Kaiser Permanente's Code of Silence
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.
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.
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.
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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