Professional Practice Evaluation

Dr. Death – System Failures

By Anne Roberts, Esq., CPMSM, CPCS

The case of Christopher Duntsch has been the topic of one of the most popular podcasts of all time, “Dr. Death”, produced by the Wondry network.  With the upcoming July 15th release date of an 8-part series also entitled “Dr. Death”, which will stream on the Peacock TV, it continues to bring awareness to the failures that occurred within the healthcare system, and how the criminal justice system had to intervene. Additionally, this case also reinforces that Medical Staff Professionals play an important role as patient safety advocates.

When we evaluate the system failures in this case, we begin with the graduate medical education training program requirements. The ACGME requires that training programs ensure that their trainees meet specific requirements in regards to the number of cases that they perform, under graduated levels of supervision.  It was discovered that this did not occur and that he was insufficiently trained. He should have never been allowed to be deemed “qualified and competent” and allowed to “successfully complete” his training program. Additionally, his program was well aware that he had prior drug abuse issues and they sent him to a rehabilitation program; however, they failed to disclose this to other organizations where he subsequently practiced.

This leads to the next system failure: Disclosures. Hospitals, Training Programs, Department Chairs and Peer References are often fearful to disclose competency or conduct concerns, despite receiving a 3^rd party release form authorizing them to do so (and protected under the peer review privilege when disclosed in good faith). Here, not only did the training program fail to be transparent and provide full disclosure, when he started having major, unheard of complications and left a wake of injured or deceased patients, hospitals still failed to report him to the NPDB, failed to provide transparent disclosure to future organizations where he was applying…essentially contributing to the subsequent patient harm that occurred. Organizations and their representatives (e.g., program directors, chairs, MSP’s, etc.) need to ensure they are following their Bylaws, Policies, etc. and addressing peer review concerns in a timely manner consistent with their governing documents and then disclosing to other organizations (upon request w/a release form) accurate and transparent information. Often times organizations fail to put patient safety first as they allow the fear of a lawsuit from the provider, to outweigh the need to be transparent in the disclosure process. 

We also identify the National Practitioner Data Bank (NPDB) as a system failure. None of the hospitals where patients were harmed reported Dr. Duntsch to the NPDB. Many organizations either do not know the reporting guidelines, misinterpret the reporting guidelines, or intentionally take action that would avoid the reporting process.  Many leaders feel the NPDB 30-day reporting time frame is arbitrary and meaningless, particularly for low-volume providers undergoing performance monitoring.  Additionally, the NPDB does not enforce the requirements, have not issued any fines to hospitals for failing to report, and it does not include comprehensive data since organizations intentionally avoid reporting, without consequence.  It’s felt by many to be an ineffective tool for really knowing if there are peer review concerns, but helpful for malpractice case reviews.

Last but not least, the investigation by the State Medical Board is also identified as a system failure.  In this case, the Texas Medical Board, despite receiving numerous complaints from other surgeons, calling Dr. Duntsch a “sociopath” and a stating that patients were at “significant risk”, still took over a year to conduct their investigation and finally revoke his license.  By this time, the criminal justice system had already taken over, recognizing that they could meet the ‘intent’ element to charge him with a crime since he clearly continued to operate despite having major complications, significant blood loss, and unheard of errors. Medical Boards must re-evaluate their investigatory processes to be able to immediately identify significant patient safety risks and take proper action in a timely manner. There is also lack of transparency, timely communication and collaboration between all of the state medical boards, resulting in different actions being taken and lack of consistency.

In an effort to bring awareness to these system break downs, the law firm of Van Wey, Presby & Williams in Dallas led the effort to develop a patient safety advisory group that consists of the plaintiff’s attorney, the district attorney that prosecuted the case, the two neurosurgeons that helped stop him and served as expert witnesses, as well as myself and a former director of the NPDB.  Collaboratively we have lobbied for CMS and the NPDB to take action and improve the way that the peer review process is governed, how actions are reported, etc. We are also speaking at numerous educational events nation-wide to continue to bring awareness to these breakdowns and push for improved patient safety awareness, including the importance of the credentialing process.  As MSP’s we want to all encourage you be the voice that continues to bring red flags to the attention of leaders and do not be discouraged – be brave and speak up, be an advocate for patient safety at your organization!

Anne Roberts, Esq., CPMSM, CPCS

For two decades, Anne Roberts has worked as a nationally recognized healthcare consultant and has served in senior leadership roles in large academic medical centers, with expertise in medical staff credentialing/privileging, quality/ performance improvement, regulatory compliance, and peer review.  Anne serves in the firm’s medical malpractice and healthcare litigation section where she represents patients and their families who have been harmed by medical errors.  She is also the Vice President, Medical Staff Services at Mount Sinai Health System in New York, NY.