Medicine's Fatal Code of Silence
Eight-year-old Richard Leonard was undergoing `minor surgery' when he died at a
Denver hospital. His anesthesiologist was known as a problem. But the peer
review system kept his parents in the dark.
Series: Medicine's Fatal Code of Silence.
FIRST OF TWO PARTS
BARRY SIEGEL.
Los Angeles Times
Aug 24, 1995.
Verbrugge, after taking a medical history, left to scrub and dress. Nurse Mary Kay
Harrell eased Richard into a wheelchair, rolled him toward an elevator. China
walked by her son, he was so quiet and tense. At Operating Room 7, she watched
him disappear through the swinging double doors.
Much has transpired since Richard's death. An outraged doctor has blown the
whistle on his colleague, inspiring an investigation and hearing.
Colorado's Board of Medical Examiners has revoked Verbrugge's license.
Denver's district attorney has charged Verbrugge with reckless
manslaughter, an extraordinary action. With the trial pending, debates
wage now over peer review secrecy, the medical profession's
self-policing and criminal prosecutions of doctors.
By several colleagues' accounts, he also was not a person who remained
ever-alert in operating rooms. After Richard's death, Verbrugge would tell a
psychiatrist it was possible that some of the St. Joseph staff reports about him
"nodding off" were accurate, related to sleep deprivation and family stress. At the
medical board hearing into Richard's death, Verbrugge would testify that "in one
particular case, I talked to the surgeon, he said he saw me nodding off . . . . I
acknowledged the possibility." He tried not to fall asleep, but "I'm sure I have . . . .
Once in a five-hour operation, the lights were down, there was absolutely nothing
for me to do."
From the moment China Leonard met Dr. Joseph Verbrugge Jr., she didn't like
him. They were in a pre-op room at Denver's St. Joseph Hospital, where China's
son Richard, 8, was being prepared for minor ear surgery. It was 7:15 a.m. on July
8, 1993. Verbrugge, the scheduled anesthesiologist, had rushed in late, acting
bristly and abrupt.
"Well, are you nervous?" Verbrugge demanded of Richard.
Richard didn't look up from the television. He'd been uncommonly subdued all
morning. Not once had China seen him cock his head and ask the customary
barrage of questions.
"Richard," Verbrugge demanded, "look at me."
Richard kept his eye on the TV.
Verbrugge shrugged, rolled his eyes at China, muttered something about kids and
TV.
China reached for her son. He was quiet, she knew, because he was scared. This
doctor seemed so curt, so unpleasant. An impulse to cancel the operation
fleetingly crossed her mind. She shook it off.
It didn't matter about this doctor's personality, she reasoned. She couldn't judge
anything by that. They were at one of the best hospitals in Colorado, top-ranked
by professional groups and consumers. The oldest private teaching hospital in
Denver, St. Joseph had been owned by the Sisters of Charity since 1873.
You have to assume you're in safe hands, China Leonard told herself. You have
to assume this doctor is good.
Although there was no possible way for her to know it, China's instincts about
Verbrugge at this moment were far more reliable than her assumptions
about the medical system.
For years, Verbrugge's hospital colleagues had been finding him just as
difficult and abrasive as did China. Worse yet, they'd grown increasingly
bothered by his inattentive behavior during surgeries. In fact, on at least
six occasions since September, 1990, they'd informed the hospital that he
appeared to be sleeping during operations.
Verbrugge had never been sued, though, or suspended, or
reported to the state Board of Medical Examiners.
St. Joseph had handled the anesthesiologist's problems
internally, through the hospital's private, confidential peer
review process. To do otherwise would have involved
hearings, lawyers, confrontations, tarnished careers.
So no one beyond the local medical community knew
about Verbrugge's problems.
And no one could know. Even if she'd raised questions, China would have
heard nothing untoward. She could not have foreseen that she and her
husband were about to receive a terrible, involuntary education concerning the
ways of medicine when it goes wrong.
Sitting in the pre-op room, China reassured her son. You'll be asleep soon, she
whispered. Before you know, it will be over. Think of what we'll do afterward.
Swimming parties, the zoo.
Verbrugge, after taking a medical history, left to scrub and dress. Nurse Mary Kay
Harrell eased Richard into a wheelchair, rolled him toward an elevator. China
walked by her son, he was so quiet and tense. At Operating Room 7, she watched
him disappear through the swinging double doors.
That would be the last moment she saw her son alive.
Much has transpired since Richard's death. An outraged doctor has blown the
whistle on his colleague, inspiring an investigation and hearing. Colorado's Board
of Medical Examiners has revoked Verbrugge's license. Denver's district attorney
has charged Verbrugge with reckless manslaughter, an extraordinary action. With
the trial pending, debates wage now over peer review secrecy, the medical
profession's self-policing and criminal prosecutions of doctors.
Yet who finally is responsible for Richard Leonard's death remains a largely
unexamined question. Only Verbrugge faces a criminal trial. Elsewhere a shaken
medical community, watching from behind the protective barrier of lawyers and
peer review privileges, is left to contemplate privately its role in Richard's death.
The question of broader moral responsibility begs still for consideration.
The Leonards' tragic loss is finally a story about doctors, nurses and
administrators who knew they had a problem physician on their hands but failed to
find a way to handle him, or stop him.
"This was not about a good doctor having a bad day," observed the physician who
blew the whistle on Verbrugge. "This was about a bad guy having a terrible day."
A Troublesome Ear
By the time Richard arrived at St. Joseph on July 8, he and his family were
thoroughly familiar with hospitals. For years, Richard had been plagued by ear
infections that resisted antibiotics. When he was 3, doctors put tubes in his ears,
to help drainage, in a 20-minute operation under general anesthesia. Later, an
infection required them to remove one tube in a second brief operation, also
under general anesthesia.
Eventually, due to repeated infections, skin tissue started growing inside Richard's
right ear. It wouldn't stop growing. "Elective surgery," the doctors called the
operation to remove it. Sooner or later, though, the skin had to go.
Sooner, the Leonards decided. The sooner Richard's impaired hearing could be
corrected, the better.
The operation, a tympanoplasty and mastoidectomy, would be delicate, meticulous
and long, up to four hours. It would involve the removal of the eardrum, drilling,
scraping, reconstruction. But for all that, it was considered by doctors a minor
procedure, with low risk.
The Leonards, who own a specialized software company, had enrolled
their employees in the Kaiser Permanente medical plan, which in Denver
contracts for hospital beds, chiefly at St. Joseph. Under Kaiser the Leonards
had their choice of the group's surgeons. Their pediatrician recommended Dr.
Patrick G. McCallion.
China and Jay Leonard liked him when they met. McCallion was just 31, but he
appeared knowledgeable. He'd done this type of surgery many times before. He
was patient, thorough, didn't seem bothered when China peppered him with
questions. He reassured them when Jay asked about risk.
The Leonards didn't inquire about anesthesiologists, and McCallion didn't work
regularly with one in particular. Under the Kaiser plan, the Leonards could have
interviewed candidates, but it never occurred to them. Richard, after all, had
undergone general anesthesia twice before, and so had others in the family. They
took the anesthesia process for granted.
Eight-year-old Richard Leonard was undergoing `minor surgery' when he died at a
Denver hospital. His anesthesiologist was known as a problem. But the peer
review system kept his parents in the dark.
Series: Medicine's Fatal Code of Silence.
FIRST OF TWO PARTS
BARRY SIEGEL.
Los Angeles Times
Aug 24, 1995.
Verbrugge, after taking a medical history, left to scrub and dress. Nurse Mary Kay
Harrell eased Richard into a wheelchair, rolled him toward an elevator. China
walked by her son, he was so quiet and tense. At Operating Room 7, she watched
him disappear through the swinging double doors.
Much has transpired since Richard's death. An outraged doctor has blown the
whistle on his colleague, inspiring an investigation and hearing.
Colorado's Board of Medical Examiners has revoked Verbrugge's license.
Denver's district attorney has charged Verbrugge with reckless
manslaughter, an extraordinary action. With the trial pending, debates
wage now over peer review secrecy, the medical profession's
self-policing and criminal prosecutions of doctors.
By several colleagues' accounts, he also was not a person who remained
ever-alert in operating rooms. After Richard's death, Verbrugge would tell a
psychiatrist it was possible that some of the St. Joseph staff reports about him
"nodding off" were accurate, related to sleep deprivation and family stress. At the
medical board hearing into Richard's death, Verbrugge would testify that "in one
particular case, I talked to the surgeon, he said he saw me nodding off . . . . I
acknowledged the possibility." He tried not to fall asleep, but "I'm sure I have . . . .
Once in a five-hour operation, the lights were down, there was absolutely nothing
for me to do."
From the moment China Leonard met Dr. Joseph Verbrugge Jr., she didn't like
him. They were in a pre-op room at Denver's St. Joseph Hospital, where China's
son Richard, 8, was being prepared for minor ear surgery. It was 7:15 a.m. on July
8, 1993. Verbrugge, the scheduled anesthesiologist, had rushed in late, acting
bristly and abrupt.
"Well, are you nervous?" Verbrugge demanded of Richard.
Richard didn't look up from the television. He'd been uncommonly subdued all
morning. Not once had China seen him cock his head and ask the customary
barrage of questions.
"Richard," Verbrugge demanded, "look at me."
Richard kept his eye on the TV.
Verbrugge shrugged, rolled his eyes at China, muttered something about kids and
TV.
China reached for her son. He was quiet, she knew, because he was scared. This
doctor seemed so curt, so unpleasant. An impulse to cancel the operation
fleetingly crossed her mind. She shook it off.
It didn't matter about this doctor's personality, she reasoned. She couldn't judge
anything by that. They were at one of the best hospitals in Colorado, top-ranked
by professional groups and consumers. The oldest private teaching hospital in
Denver, St. Joseph had been owned by the Sisters of Charity since 1873.
You have to assume you're in safe hands, China Leonard told herself. You have
to assume this doctor is good.
Although there was no possible way for her to know it, China's instincts about
Verbrugge at this moment were far more reliable than her assumptions
about the medical system.
For years, Verbrugge's hospital colleagues had been finding him just as
difficult and abrasive as did China. Worse yet, they'd grown increasingly
bothered by his inattentive behavior during surgeries. In fact, on at least
six occasions since September, 1990, they'd informed the hospital that he
appeared to be sleeping during operations.
Verbrugge had never been sued, though, or suspended, or
reported to the state Board of Medical Examiners.
St. Joseph had handled the anesthesiologist's problems
internally, through the hospital's private, confidential peer
review process. To do otherwise would have involved
hearings, lawyers, confrontations, tarnished careers.
So no one beyond the local medical community knew
about Verbrugge's problems.
And no one could know. Even if she'd raised questions, China would have
heard nothing untoward. She could not have foreseen that she and her
husband were about to receive a terrible, involuntary education concerning the
ways of medicine when it goes wrong.
Sitting in the pre-op room, China reassured her son. You'll be asleep soon, she
whispered. Before you know, it will be over. Think of what we'll do afterward.
Swimming parties, the zoo.
Verbrugge, after taking a medical history, left to scrub and dress. Nurse Mary Kay
Harrell eased Richard into a wheelchair, rolled him toward an elevator. China
walked by her son, he was so quiet and tense. At Operating Room 7, she watched
him disappear through the swinging double doors.
That would be the last moment she saw her son alive.
Much has transpired since Richard's death. An outraged doctor has blown the
whistle on his colleague, inspiring an investigation and hearing. Colorado's Board
of Medical Examiners has revoked Verbrugge's license. Denver's district attorney
has charged Verbrugge with reckless manslaughter, an extraordinary action. With
the trial pending, debates wage now over peer review secrecy, the medical
profession's self-policing and criminal prosecutions of doctors.
Yet who finally is responsible for Richard Leonard's death remains a largely
unexamined question. Only Verbrugge faces a criminal trial. Elsewhere a shaken
medical community, watching from behind the protective barrier of lawyers and
peer review privileges, is left to contemplate privately its role in Richard's death.
The question of broader moral responsibility begs still for consideration.
The Leonards' tragic loss is finally a story about doctors, nurses and
administrators who knew they had a problem physician on their hands but failed to
find a way to handle him, or stop him.
"This was not about a good doctor having a bad day," observed the physician who
blew the whistle on Verbrugge. "This was about a bad guy having a terrible day."
A Troublesome Ear
By the time Richard arrived at St. Joseph on July 8, he and his family were
thoroughly familiar with hospitals. For years, Richard had been plagued by ear
infections that resisted antibiotics. When he was 3, doctors put tubes in his ears,
to help drainage, in a 20-minute operation under general anesthesia. Later, an
infection required them to remove one tube in a second brief operation, also
under general anesthesia.
Eventually, due to repeated infections, skin tissue started growing inside Richard's
right ear. It wouldn't stop growing. "Elective surgery," the doctors called the
operation to remove it. Sooner or later, though, the skin had to go.
Sooner, the Leonards decided. The sooner Richard's impaired hearing could be
corrected, the better.
The operation, a tympanoplasty and mastoidectomy, would be delicate, meticulous
and long, up to four hours. It would involve the removal of the eardrum, drilling,
scraping, reconstruction. But for all that, it was considered by doctors a minor
procedure, with low risk.
The Leonards, who own a specialized software company, had enrolled
their employees in the Kaiser Permanente medical plan, which in Denver
contracts for hospital beds, chiefly at St. Joseph. Under Kaiser the Leonards
had their choice of the group's surgeons. Their pediatrician recommended Dr.
Patrick G. McCallion.
China and Jay Leonard liked him when they met. McCallion was just 31, but he
appeared knowledgeable. He'd done this type of surgery many times before. He
was patient, thorough, didn't seem bothered when China peppered him with
questions. He reassured them when Jay asked about risk.
The Leonards didn't inquire about anesthesiologists, and McCallion didn't work
regularly with one in particular. Under the Kaiser plan, the Leonards could have
interviewed candidates, but it never occurred to them. Richard, after all, had
undergone general anesthesia twice before, and so had others in the family. They
took the anesthesia process for granted.
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Secrets Doctors Keep from the Public
Written "Codes of silence" are part of the contract doctors are required to
sign at many hospitals (see second story below)
See also SV-40
Written "Codes of silence" are part of the contract doctors are required to
sign at many hospitals (see second story below)
See also SV-40
It isn't just Kaiser that covers up the truth to protect the
organization
Shocking Provisions in Medical Staff Bylaws
Jan 7, 2012
Submitted by a physician:
Here is one of the most shocking provisions concerning criteria for initiation of
corrective action in medical staff bylaws I have seen to date.
Comments from physician on above criteria:
1. "fails to provide quality care in an efficient or resource-effective manner
Physicians who prefer to use certain name-brand medications (or expensive IV
antibiotics)
over generics, or who believe that certain surgical implants
are superior to cheaper alternatives could be prime candidates
for attack under this provision. I am aware of one case where the
spine surgeon refused to use very cheap, inferior implants because
he believed they were unsafe for patients, and the hospital attacked him
on that issue.
2. "significantly affects reimbursement to the Hospital in an adverse manner"
Those physicians who refuse to go along with the "creative" coding
of the professional coders employed by the hospital (perhaps because
they believe it is fraud) so as to maximize revenue from the third party
payor could find themselves on the hospital's "hit list." Also, what happens
if a managed care company insists that 100% of physicians on medical staff
participate with their plan or they will provide a much lower level of
reimbursement
to the hospital?
3. "causes an intensified review of the Hospital by any government or private
reviewing agency"
A physician who is not successful in correcting a hospital-created
deficiency or substandard or unsafe care situation by going through
the hospital system, may ethically decide to report substandard or
unsafe care to an outside agency - HHS, Dept of Health, JCAHO etc.
However, if the physician did that, it could lead to an investigation,
which would then meet criteria to initiate corrective action against the physician.
We have seen this type of policy promulgated in the "code of conduct" in
hospitals,
where they essentially specifiy "thou shalt not be a physician whistleblower."
This, however, is the first time I have seen it specifically listed in medical staff
bylaws as a criteria to initiate corrective action. Remember the Clark v. Columbia
HCA case from 2001. This is precisely what happened to Dr. Clark. Because he
reported substandard care to outside agencies (after calling it to the hospital
administration's attention and the hospital refused to correct the situation),
the hospital terminated Dr. Clark's privileges. Dr. Clark eventually prevailed in
court.
organization
Shocking Provisions in Medical Staff Bylaws
Jan 7, 2012
Submitted by a physician:
Here is one of the most shocking provisions concerning criteria for initiation of
corrective action in medical staff bylaws I have seen to date.
Comments from physician on above criteria:
1. "fails to provide quality care in an efficient or resource-effective manner
Physicians who prefer to use certain name-brand medications (or expensive IV
antibiotics)
over generics, or who believe that certain surgical implants
are superior to cheaper alternatives could be prime candidates
for attack under this provision. I am aware of one case where the
spine surgeon refused to use very cheap, inferior implants because
he believed they were unsafe for patients, and the hospital attacked him
on that issue.
2. "significantly affects reimbursement to the Hospital in an adverse manner"
Those physicians who refuse to go along with the "creative" coding
of the professional coders employed by the hospital (perhaps because
they believe it is fraud) so as to maximize revenue from the third party
payor could find themselves on the hospital's "hit list." Also, what happens
if a managed care company insists that 100% of physicians on medical staff
participate with their plan or they will provide a much lower level of
reimbursement
to the hospital?
3. "causes an intensified review of the Hospital by any government or private
reviewing agency"
A physician who is not successful in correcting a hospital-created
deficiency or substandard or unsafe care situation by going through
the hospital system, may ethically decide to report substandard or
unsafe care to an outside agency - HHS, Dept of Health, JCAHO etc.
However, if the physician did that, it could lead to an investigation,
which would then meet criteria to initiate corrective action against the physician.
We have seen this type of policy promulgated in the "code of conduct" in
hospitals,
where they essentially specifiy "thou shalt not be a physician whistleblower."
This, however, is the first time I have seen it specifically listed in medical staff
bylaws as a criteria to initiate corrective action. Remember the Clark v. Columbia
HCA case from 2001. This is precisely what happened to Dr. Clark. Because he
reported substandard care to outside agencies (after calling it to the hospital
administration's attention and the hospital refused to correct the situation),
the hospital terminated Dr. Clark's privileges. Dr. Clark eventually prevailed in
court.
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