplant surgeon available. I decided that was unclear, since they sometimes had a surgeon available. Therefore, I've changed this post a little bit to refer to the lack of a "full time" transplant surgeon, as opposed to the lack of "a transplant surgeon." ]

UCI had a website in which they named Dr. Marquis Hart and Dr. Ajai Khanna as their transplant surgeons, and did not mention that those two surgeons were actually on staff at UCSD, almost 100 miles away. Federal inspections of UC Irvine revealed that there was no liver transplant surgeon "in the immediate vicinity of the hospital."

UC Irvine did make their facilities available on an occasional basis to transplants, doing 8 transplants each year from 2002-2004, and five transplants in 2005 (as opposed to the federal requirement that at least 12 transplants be done each year by a liver transplant program in order to maintain certification), with a 2002-2004 1 year survival rate of 68.8%, as opposed to the near-85% national 1-year survival rate. Meanwhile, UCI recruited more patients with liver disease (28 in 2005), refused organs made available to those patients (apparently since there was generally no surgeon available to transplant those organs) and, except for the occasional transplant recipient, allegedly waited for everyone else on the list to die. In fact, according to the LA times, at least 30 patients died over the last 2 years while waiting for liver transplants. The livers were apparently available (contra what had been told to the patients). It was the transplant itself -- in particular, a transplant surgeon -- who was not.

The story came to light due to a lawsuit filed by Elodie Irvine, who had fruitlessly been on the UCI waiting list for years before moving to Cedars-Sinai, where she got a transplant. During the time that Ms. Irvine was at UCI, UCI turned down 38 livers and 57 kidneys on her "behalf," while telling her that UCI was simply waiting for organs for transplant. "They left me to die," said Ms. Irvine.

Well, that’s most of the story. However, I am certain that, during the time that Ms. Irvine was on the "transplant" list at UCI, she was attended to (and billed for):

Gastroenterologists for GI symptoms
Nephrologists for renal symptoms
Anesthesiologists / pain management specialists for her pain
General internists for non-hepatic non-renal problems
Fellows, residents, interns, and medical students
Nurses, nursing assistants, phlebotomists, and lab techs
Multitudes of administrative personnel including "transplant" coordinators and billing specialists

And apparently, except for one eventual, apparently informal, referral to Cedars Sinai, not one of those people happened to mention to this old woman on the "transplant" list, nor to anyone else "waiting" for a transplant … "hey, you know … UCI doesn’t really have a full-time transplant surgeon. If you’re waiting for a transplant, that’s something you’d like to keep in mind."

Once, I would have wondered how that could be possible. If you’ve read my earlier posts, however, particularly the June 16, 2002 post, you already have a good idea as to how that could happen. I objected to the apparently needless (but profitable) hospitalization of not-really-sick people during my internship through UCI, and I was told to shut up and do my job. I told people the risks of anesthesia at UCLA, and they rearranged my residency schedule so I would not have any contact with liver transplant patients, then forced me out. One of the trustees at UCI objected to the University’s defense of the reproductive endocrinology program that stole the eggs of patients, and, according to him, he had little choice but to resign. The whistleblower who notified the HCFA (health care financing administration) that the UC medical centers were billing for services provided by attendings who were not in the hospital was apparently fired, blackballed, and was involved in lawsuits for years. There’s a pattern there. It's not the pattern I originally thought it was, but I think I’ve figured it out now. You are welcome to do the same.

Presented without comment: one (of many) stories about UC Irvine residency alum Dr. George Steven Kooshian

Here's an interesting story based on this data. This study looked at MI, pneumonia, and CHF, which generally have well-understood treatments with well-documented mechanisms and goals of treatment. In the words of Dr. Ashish K. Jha, the study's lead researcher and an assistant professor of health policy and management at the Harvard School of Public Health "These are all really relatively simple things."

And yet, according to the LA Times, "hospitals serving the Inland Empire overall ranked worst in the country last year in their treatment of patients with heart attacks and pneumonia, according to a new study," and "care provided by the Inland Empire market ranked 34th among the 40 largest hospital markets in the nation [for CHF]." "[hospitals in] the San Diego area ranked in the bottom five for their treatment of congestive heart failure and pneumonia, and [hospital care in] Los Angeles was next to last for its pneumonia care.No region in the state ranked among the top five in treating any of the three medical conditions studied."

I might comment on this later, but, for now, there's a major clue as to the problem in the quote of Jim Lott, executive vice president of the Hospital Assn. of Southern California. According to Mr. Lott, '"These people are trained the same places everybody else is trained,' (Mr. Lott) said, referring to the medical staffs." Uh, no. California doctors tend to be Californians, and tend to have been trained in California. That's one of the reasons people pick a residency program, particularly if they plan to go into private practice ... because it's in the area, or at least the state, in which they plan to practice. In other words, the people responsible for this poor showing are likely to have trained in California, and particularly likely to have trained at the University of California (since the U. of California is the 800 pound gorilla of academic medicine in California).

As per the other posts further down this page, I invite you to draw your own conclusions.

The rabbit hole gets a little bit deeper

Whoa. According to this article, Filipino veterans of WWII are asking for VA benefits from the US department of Veteran’s affairs. According to the article, last year (2004) was the year that Filipino veterans were allowed into the US VA health care system.

That’s a surprise to me. In 1992, while I was an intern at the Long Beach VA Medical Center, which is partially administered by UC Irvine, one of my inpatients was a Filipino veteran who was never a member of the US regular armed services, but of the Filipino armed services. This man lived in the inpatient units of the VA for, to the best of my knowledge, months at a time, and had been a long term patient of the VA before I was hired, and continued to be a patient after I left. I asked about this at the time, and was told that President Roosevelt had authorized Filipino Vets to be treated in the US VA system, so it was legit.

On the other hand, according to the Sun-Times article linked above, the US Congress elected not to recognize Filipino veterans as "active veterans" in 1946. So, if my reading of the the Sun Times article is correct, from 1946 until 2004, barring unusual circumstances (and, based on the other irregularities I’ve described in the posts below this one, and the fact that no other unusual circumstances were described when I first asked about this back in 1992, my first guess as to the most likely set of operative "unusual circumstances" is fraud), Filipino veterans were not authorized for treatment at the VA medical centers. And yet, there he was. Makes me wonder about the other VA patients I met who were not US veterans. Also makes me wonder about the elderly woman whose records and ID had a man's name (her husband's name, according to her) on them, and who was also a long-term patient of the VA.

Anyone from the Long Beach VAMC or UC Irvine want to explain this? (bearing in mind that I’ve already gotten the "President Roosevelt gave them this, so it’s OK" explanation from the VA, which is apparently not true) I’m at pbanos[at]yahoo.com