Wow. Los Alamos National Labs (run by the University of California) had yet another apparent breach of national security. A drug raid on a Los Alamos scientist's home in New Mexico turned up what appeared to be classified documents taken from the nuclear weapons lab. This is, of course, after Wen Ho Lee, and after an episode of missing classified disks that the lab later said "never existed."
As always, draw your own conclusions.
Update:
It took a while, but it eventually became clear how this episode fits into the "cut any corner to bill more or pay less" pattern that seems to have emerged from the events documented below. In most of the other posts below this one, the University of California cut corners, and people died (32 in the UC Irvine and UC San Deigo liver transplant non-program) or were left to die in agony but didn't actually die (an unknown number, but approx. 200 in that same program) or ... well, read the posts below. In this post, the University of California cut corners, and national security was compromised (again).
The person who took classified documents home was, it turns out, a Lab archivist. The archivists were supposed to work in pairs, so that each could keep an eye on each other, and so that each would be less likely to take classified documents. The University actually did hire two archivists, and presumably billed the DOE (on whose behalf the University runs the labs) for the two archivists.
The labs then assigned the two archivists to different parts of the labs. This completely negated the point of having archivists work in pairs in the first place. Well, it negated the national-security reason for having archivists work in pairs, anyway. The justification for billing for two archivists probably remained.
Tuesday, October 24, 2006
Tuesday, September 26, 2006
Last week, I worked with a nurse by the name of Natalie Dizon. Ms. Dizon has allowed me to tell her story.
Ms. Dizon had a pelvic procedure done by Dr. Schlomo Raz at UCLA. After that first procedure, she claims that she was in agonizing pain, and believed that something had been left in her during the surgery.
After a while, Dr. Raz took Nurse Dizon back to the OR. After recovery from the second visit to the OR, Ms. Dizon says that the previous great pain was gone. Ms. Dizon stated that, during recovery, another nurse, who had been present during the second procedure, told Ms. Dizon that Dr. Raz had taken a surgical sponge (apparently left there after the first procedure) out of her. That would have explained the pain, as well as the sudden disappearance of the pain after another visit to the operating room.
Nurse Dizon then tried to get her medical records to find out what had happened in the OR. Despite the fact that all the information in the medical records is hers, she was not given all the medical records, but only face sheets and billing information. In the meantime, she states that she was told that the presence of the surgical sponge on the second procedure had not been documented, and there was no point in looking for a record to indicate it's existence.
Just another UCLA data point.
Ms. Dizon had a pelvic procedure done by Dr. Schlomo Raz at UCLA. After that first procedure, she claims that she was in agonizing pain, and believed that something had been left in her during the surgery.
After a while, Dr. Raz took Nurse Dizon back to the OR. After recovery from the second visit to the OR, Ms. Dizon says that the previous great pain was gone. Ms. Dizon stated that, during recovery, another nurse, who had been present during the second procedure, told Ms. Dizon that Dr. Raz had taken a surgical sponge (apparently left there after the first procedure) out of her. That would have explained the pain, as well as the sudden disappearance of the pain after another visit to the operating room.
Nurse Dizon then tried to get her medical records to find out what had happened in the OR. Despite the fact that all the information in the medical records is hers, she was not given all the medical records, but only face sheets and billing information. In the meantime, she states that she was told that the presence of the surgical sponge on the second procedure had not been documented, and there was no point in looking for a record to indicate it's existence.
Just another UCLA data point.
Tuesday, April 25, 2006
Well, now it's more clear why the U. of California needed that money:
From today’s LA Times:
“For the last decade, University of California leaders systematically failed to disclose to UC's governing board the details of pay packages and perquisites granted to senior executives, despite policies requiring such disclosure, according to an audit released Monday.”
In other words, UC administrators spent University money on themselves without notifying thier nominal bosses (the regents), the legislature, or the public. Think about this in the context of a private company for a second; say you owned a business, and the hired help spent the business money on themselves without notifying anyone. In such a case, it could be embezzelment, plain and simple.
Futher:
“The report also noted that some compensation for a number of employees, including the extra income for Dynes, [the current University president] was not reported to the Internal Revenue Service. Officials said amended W-2 forms would be submitted.”
Again, in the context of a private company, that could be tax evasion.
Just sayin’
Addendum: The amount of money involved in the story above was not disclosed by the LA times. According to the NY Times story, "University of California Backs President," published May 18, 2006 (no active link at this time):"A state audit found the extra compensation accounted for $334 million."
334 MILLION DOLLARS. Wow.
From today’s LA Times:
“For the last decade, University of California leaders systematically failed to disclose to UC's governing board the details of pay packages and perquisites granted to senior executives, despite policies requiring such disclosure, according to an audit released Monday.”
In other words, UC administrators spent University money on themselves without notifying thier nominal bosses (the regents), the legislature, or the public. Think about this in the context of a private company for a second; say you owned a business, and the hired help spent the business money on themselves without notifying anyone. In such a case, it could be embezzelment, plain and simple.
Futher:
“The report also noted that some compensation for a number of employees, including the extra income for Dynes, [the current University president] was not reported to the Internal Revenue Service. Officials said amended W-2 forms would be submitted.”
Again, in the context of a private company, that could be tax evasion.
Just sayin’
Addendum: The amount of money involved in the story above was not disclosed by the LA times. According to the NY Times story, "University of California Backs President," published May 18, 2006 (no active link at this time):"A state audit found the extra compensation accounted for $334 million."
334 MILLION DOLLARS. Wow.
Here's a little list (compiled mainly from stories out of the LA Times and the OC Register) of UC Irvine scandals over the last few years, just to help me keep track of all this:
In 2005 came news of the death of 32 patients waiting for liver transplants that were never going to come. The livers were available, but, for two years, UCI did not have a full time surgeon to implant them, in contravention of federal regulations. UCI's surgeon was actually on staff at UC San Diego, almost 100 miles away. UC Irvine never notified the dying patients that they didn't have a full time surgeon on staff. Just before leaving the program with no full-time surgeon, the last UCI transplant surgeon, who had been performing an unusually small number of transplants, with a survival rate below federal standards, is alleged to have threatened staff members with "liability" should "patients find out something and decide to sue."
The woman whose lawsuit eventually led to exposure of this scandal was Elodie Irvine. Ms. Irvine, who had liver and kidney disease, had 95 organs offered to her by UNOS, the United Network for Organ Sharing, while she waited for a transplant at UCI. All those organs were rejected by UCI, while she was told they were just waiting for organs. Only one UCI physician advised her to look elsewhere for a transplant. The rest of UCI allegedly left her, and most everyone else on the “transplant” list, to die.
In the 90s, UCI allegedly stole eggs from women who had come for fertility treatments. The responsible physicians fled the country to escape federal prosecution. At least one UCI trustee claims to have resigned his post largely because (he claimed) that the trustees were planning to support the errant physicians.
In 2006 it was alleged that, for approximately 15 years, the University had been covering up the existence of children from those stolen eggs. In at least one case, it appears that the process of removing eggs from an unwitting young woman, who had come for a fallopian tube procedure, rendered her infertile. That young woman's eggs developed into at least two children, who are now in their late teens, but the woman was never able to conceive. She did not know that she had children until 2005. Another approximately 20 such children, from 20 unwitting "donors," are now in their late teens, and the families are suing for damages and to learn the identity of their children. The University is arguing that the statute of limitations for this case has expired.
In December 2005, UCI settled a lawsuit brought over the (still-missing) body of Anneliese Yuenger. UC employees allegedly tried to pass off a bag of miscellaneous cremated body parts, instead of Yuenger’s body, to the family. This was only a small part of a willed-body scandal that affected many families, UCI, and UCLA.
In 2003, UCI hired Jagat Narula and Mani Vannan as the chief and division chief of cardiology. Neither was board certified in internal medicine nor cardiology, and neither had a California medical license. Narula then allegedly forced out electrocardiologist Michael Brodsky, and hired David Cesario, the son of med school dean Thomas Cesario, to take his place.
In 2003, Dr. Glenn Prevost presented a 13-signature petition alleging anesthesia safety problems. He says that soon after complaining about a supervisor forcing him "to take patients to the operating room without consent, chart, or preoperative check-in by the operating room nurse ... in an attempt to cut costs," he was fired and allegely blackballed.
In Feb 2001, the University of California agreed to pay $22.5 million to settle allegations that it's teaching hospitals routinely submitted false billings to Medicare, Medicaid and other Federally-funded health programs. The whistleblower, who had been at UCI, left UCI, and was allegedly blackballed. She’s since been embroiled in lawsuits against the University of California.
In 2005 came news of the death of 32 patients waiting for liver transplants that were never going to come. The livers were available, but, for two years, UCI did not have a full time surgeon to implant them, in contravention of federal regulations. UCI's surgeon was actually on staff at UC San Diego, almost 100 miles away. UC Irvine never notified the dying patients that they didn't have a full time surgeon on staff. Just before leaving the program with no full-time surgeon, the last UCI transplant surgeon, who had been performing an unusually small number of transplants, with a survival rate below federal standards, is alleged to have threatened staff members with "liability" should "patients find out something and decide to sue."
The woman whose lawsuit eventually led to exposure of this scandal was Elodie Irvine. Ms. Irvine, who had liver and kidney disease, had 95 organs offered to her by UNOS, the United Network for Organ Sharing, while she waited for a transplant at UCI. All those organs were rejected by UCI, while she was told they were just waiting for organs. Only one UCI physician advised her to look elsewhere for a transplant. The rest of UCI allegedly left her, and most everyone else on the “transplant” list, to die.
In the 90s, UCI allegedly stole eggs from women who had come for fertility treatments. The responsible physicians fled the country to escape federal prosecution. At least one UCI trustee claims to have resigned his post largely because (he claimed) that the trustees were planning to support the errant physicians.
In 2006 it was alleged that, for approximately 15 years, the University had been covering up the existence of children from those stolen eggs. In at least one case, it appears that the process of removing eggs from an unwitting young woman, who had come for a fallopian tube procedure, rendered her infertile. That young woman's eggs developed into at least two children, who are now in their late teens, but the woman was never able to conceive. She did not know that she had children until 2005. Another approximately 20 such children, from 20 unwitting "donors," are now in their late teens, and the families are suing for damages and to learn the identity of their children. The University is arguing that the statute of limitations for this case has expired.
In December 2005, UCI settled a lawsuit brought over the (still-missing) body of Anneliese Yuenger. UC employees allegedly tried to pass off a bag of miscellaneous cremated body parts, instead of Yuenger’s body, to the family. This was only a small part of a willed-body scandal that affected many families, UCI, and UCLA.
In 2003, UCI hired Jagat Narula and Mani Vannan as the chief and division chief of cardiology. Neither was board certified in internal medicine nor cardiology, and neither had a California medical license. Narula then allegedly forced out electrocardiologist Michael Brodsky, and hired David Cesario, the son of med school dean Thomas Cesario, to take his place.
In 2003, Dr. Glenn Prevost presented a 13-signature petition alleging anesthesia safety problems. He says that soon after complaining about a supervisor forcing him "to take patients to the operating room without consent, chart, or preoperative check-in by the operating room nurse ... in an attempt to cut costs," he was fired and allegely blackballed.
In Feb 2001, the University of California agreed to pay $22.5 million to settle allegations that it's teaching hospitals routinely submitted false billings to Medicare, Medicaid and other Federally-funded health programs. The whistleblower, who had been at UCI, left UCI, and was allegedly blackballed. She’s since been embroiled in lawsuits against the University of California.
Monday, December 19, 2005
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.
Wednesday, November 30, 2005
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.
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.
Saturday, August 27, 2005
Presented without comment: one (of many) stories about UC Irvine residency alum Dr. George Steven Kooshian
Thursday, July 28, 2005
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.
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.
Monday, April 11, 2005
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
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
Sunday, July 11, 2004
Since the time I wrote my last post below, describing my experiences at the University of California, people have asked me if I know of any other problems there. Indeed I do. So, over the next few postings, I will describe a few examples of what I believe to be large-scale insurance fraud that I saw, or otherwise know of, at the University of California medical system.
The largest case of which I am aware involved large scale ... umm ... mistaken billing for intern and resident services. I did my medical internship through the University of California, Irvine. I made $29,000 for one year of work, for which I worked approximately 80 to 100 hours / week. The University, however, apparently didn’t bill for my services as if I was making $29,000 / year. Instead, they allegedly billed for the services provided by the interns and residents, as if the services had been provided by attending physicians. (note: I don't know if services I personally performed were billed "incorrectly," just that large numbers of services around the time I was working for UC Irvine were "incorrectly" billed. I assume that some of what I did was billed "in error.") They even billed for attending physicians doing procedures at times when those attendings were documented to have not been in the hospital at all.
In February 2001, after years of appeals, but with new federal DA's on the way after the 2000 federal elections were eventually finalized, the University of California settled those
"erroneous" billing claims (referred to as "routine misbilling of medicare, medicaid, and other federal health care programs") for $22.5 million. (!) The last I read about this, in the LA Times, the whistleblower, from the University of California, Irvine billing department, was still wading through lawsuits and trying to get her life back on track.
The largest case of which I am aware involved large scale ... umm ... mistaken billing for intern and resident services. I did my medical internship through the University of California, Irvine. I made $29,000 for one year of work, for which I worked approximately 80 to 100 hours / week. The University, however, apparently didn’t bill for my services as if I was making $29,000 / year. Instead, they allegedly billed for the services provided by the interns and residents, as if the services had been provided by attending physicians. (note: I don't know if services I personally performed were billed "incorrectly," just that large numbers of services around the time I was working for UC Irvine were "incorrectly" billed. I assume that some of what I did was billed "in error.") They even billed for attending physicians doing procedures at times when those attendings were documented to have not been in the hospital at all.
In February 2001, after years of appeals, but with new federal DA's on the way after the 2000 federal elections were eventually finalized, the University of California settled those
"erroneous" billing claims (referred to as "routine misbilling of medicare, medicaid, and other federal health care programs") for $22.5 million. (!) The last I read about this, in the LA Times, the whistleblower, from the University of California, Irvine billing department, was still wading through lawsuits and trying to get her life back on track.
So, since I’m blogging today, I thought I’d describe one more apparent impropriety at the University of California. This one doesn’t involve the University of California directly, but is about the Long Beach VA Medical Center, which is partly staffed by UC Irvine. The content of this post comes in 2 parts:
PART 1:
As an intern, I rotated through the Long Beach VA Medical Center Emergency Room. After a while, it became obvious that the VAMC ER was admitting a lot of people who didn’t need to be admitted; people who weren’t really sick. I asked about that (made a stink is more like it), and eventually was summoned to the office of the director of Emergency Medicine at the Long Beach VA. She basically told me to shut up and do my job, but she also told me that the department of emergency medicine there was contracted (apparently in an unwritten contract) to admit at least 30% of their patients to inpatient units. It was implied that this was whether 30% of the ER patients were really all that sick or not.
OK, that’s possible fraud right there. But still, it was possible that 30% of the ER visits were legitimate admits. However, while working in the ER, and later while working in inpatient VA units, I noticed that some of the admits were not even close to being legitimate. I am not referring to old men with bronchitis who could have been treated as outpatients, but who were admitted for observation, or similar judgment calls. I am, instead, referring to the practice I observed of simply making up a serious diagnosis for ER patients, then using that diagnosis as an admitting diagnosis for inpatient admission.
PART 2:
For example, I had a patient, admitted by Dr. Queeda Draine of the VA, who was admitted for digoxin overdose. Digoxin is a medicine given to people for certain heart diseases; in overdose, it can cause arrhythmias and death. Admitting someone to the inpatient units for dig overdose is perfectly reasonable. However, this patient had no signs of digoxin overdose. His EKG was normal. He had no cardiac history which would have required digoxin therapy. He was not on digoxin. He claimed that he had never taken digoxin in his life. His serum dig level, which was available to me as the patient was being wheeled out of the ER to the ward, and which therefore should have been available to the ER attending Dr. Draine, was zero. To me the conclusion was inescapable: the admitting diagnosis of digoxin toxicity had been simply made up. Before admitting this patient, I called Dr. Draine to ask how the patient could have digoxin toxicity with a dig level of zero; Dr. Draine hung up on me.
Under orders from my attending, I admitted this patient for observation. The patient, as healthy in the morning as he had been on admission, was discharged at morning rounds, after I opined in morning report that this admission constituted pretty obvious fraud. I don't think it was the "fraud" part that caused the patient to be discharged; I think it was the "pretty obvious" part.
The patient never really knew why he'd been admitted; according to him, he spent the night in the hospital because 'that doctor in the ER thought I should.' As for why he had come to the ER in the first place, it is my recollection that he had come with complaints of "being tired." Being tired is a problem, but is generally not justification for an emergency admission.
Nevertheless, I have no doubt that the hospital billed for my services in admitting this patient for an apparently made-up diagnosis, and for observing him overnight for a disease which he did not have. In fact, based on the events referenced in the post immediately above this one, I have no doubt that the hospital overbilled for that work.
I observed a lot more examples like part 2, and was left with my own conclusions about inpatient admissions at that facility. I invite you to draw your own conclusions.
PART 1:
As an intern, I rotated through the Long Beach VA Medical Center Emergency Room. After a while, it became obvious that the VAMC ER was admitting a lot of people who didn’t need to be admitted; people who weren’t really sick. I asked about that (made a stink is more like it), and eventually was summoned to the office of the director of Emergency Medicine at the Long Beach VA. She basically told me to shut up and do my job, but she also told me that the department of emergency medicine there was contracted (apparently in an unwritten contract) to admit at least 30% of their patients to inpatient units. It was implied that this was whether 30% of the ER patients were really all that sick or not.
OK, that’s possible fraud right there. But still, it was possible that 30% of the ER visits were legitimate admits. However, while working in the ER, and later while working in inpatient VA units, I noticed that some of the admits were not even close to being legitimate. I am not referring to old men with bronchitis who could have been treated as outpatients, but who were admitted for observation, or similar judgment calls. I am, instead, referring to the practice I observed of simply making up a serious diagnosis for ER patients, then using that diagnosis as an admitting diagnosis for inpatient admission.
PART 2:
For example, I had a patient, admitted by Dr. Queeda Draine of the VA, who was admitted for digoxin overdose. Digoxin is a medicine given to people for certain heart diseases; in overdose, it can cause arrhythmias and death. Admitting someone to the inpatient units for dig overdose is perfectly reasonable. However, this patient had no signs of digoxin overdose. His EKG was normal. He had no cardiac history which would have required digoxin therapy. He was not on digoxin. He claimed that he had never taken digoxin in his life. His serum dig level, which was available to me as the patient was being wheeled out of the ER to the ward, and which therefore should have been available to the ER attending Dr. Draine, was zero. To me the conclusion was inescapable: the admitting diagnosis of digoxin toxicity had been simply made up. Before admitting this patient, I called Dr. Draine to ask how the patient could have digoxin toxicity with a dig level of zero; Dr. Draine hung up on me.
Under orders from my attending, I admitted this patient for observation. The patient, as healthy in the morning as he had been on admission, was discharged at morning rounds, after I opined in morning report that this admission constituted pretty obvious fraud. I don't think it was the "fraud" part that caused the patient to be discharged; I think it was the "pretty obvious" part.
The patient never really knew why he'd been admitted; according to him, he spent the night in the hospital because 'that doctor in the ER thought I should.' As for why he had come to the ER in the first place, it is my recollection that he had come with complaints of "being tired." Being tired is a problem, but is generally not justification for an emergency admission.
Nevertheless, I have no doubt that the hospital billed for my services in admitting this patient for an apparently made-up diagnosis, and for observing him overnight for a disease which he did not have. In fact, based on the events referenced in the post immediately above this one, I have no doubt that the hospital overbilled for that work.
I observed a lot more examples like part 2, and was left with my own conclusions about inpatient admissions at that facility. I invite you to draw your own conclusions.
Sunday, June 16, 2002
Bill Quick and Megan McArdle seem to have an interesting debate about resident work hours going on on their blogs. I personally believe that resident work hours are often onerous beyond any need for patient care, but I don’t think that’s necessarily a disaster in and of itself. I believe that the long work hours are, in fact, not a problem, but a symptom of the real problem, which is the total control residency programs have over medical licensure and board certification. This control can be misused in many ways, like making residents work long hours for cheap; to me, however, the greater misuse of that control is the ability of residency program directors to demand unethical and arguably criminal behavior from their residents.
Yeah, I bet that got your attention. What am I talking about? Well, here’s my story.
While in medical school, I was the second author of a national presentation on the law and ethics of informed consent in emergency situations (Prehospital use of Tissue Plasminogen Activator, Pamela Grim et al, presented at the 1988 meeting of the University Association for Emergency Medicine). In order to help create that presentation, I studied the law of informed consent from many perspectives. As such, I feel that I was, and to a lesser extent still am, well versed in the legal and ethical requirements of obtaining informed consent for medical procedures.
One of the main tenets of obtaining informed consent is the requirement that the patient, or the patient’s guardian be informed about all significant risks to a procedure. There are some exceptions for emergencies, and a few other situations, under the “doctrine of implied consent,” but, in general, patients rely on their doctors to inform them, and doctors have an obligation to do so. Contrary to some opinions, it is not the job of a physician to talk the patients into whatever cockamamie procedure happens to generate the highest reimbursements.
For anesthesiologists, for example, what constitutes a “significant risk” is often a matter of disagreement but it’s very hard to make the argument that THE most common cause of lawsuits against anesthesiologists should not be considered a “significant risk.” On the other end of the spectrum, it’s very hard to argue that death, which, though rare, is a particularly horrible consequence of general and spinal anesthesia, is not a significant risk.
After graduating from medical school, I took a residency spot at the UCLA department of Anesthesia. I made an effort to meet my responsibilities regarding informed consent, and it was there that I eventually realized that there was a problem. After obtaining consent for various procedures, I was often told that I could not tell patients the risks I had just told them. There seemed to be no set of risks that I was allowed to tell patients. In particular, Dr. Michael Sopher, the residency program head, specifically told me that I could not tell patients about the risks of dental damage (the number one source of lawsuits against anesthesiologists) because dental damage “wasn’t a significant risk.” He told me that I could not inform patients about the risk of death because “it was too rare.”
A quick aside: although I believe that death is a significant risk even if the chance of death is rare, the sad fact is that death from anesthetic misadventure was all too common at UCLA. I am aware of two children who died prematurely while under anesthesia at UCLA during the less-than-a-year that I was there. One child was not my patient, but I understand it was a healthy child who suffered an arrest while under, and simply died for “no reason.”
The other child was one of my patients, assigned to me when I had been a resident for about two months. This two year old child had a congenital heart defect, and essential tachycardia, with baseline hypoxia. Because of that tachycardia, my attending elected not to give the child pre-induction atropine. When the child was induced, he had an apparently vagal response to intubation, had a short period of bradycardia, and got even more hypoxic. This was followed by asystole. He was coded, and his heart came back, but the child never woke up. An EEG two days later was flat. If the child had been atropinized, I believe he might have survived the procedure (a hernia repair, for anyone who is interested).
It was bad enough that these children died. What was completely mind-boggling was that there was no M&M (morbidity and mortality conference) related to those deaths. In the case of "my" patient who died: once it became obvious that the resident (me) could not be blamed for the death, it was as if the death never happened. (It was the attending's plan that had gone wrong, and the attending never had a chance to leave the OR after induction since the plan went wrong so quickly.) In neither case was there a serious investigation into the cause of death, nor any attempt to generate lessons learned. Yes, I learned something – always atropinize children before induction of general anesthesia – but my attending and I should have presented that mismanaged case to the rest of the department, in an effort to prevent future mishaps. I probably should have learned something from the death of the healthy child who died for "no reason," but that death was also never presented at M&M. Draw your own conclusions. That sort of pretending that bad things didn't really happen had echoes in other cases, such as the "intentional, despicable and unprofessional" actions surrounding damage to Ms. Denise DeSoto. (last link added 03/26/2011)
Back to the main story. Dr. Sopher told me that I would bear no legal responsibility for failure to inform of the risks of anesthesia because “I guarantee you, no one has ever been sued for that.” Another attending, Dr. Blockmaans, told me “you can’t tell old people the risks of anesthesia …. old people just can’t handle it.” Finally, I was 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?” The implication was clear to me then, and I trust it is clear to you now.
Of course, every one of the quoted statements above is mistaken, and was mistaken at the time. It is relevant to note that, since I left UCLA, UCLA, UCI, UCSD, and UCSF have all had suspension or cancellation of programs after medical research or practice was done without proper informed consent. In UCLA’s case, the Westwood VA (partially administered by UCLA, with physicians who work at both UCLA and at the Westwood VA) had it’s human research approval suspended because they had conducted research on people not only without their consent, but allegedly over the express refusal of at least one patient (I can't find a reference for that last part, but I believe that's what led the VA to suspend human research).
Due to my expressed difference of opinion about what constituted proper informed consent, I made multiple appointments with my residency program director to watch him obtain informed consent. He missed every appointment, and I never saw him obtain any consents.
It is also relevant to note, that, before I left UCLA, I encountered a patient who had apparently been advised by her surgeon, Dr. Susan Love, to bring a tape recorder with her to her preoperative meeting with the anesthesia department. I never spoke to Dr. Love about this, so I don’t know her motivation behind that recommendation, but it is my guess that Dr. Love also understood that the consent obtained by the department of anesthesia was not truly informed.
I also encountered what I eventually realized was “Hollywood-style” medicine. In one case, I personally witnessed the director of the pain management program, Dr. Anthony Nyurges, berate one of my postoperative patients to the point of tears when she requested Demerol (as opposed to other narcotics) for her pain (this patient was a former drug abuser, and knew her narcotics). I don’t believe in Demerol, but this same physician, on the same service, in the same hospital, in the same month, authorized very large doses of Demerol, on an ongoing basis (i.e. not immediately post-op) for a “powerful” Los Angeles figure when that patient had no objective signs of pain. Demerol is generally considered to have one of the greatest euphorogenic to analgesic ratio of any common narcotic (i.e. it makes people feel “happy” out of proportion to it’s pain-killing properties), and is therefore a drug generally favored by people who want to get high, and disfavored by people who are in actual pain.
I admit, and am glad, that I did not fit into the UCLA anesthesia residency program. I resigned from that program.
Unbeknownst to me at the time, federal agencies were also finding fault with University of California informed consent procedures while I was struggling to convince my superiors at UCLA of the importance of informed consent. Here is a list of publicized scandals revolving around informed consent in the University of California System:
UCLA: From the LA times:
• 1993: UCLA informed consent procedures had already been criticized by federal regulators, and had been changed in response to federal requirements. Even so, a 1993 law review article by Dr. Jay Katz of Yale, “tore into the new [informed consent] form that UCLA created in response to the government's [earlier] requirements, still finding it misleading, vague and inadequate.”
• March 1994: Dr. Michael Gitlin and Dr. Keith Nuechterlein of UCLA were officially reprimanded by the NIH in March of 1994 for issues with the procedure used to obtain informed consent. Procedures used to obtain informed consent, presumably approved by the UCLA IRB, were described as “immoral from the perspective of informed consent, because (they) were deceiving subjects” in an article about this in the LA times. The research for which Drs Gitlin and Neuchterlien apparently did not obtain informed consent may have been responsible for the suicide of Tony Lamadrid, one of the research subjects.
(addendum: Mr. LaMadrid, apparently unknown to him, was a research subject in an experimental protocol designed to assay the pharmacokinetics of drugs for schitzophrenia. According to the father of one of the surviving members of the Nuechterliein-Gitlin study, Mr. Lamadrid, a previously well-compensated adult, and apparently unaware that he was in the study, drifted into decompensated schitzophrenia as his meds were replaced with placebos. Mr. Lamadrid then told his "counsellor," who apparently was, in reality, a research monitor, that he was planning to kill himself. Nothing was done, Mr. Lamadrid's meds were not restarted, and Mr. Lamadrid went home and killed himself.
Further, according to this same source, the existence of a federally-required advocate whose presence might have prevented such an outcome had been fraudulently certified by someone in the office of the Chancellor of UCLA. In other words, a ghost UCLA employee had been created and certified to exist, but was later found out never to have been real.
You may wish to keep those items in mind as you read the next sentence)
• September 1994: According to the LA times, “from all appearances, the controversy over the Nuechterlein-Gitlin study hasn't caused any deep soul-searching at UCLA.”
• March 1999: The West Los Angeles Veterans Affairs Medical Center (which shares physicians, staff, research, etc with UCLA) had it’s authorization to conduct human research suspended after continuing allegations of failure to obtain informed consent for studies. I can’t find documentation for the following assertion, but I believe that, in this case, at least one person was alleged to have been the subject of medical experimentation even after expressly refusing to be part of a research protocol.
UCI (From the Orange County Register):
• May 1995: Three doctors at UCI Center for Reproductive Health accused of stealing eggs from an Orange County patient without her consent and transferring them to another woman, who delivered a baby boy. Eventually, doctors resign from university, two flee country and clinic closes. More than 100 women are victims.
Years later, (the rest of this paragraph is not from the OC register) I worked with a former trustee of the University of California who told me why he had resigned his trusteeship. According to him, up until the time the reproductive endocrinology staff fled the country, the trustees had been planning to back them to the hilt, not because of contractual obligations, a sense that they had been unfairly accused, or a commitment to their employees, but because of the money brought in by the reproductive endocrinology clinic. When the department fled the country to avoid federal prosecution, the point was moot, but this trustee resigned anyway.
• 1996: Researcher Dr. John Hiserodt treated cancer patients with unapproved doses of experimental vaccine, grew human tissues without required federal and university approval, and injected experimental compound not approved for human use into brain of Miami girl dying from cancer.
• June 1997: UCI Medical Center tissue and organ bank closed after finding employee has personal relationship with president of company that does business with the bank. Hundreds of human-tissue specimens had to be destroyed because of poor record-keeping and storage.
• December 1998: UCI officials say 27 dying cancer patients in clinical trials may have been improperly charged thousands of dollars. At least nine others were encouraged to make donations to get loved ones into trials. UCI offers refunds of $1,450 to $4,000.
• September 1998: Associate clinical professor Dr. Darryl See resigns after university inquiry concludes he used patients' blood samples in two unapproved research projects on AIDS and chronic fatigue syndrome. He later publishes a study, purportedly based on his UCI research, that is used to sell nutritional supplements.
• August 1999: UCI suspends the director of the medical school's Willed Body Program, Christopher S. Brown, after finding evidence that he sold donated bodies. UCI fires him in September.
UC San Diego:
• 1995: Dr. Ricardo Asch, as well as Drs. Jose Balmaceda and Sergio Stone, and their employee, Dr. Jane Frederick, of UCSD, are sued by three different parties alleging unapproved use of human eggs for zoology research, and transfer to other childless couples without the consent or knowledge of the egg “donor.” I don’t have the results of those lawsuits.
Again, the above cases are simply the ones that made the papers. I know of more.
My point? Residency programs have far too much power over their residents, and can generally act with impunity towards them. This causes problems. Just this month, I became aware of a woman who came to UCLA with chest pain in late May 2002, was sedated for the pain, and WHILE SEDATED AND ALONE was then induced to give consent for entry into a cardiology research protocol.
This wasn't a resuscitation situation, or apparently even much of an urgent situation. This woman's caretaker had simply gone out to the car to get a few things, and, in the interim, the sedated woman "gave consent" to be entered into a research protocol. This same woman eventually sustained so much heart damage that she wound up getting a heart transplant. It’s my bet that the resident or fellow who got the "consent" for research felt that he was under pressure to enroll people in the study, and that it wasn’t such a great idea to wait for family members or for the patient to no longer be sedated. Long work hours aren’t the worst effect of the control training programs have over their trainees. Not by a long shot.
Oh yeah ... since I'm naming names, I might as well put up my own name. For those who don't want to deal with the challenge of figuring out who I am ... my name is Peter T. Banos, MD, MBA. I got the MBA a few years after leaving UCLA; graduated from the University of Chicago in 1999, with concentrations in entrepreneurship and finance. And yes, I have met Megan McArdle.
Yeah, I bet that got your attention. What am I talking about? Well, here’s my story.
While in medical school, I was the second author of a national presentation on the law and ethics of informed consent in emergency situations (Prehospital use of Tissue Plasminogen Activator, Pamela Grim et al, presented at the 1988 meeting of the University Association for Emergency Medicine). In order to help create that presentation, I studied the law of informed consent from many perspectives. As such, I feel that I was, and to a lesser extent still am, well versed in the legal and ethical requirements of obtaining informed consent for medical procedures.
One of the main tenets of obtaining informed consent is the requirement that the patient, or the patient’s guardian be informed about all significant risks to a procedure. There are some exceptions for emergencies, and a few other situations, under the “doctrine of implied consent,” but, in general, patients rely on their doctors to inform them, and doctors have an obligation to do so. Contrary to some opinions, it is not the job of a physician to talk the patients into whatever cockamamie procedure happens to generate the highest reimbursements.
For anesthesiologists, for example, what constitutes a “significant risk” is often a matter of disagreement but it’s very hard to make the argument that THE most common cause of lawsuits against anesthesiologists should not be considered a “significant risk.” On the other end of the spectrum, it’s very hard to argue that death, which, though rare, is a particularly horrible consequence of general and spinal anesthesia, is not a significant risk.
After graduating from medical school, I took a residency spot at the UCLA department of Anesthesia. I made an effort to meet my responsibilities regarding informed consent, and it was there that I eventually realized that there was a problem. After obtaining consent for various procedures, I was often told that I could not tell patients the risks I had just told them. There seemed to be no set of risks that I was allowed to tell patients. In particular, Dr. Michael Sopher, the residency program head, specifically told me that I could not tell patients about the risks of dental damage (the number one source of lawsuits against anesthesiologists) because dental damage “wasn’t a significant risk.” He told me that I could not inform patients about the risk of death because “it was too rare.”
A quick aside: although I believe that death is a significant risk even if the chance of death is rare, the sad fact is that death from anesthetic misadventure was all too common at UCLA. I am aware of two children who died prematurely while under anesthesia at UCLA during the less-than-a-year that I was there. One child was not my patient, but I understand it was a healthy child who suffered an arrest while under, and simply died for “no reason.”
The other child was one of my patients, assigned to me when I had been a resident for about two months. This two year old child had a congenital heart defect, and essential tachycardia, with baseline hypoxia. Because of that tachycardia, my attending elected not to give the child pre-induction atropine. When the child was induced, he had an apparently vagal response to intubation, had a short period of bradycardia, and got even more hypoxic. This was followed by asystole. He was coded, and his heart came back, but the child never woke up. An EEG two days later was flat. If the child had been atropinized, I believe he might have survived the procedure (a hernia repair, for anyone who is interested).
It was bad enough that these children died. What was completely mind-boggling was that there was no M&M (morbidity and mortality conference) related to those deaths. In the case of "my" patient who died: once it became obvious that the resident (me) could not be blamed for the death, it was as if the death never happened. (It was the attending's plan that had gone wrong, and the attending never had a chance to leave the OR after induction since the plan went wrong so quickly.) In neither case was there a serious investigation into the cause of death, nor any attempt to generate lessons learned. Yes, I learned something – always atropinize children before induction of general anesthesia – but my attending and I should have presented that mismanaged case to the rest of the department, in an effort to prevent future mishaps. I probably should have learned something from the death of the healthy child who died for "no reason," but that death was also never presented at M&M. Draw your own conclusions. That sort of pretending that bad things didn't really happen had echoes in other cases, such as the "intentional, despicable and unprofessional" actions surrounding damage to Ms. Denise DeSoto. (last link added 03/26/2011)
Back to the main story. Dr. Sopher told me that I would bear no legal responsibility for failure to inform of the risks of anesthesia because “I guarantee you, no one has ever been sued for that.” Another attending, Dr. Blockmaans, told me “you can’t tell old people the risks of anesthesia …. old people just can’t handle it.” Finally, I was 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?” The implication was clear to me then, and I trust it is clear to you now.
Of course, every one of the quoted statements above is mistaken, and was mistaken at the time. It is relevant to note that, since I left UCLA, UCLA, UCI, UCSD, and UCSF have all had suspension or cancellation of programs after medical research or practice was done without proper informed consent. In UCLA’s case, the Westwood VA (partially administered by UCLA, with physicians who work at both UCLA and at the Westwood VA) had it’s human research approval suspended because they had conducted research on people not only without their consent, but allegedly over the express refusal of at least one patient (I can't find a reference for that last part, but I believe that's what led the VA to suspend human research).
Due to my expressed difference of opinion about what constituted proper informed consent, I made multiple appointments with my residency program director to watch him obtain informed consent. He missed every appointment, and I never saw him obtain any consents.
It is also relevant to note, that, before I left UCLA, I encountered a patient who had apparently been advised by her surgeon, Dr. Susan Love, to bring a tape recorder with her to her preoperative meeting with the anesthesia department. I never spoke to Dr. Love about this, so I don’t know her motivation behind that recommendation, but it is my guess that Dr. Love also understood that the consent obtained by the department of anesthesia was not truly informed.
I also encountered what I eventually realized was “Hollywood-style” medicine. In one case, I personally witnessed the director of the pain management program, Dr. Anthony Nyurges, berate one of my postoperative patients to the point of tears when she requested Demerol (as opposed to other narcotics) for her pain (this patient was a former drug abuser, and knew her narcotics). I don’t believe in Demerol, but this same physician, on the same service, in the same hospital, in the same month, authorized very large doses of Demerol, on an ongoing basis (i.e. not immediately post-op) for a “powerful” Los Angeles figure when that patient had no objective signs of pain. Demerol is generally considered to have one of the greatest euphorogenic to analgesic ratio of any common narcotic (i.e. it makes people feel “happy” out of proportion to it’s pain-killing properties), and is therefore a drug generally favored by people who want to get high, and disfavored by people who are in actual pain.
I admit, and am glad, that I did not fit into the UCLA anesthesia residency program. I resigned from that program.
Unbeknownst to me at the time, federal agencies were also finding fault with University of California informed consent procedures while I was struggling to convince my superiors at UCLA of the importance of informed consent. Here is a list of publicized scandals revolving around informed consent in the University of California System:
UCLA: From the LA times:
• 1993: UCLA informed consent procedures had already been criticized by federal regulators, and had been changed in response to federal requirements. Even so, a 1993 law review article by Dr. Jay Katz of Yale, “tore into the new [informed consent] form that UCLA created in response to the government's [earlier] requirements, still finding it misleading, vague and inadequate.”
• March 1994: Dr. Michael Gitlin and Dr. Keith Nuechterlein of UCLA were officially reprimanded by the NIH in March of 1994 for issues with the procedure used to obtain informed consent. Procedures used to obtain informed consent, presumably approved by the UCLA IRB, were described as “immoral from the perspective of informed consent, because (they) were deceiving subjects” in an article about this in the LA times. The research for which Drs Gitlin and Neuchterlien apparently did not obtain informed consent may have been responsible for the suicide of Tony Lamadrid, one of the research subjects.
(addendum: Mr. LaMadrid, apparently unknown to him, was a research subject in an experimental protocol designed to assay the pharmacokinetics of drugs for schitzophrenia. According to the father of one of the surviving members of the Nuechterliein-Gitlin study, Mr. Lamadrid, a previously well-compensated adult, and apparently unaware that he was in the study, drifted into decompensated schitzophrenia as his meds were replaced with placebos. Mr. Lamadrid then told his "counsellor," who apparently was, in reality, a research monitor, that he was planning to kill himself. Nothing was done, Mr. Lamadrid's meds were not restarted, and Mr. Lamadrid went home and killed himself.
Further, according to this same source, the existence of a federally-required advocate whose presence might have prevented such an outcome had been fraudulently certified by someone in the office of the Chancellor of UCLA. In other words, a ghost UCLA employee had been created and certified to exist, but was later found out never to have been real.
You may wish to keep those items in mind as you read the next sentence)
• September 1994: According to the LA times, “from all appearances, the controversy over the Nuechterlein-Gitlin study hasn't caused any deep soul-searching at UCLA.”
• March 1999: The West Los Angeles Veterans Affairs Medical Center (which shares physicians, staff, research, etc with UCLA) had it’s authorization to conduct human research suspended after continuing allegations of failure to obtain informed consent for studies. I can’t find documentation for the following assertion, but I believe that, in this case, at least one person was alleged to have been the subject of medical experimentation even after expressly refusing to be part of a research protocol.
UCI (From the Orange County Register):
• May 1995: Three doctors at UCI Center for Reproductive Health accused of stealing eggs from an Orange County patient without her consent and transferring them to another woman, who delivered a baby boy. Eventually, doctors resign from university, two flee country and clinic closes. More than 100 women are victims.
Years later, (the rest of this paragraph is not from the OC register) I worked with a former trustee of the University of California who told me why he had resigned his trusteeship. According to him, up until the time the reproductive endocrinology staff fled the country, the trustees had been planning to back them to the hilt, not because of contractual obligations, a sense that they had been unfairly accused, or a commitment to their employees, but because of the money brought in by the reproductive endocrinology clinic. When the department fled the country to avoid federal prosecution, the point was moot, but this trustee resigned anyway.
• 1996: Researcher Dr. John Hiserodt treated cancer patients with unapproved doses of experimental vaccine, grew human tissues without required federal and university approval, and injected experimental compound not approved for human use into brain of Miami girl dying from cancer.
• June 1997: UCI Medical Center tissue and organ bank closed after finding employee has personal relationship with president of company that does business with the bank. Hundreds of human-tissue specimens had to be destroyed because of poor record-keeping and storage.
• December 1998: UCI officials say 27 dying cancer patients in clinical trials may have been improperly charged thousands of dollars. At least nine others were encouraged to make donations to get loved ones into trials. UCI offers refunds of $1,450 to $4,000.
• September 1998: Associate clinical professor Dr. Darryl See resigns after university inquiry concludes he used patients' blood samples in two unapproved research projects on AIDS and chronic fatigue syndrome. He later publishes a study, purportedly based on his UCI research, that is used to sell nutritional supplements.
• August 1999: UCI suspends the director of the medical school's Willed Body Program, Christopher S. Brown, after finding evidence that he sold donated bodies. UCI fires him in September.
UC San Diego:
• 1995: Dr. Ricardo Asch, as well as Drs. Jose Balmaceda and Sergio Stone, and their employee, Dr. Jane Frederick, of UCSD, are sued by three different parties alleging unapproved use of human eggs for zoology research, and transfer to other childless couples without the consent or knowledge of the egg “donor.” I don’t have the results of those lawsuits.
Again, the above cases are simply the ones that made the papers. I know of more.
My point? Residency programs have far too much power over their residents, and can generally act with impunity towards them. This causes problems. Just this month, I became aware of a woman who came to UCLA with chest pain in late May 2002, was sedated for the pain, and WHILE SEDATED AND ALONE was then induced to give consent for entry into a cardiology research protocol.
This wasn't a resuscitation situation, or apparently even much of an urgent situation. This woman's caretaker had simply gone out to the car to get a few things, and, in the interim, the sedated woman "gave consent" to be entered into a research protocol. This same woman eventually sustained so much heart damage that she wound up getting a heart transplant. It’s my bet that the resident or fellow who got the "consent" for research felt that he was under pressure to enroll people in the study, and that it wasn’t such a great idea to wait for family members or for the patient to no longer be sedated. Long work hours aren’t the worst effect of the control training programs have over their trainees. Not by a long shot.
Oh yeah ... since I'm naming names, I might as well put up my own name. For those who don't want to deal with the challenge of figuring out who I am ... my name is Peter T. Banos, MD, MBA. I got the MBA a few years after leaving UCLA; graduated from the University of Chicago in 1999, with concentrations in entrepreneurship and finance. And yes, I have met Megan McArdle.
Saturday, May 04, 2002
Via email, I just got a request to sign this petition opposing a new INS rule allowing the INS to issue 30-day tourist visas (instead of the usual 6-month tourist visas).
Personally, I think that restricting tourist visas from foreign countries is completely reasonable during this time of crisis. Yes, I know that many people find it convenient to come to the US for six months, and, ordinarily, I think that’s great. In general, I am all for unrestricted tourism; there’s plenty of room, and, as long as visitors don’t become a public charge, I think it’s great that they come and spend money.
This isn’t, however, a time for “in general.” In February 1993, and again on September 11, 2001, it became blindingly obvious that there is a well-organized, dangerous group of people out there who are TRYING TO KILL US. All of us. Any of us. Whichever of us they can get. Letting almost everyone in on a six-month visa makes it easier for terrorists to come here, plan an attack, and carry it out.
Some would say that there is a case to be made for the complete elimination of tourist visas until the threat from foreign terrorists continues. Limiting tourist visa durations to one month is a compromise. If tourist visa durations are shortened, and enforcement procedures are improved to make visitors check in every month, then perhaps it will be harder for the next batch of terrorists to successfully organize the next terrorist attack. People who want to stay longer will probably have to check in with the INS every month. In a worst-likely-case-scenario, potential tourists will have to visit Canada or Mexico once a month. The INS will still be able to grant 6-month or longer tourist visas, if necessary. And, of course, this new 30-day rule will have no effect on student, work or business visas, or on legal immigration.
The petition organizers point out that the 30-day rule may invite retaliation from other governments. To me, that putative willingness of other governments to restrict US citizens is a feedback mechanism that will reduce the chance that the INS will apply the 30-day rule to everyone or in an unreasonable manner. The existence of such a feedback mechanism is another argument to adopt the 30-day rule.
Maybe it’ll work. Maybe it won’t. If it has a reasonable chance of preventing another terrorist attack, then it’s worth a try.
Should INS officials have the discretion to decide who gets a 1-month visa and who gets a 6-month visa? Given the abysmal record of the INS in keeping terrorists out, the answer seems to be a clear “no.” There’s just one problem: there’s nobody else to do it. So, by default, the INS gets the job.
The petition for the repeal of the 30-day rule points out that the new rule affects tourists from all over the world. The September 11 terrorists did not come to the US directly from Saudi Arabia, but from various countries in Europe. Lest someone think that there are no longer any potential terrorists in Europe, I present this picture FROM BERLIN:
Someone IN BERLIN dressed up the little girl as a weapon. Someone IN BERLIN thought it was a good idea to portray that child as nothing more than an expendable dynamite holder, destined to be reduced to little shreds of cooling meat after completing her terrorist mission. Allowing that person into the US for six full months is madness, even though that person is in Europe.
There are no rights, constitutional or otherwise, diminished by this new rule. Based on my review of the petition website, and a scan of some of the comments, the organizers and signatories make no argument that the 30-day rule would hinder or would not affect the war on terrorism. The tradeoff opposed by the petition organizers seems to be simply this: the US government is demanding that some non-citizens on pleasure trips get less bang for their travel buck, so that thousands of US citizens are less likely to be horribly slaughtered. I am shocked and saddened that so many people are unwilling to at least give that tradeoff a try.
UPDATE:
Holy smokes. According to this LA Times article, the INS has cited airlines 6,000 times for not ensuring that people who entered the US with NO visa actually left the country. Seems that the INS has a lot of fronts to cover.
Personally, I think that restricting tourist visas from foreign countries is completely reasonable during this time of crisis. Yes, I know that many people find it convenient to come to the US for six months, and, ordinarily, I think that’s great. In general, I am all for unrestricted tourism; there’s plenty of room, and, as long as visitors don’t become a public charge, I think it’s great that they come and spend money.
This isn’t, however, a time for “in general.” In February 1993, and again on September 11, 2001, it became blindingly obvious that there is a well-organized, dangerous group of people out there who are TRYING TO KILL US. All of us. Any of us. Whichever of us they can get. Letting almost everyone in on a six-month visa makes it easier for terrorists to come here, plan an attack, and carry it out.
Some would say that there is a case to be made for the complete elimination of tourist visas until the threat from foreign terrorists continues. Limiting tourist visa durations to one month is a compromise. If tourist visa durations are shortened, and enforcement procedures are improved to make visitors check in every month, then perhaps it will be harder for the next batch of terrorists to successfully organize the next terrorist attack. People who want to stay longer will probably have to check in with the INS every month. In a worst-likely-case-scenario, potential tourists will have to visit Canada or Mexico once a month. The INS will still be able to grant 6-month or longer tourist visas, if necessary. And, of course, this new 30-day rule will have no effect on student, work or business visas, or on legal immigration.
The petition organizers point out that the 30-day rule may invite retaliation from other governments. To me, that putative willingness of other governments to restrict US citizens is a feedback mechanism that will reduce the chance that the INS will apply the 30-day rule to everyone or in an unreasonable manner. The existence of such a feedback mechanism is another argument to adopt the 30-day rule.
Maybe it’ll work. Maybe it won’t. If it has a reasonable chance of preventing another terrorist attack, then it’s worth a try.
Should INS officials have the discretion to decide who gets a 1-month visa and who gets a 6-month visa? Given the abysmal record of the INS in keeping terrorists out, the answer seems to be a clear “no.” There’s just one problem: there’s nobody else to do it. So, by default, the INS gets the job.
The petition for the repeal of the 30-day rule points out that the new rule affects tourists from all over the world. The September 11 terrorists did not come to the US directly from Saudi Arabia, but from various countries in Europe. Lest someone think that there are no longer any potential terrorists in Europe, I present this picture FROM BERLIN:
Someone IN BERLIN dressed up the little girl as a weapon. Someone IN BERLIN thought it was a good idea to portray that child as nothing more than an expendable dynamite holder, destined to be reduced to little shreds of cooling meat after completing her terrorist mission. Allowing that person into the US for six full months is madness, even though that person is in Europe.
There are no rights, constitutional or otherwise, diminished by this new rule. Based on my review of the petition website, and a scan of some of the comments, the organizers and signatories make no argument that the 30-day rule would hinder or would not affect the war on terrorism. The tradeoff opposed by the petition organizers seems to be simply this: the US government is demanding that some non-citizens on pleasure trips get less bang for their travel buck, so that thousands of US citizens are less likely to be horribly slaughtered. I am shocked and saddened that so many people are unwilling to at least give that tradeoff a try.
UPDATE:
Holy smokes. According to this LA Times article, the INS has cited airlines 6,000 times for not ensuring that people who entered the US with NO visa actually left the country. Seems that the INS has a lot of fronts to cover.
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