How many reading this know that California has a Medical Board whose sole
purpose is to regulate doctors in order to keep patients safe? Did you know that
you can report a complaint about a doctor to the Medical Board? Our organization
comes across people all the time who had no idea they could file a complaint
against a doctor. Far too many people, unfortunately, put doctors on pedestals and
think they can do no wrong, and even more believe that medical errors will never
happen to them or a loved one. Think again, it’s happened to both of us, three
times for Eric Andrist. More on that later.
Now, how many believe that if you did report a bad doctor to the Medical Board,
they would effectively handle the complaint, and protect consumers from further
harm?
It is estimated that over 40,000 patients die in California alone each and every year, from preventable medical errors, making it the third leading cause of death behind cancer and heart disease. We’re not talking about accidents, we’re talking about errors that absolutely could have been avoided.
Here’s another stat for you: The Medical Board of California takes in nearly 11,000
complaints every year, but only about 4%* of them end up with any discipline.
[*From the 2017-2018 Annual Report of the Medical Board of California. If you add up the “Administrative Outcomes” in the far right column, it comes to 406, which is about 3.7% of the 10,888 complaints they took in, in the top graphic.]
So what’s going on with the other 96%? That’s what we’d like to know, too, but the Board is protected by laws that allow them to hide their actions from the public. The Board will post disciplines against doctors — but not complaints. Every 4 years, through the Sunset Review the legislature pretends to care about making the Board better and fixing any problems, but there is little real accountability going on. We sent the legislature a 200+ page report detailing problems with the Medical Board, and not one legislator contacted us and thanked us or bothered to ask any questions, they just extended the Board for another 4 years despite what we told them.
IF THE MEDICAL BOARD MOVED ANY SLOWER, THEY’D GO IN REVERSE.
What is even more surprising is that the Medical Board takes on average, 2 1⁄2 to 3
years to complete a full investigation of a doctor and levy a discipline. We’ve even
unearthed investigations that took between 4 and 6 years.
20-year-old Alex Smick of Downey was overdosed to death after he checked himself into a hospital after taking too many pain meds for sports injury. Dr. Daniel Headrick gave him a lethal cocktail of medications and then instructed the staff to NOT check on him while he was sleeping. The next morning he was found face down in his bed in a pile of vomit, dead. It had been so long since anyone had checked on him that he was already in rigor mortis. Alex died on February 23, 2012. His family filed a Medical Board complaint against Dr. Headrick on November 6, 2013. The Board couldn’t be bothered interviewing the doctor until October of 2015 almost two full years after the complaint was filed. It took another 8 months for it to be referred to the Attorney General’s office and then another 4 months until an Accusation was filed against the doctor. Then, right before Christmas of 2017, 5 1⁄2 years after Alex’s death, the family received the Medical Board’s decision in the death of their son. Dr. Daniel Hearick was given a “Public Reprimand,” a disciplinary action that is only intended for the most minor of violations, certainly not a death. In total, it took 4 years and 16 days (or 1477 days) for the Medical Board to process the Smick’s complaint. Watch Alex’s parents as they hold the Medical Board accountable at one of their quarterly meetings. Dr. Headrick later went on a public television show, bragging about his lenient discipline from the Board and putting the blame on everyone but himself.
Alex Smick, left, Dr. Daniel Headrick, right. Photo sources: Tammy Smick and “Inside OC with Rick Reiff”
Some of the complaints that are under review at this moment are from 2013; the
Medical Board does not move quickly to resolve complaints even when they
involve the death of a patient.
96% DISCIPLINARY FAIL RATE
Ponder this. The Medical Board derives the bulk of its working capital from the
license fees of the very doctors that they also have to discipline. How is that not an
automatic conflict of interest? If they revoke too many licenses, they’d lose those
license fees. The Board complains all the time about not having enough money to
pay staff and investigators (even with a budget over $60 million) and that’s with
closing 96% of the consumer complaints. If even 50% of those closed complaints
are legitimate, how could they possibly investigate them, when they apparently
don’t even have enough money to investigate the 4% they do end up disciplining?
On January 22, 1993, the Los Angeles Times published an article detailing how rank and file employees of the Medical Board blew the whistle on their superiors who had been literally throwing consumer complaints in the trash in order to clear their desks of them.
“Among the investigation’s findings was the disclosure that
hundreds of Medical Board cases had been improperly
dismissed–and in many instances destroyed–in an apparent
attempt to reduce a backlog that had prompted criticism from the
Legislature. [Whistleblowers] said a three-person management
team marched into several key offices in 1990 and began going
through files. They said certain files were tagged, indicating that
they should be closed and in some cases destroyed. Those that
were targeted, they said, seemed to be the cases involving
doctors free from previous complaints or patients who had not
followed up to see if the board had pursued their complaints. “You
would see a stack of files two feet high on a supervisor’s desk one
day and by the next hardly any would be left,” recalled one
investigator. [Los Angeles Times, January 22, 1993]
It’s hard to not wonder whether this is still happening today.
Annette Ramirez of South Bay was harmed by Dr. James Scharffenberger who sliced her bowel after a routine surgery. For more than 36 hours nurses failed to report her abnormal vital signs and her doctor failed to adequately follow up to check her condition after surgery. An infection rapidly spread through her system causing her to go into septic shock. Gangrene spread to her arms and legs, which led to the amputation of her arms and legs, as well as the excision of flesh from multiple areas of her body.
Annette filed a complaint with the Medical Board only to have them close it down
within months without any discipline for the doctor that left her in this condition.
And lest you think Annette’s story is an exception, we have gathered a number of egregious stories of patients being harmed and the Medical Board closing their complaints, including 2 others with patients who had their arms and legs amputated: Robert Downey, Mario Guzman, Daniela Zelig, Morgan Westhoff, Cali Andrist, Eric Andrist.
DEALS, DEALS AND MORE DEALS!
In April of 2016, the son of TV Judge Glenda Hatchett, Charles Johnson and his wife Kyira, checked into Cedars Sinai to have a baby by repeat elective cesarean delivery in the early afternoon. The procedure was performed by Dr. Arjang Naim.
Not long after their son Langston was born, blood-tinged urine was seen in Kyira’s catheter. Six hours later, Dr. Naim was notified about a concern for internal bleeding. A massive transfusion was initiated and she was taken to the operating room shortly before midnight. During that surgery, Kyira was found to have 3 liters (or about 4⁄5 of a gallon) of blood in her abdomen. Kyira’s heart stopped on the operating table at 1:15 AM; she was declared dead at 2:20 AM, not being able to survive the massive blood loss. Charles Johnson filed a complaint with the Medical Board and in October of 2018, the Board gave Dr. Naim just 4 years of probation, an amount less than their own minimum guidelines recommend. At our request, Charles flew to San Diego for the Medical Board’s quarterly meeting shortly after the decision was announced, and confronted them about it. His passionate speech can be viewed HERE.
PERVERTED DOCTORS IN THE NEWS
We’ve been working with several news outlets on reports about local area doctors. This past November, 10News in San Diego ran a story on more than 150 area doctors who were disciplined for sexual abuse and other serious violations. In December NBC-LA chronicled the story of Sarah Al-Habib and how she had been sexually assaulted by her doctor, Dr. Zaher Azzawi of Rancho Cucamonga. In February, NBC told the story of three L.A.-area doctors, all of whom are on the Sex Offender Registry, but are still practicing medicine, and how the Medical Board of California makes no effort whatsoever to warn patients about them. Here’s 32 doctors in the state of California who appear on the Sex Offender Registry (most of them are no longer practicing.)
Recently, we discovered the case of a Dr. Robert Stephens, an anesthesiologist in San Diego. Several nurses reported witnessing him sexually assaulting a number of unconscious patients. The case was reported to the California Department of Public Health who in turn should have reported it to the Medical Board of California. We have been unable to find any evidence that they did. The Medical Board verified that he is under investigation, but they refuse to warn the people of this state about him, insisting that the law does not require them to. Oddly, though, their sister agency, the Contractors State License Board does warn consumers when one of their contractors has had a complaint filed against them. Apparently, our legislators think consumers should know about a bad bathroom contractor, but not about a doctor that could sexually assault them the next time they’re in the hospital, unconscious.
To show how bad the laws are that govern the Medical Board, take a look at the case of Dr. Ryszard Chetkowski, who runs a fertility clinic in Berkeley. Chetkowski was accused by at least six women of sexual misconduct. Even after the Medical Board detailed the horrific sexual assaults in seven causes for discipline in an accusation, the Board still only gave him a Public Reprimand. By law, Public Reprimand’s disappear from the Board’s website after 10 years, unlike other documents which remain visible indefinitely. So, if you look up Chetkowski on the Board’s website now, he has a completely clean record; there’s not one mention of the sexual assaults anywhere. It begs the question, were favors done for this doctor so that he was purposely given a discipline that would eventually disappear, even with the severity of the charges? Is no act heinous enough that it can’t be bartered away?
By not acting quickly enough (or at all), the Medical Board puts consumers in danger. A great example of this is the case of Dr. Michael Popkin of Granada Hills. According to reports, the Medical Board knew about sexual assault complaints against Popkin as far back as 2001. An accusation was filed against him in November of 2003, but contained no charges of sexual misconduct. It became clear that he had continued to sexually assault patients when he was arrested in 2016. The court issued a court order preventing him from treating female patients in October of 2017 and the Medical Board finally revoked his license in April of 2018, some SEVENTEEN YEARS after first receiving sexual assault complaints about him. Because of the Board’s inaction, more people were harmed.
Dr. Michael Popkin’s mugshot. Photo source: LAPD.
ABSOLUTE POWER CORRUPTS ABSOLUTELY
When we first started doing our in-depth investigation of the Medical Board, one of the first cases we looked into was that of Dr. Hari Reddy, a doctor who had his license revoked over the sexual assault of 4 patients, one of which was a 15-year-old girl. He tried once to petition the Board to get his license back and they denied the request. He applied one more time in 2010. This was shortly before Governor Jerry Brown appointed Reddy’s friend, classmate and co-worker, Dr. Dev GnanaDev to the Medical Board. Long story short (and you can read more about it HERE), on GnanaDev’s very first disciplinary panel case, they voted to give Reddy his license back. Not long after this occurred, Reddy’s brother-in-law, another Reddy by the name of Prem Reddy (CEO of the always-in-trouble Prime Healthcare), donated over $40 million to GnanaDev’s new medical school in the Inland Empire, and now serves as the school’s chairman of the board.
Dr. Hari Reddy, left. Photo source Vimeo. Dr. Dev GnanaDev, middle. Photo source calmedu.org. Dr. Prem Reddy, right. Photo source calmedu.org
Recently, the Medical Board and the Attorney General’s Office had to fess up to one of their own medical “experts” (Dr. Aaron Stone) behaving in such a way that the accusation against Beverly Hills plastic surgeon, Dr. Kenneth Hughes, had to be dismissed. Hughes’ attorney basically called the expert a liar and corrupt. So, while the accusation very well could have had legitimate concerns in it, the Board was forced to dismiss the action and now, Hughes’ profile on their website provides no information whatsoever to the public in regard to anything a patient might need to be concerned about. You can watch key portions of the hearing exposing the “corrupt expert” HERE. Hughes has at least two pending court cases in the Los Angeles Superior Court, but you won’t find that information on the Medical Board’s website, either.
In 2014, Eric Andrist, the co-author of this article, was diagnosed with 4 hernias. He went to see a surgeon, (Dr. Kulmeet Sandhu) in 2015 and laparoscopic surgery was performed that fall. A few months later, all of his symptoms returned and he went back to her in 2016. She ran more tests and blamed the reoccurrence on his “bad genes.” He went back in for a re-do surgery in the fall of 2016. A few months later, all of his symptoms returned once again and he again went back to see the surgeon. She ran more tests and found that the hernia was even worse than when he had started out. She was prepared to take him in for a third surgery, but now, not trusting that she knew what she was doing, he went to get a second opinion. The new surgeon ran a battery of tests and told him he was in terrible condition and they needed to do surgery right away, which took place in the fall of 2017. During the surgery, the new surgeon found that Dr. Sandhu had actually sewn his stomach to itself (in a procedure called a Full Nissen Fundoplication), instead of to the esophagus, rendering it useless. To top it all off, the hospital sent him home after the surgery without checking the surgery site. When he got home, he discovered that his eight-inch incision had popped open and he could see into his abdomen. He filed complaints with both the Medical Board (on Sandhu) and the Department of Public Health (on Glendale Adventist Hospital). Both complaints were closed without investigation.
There appears to be a price to pay when someone tries to hold the government
accountable.
We started our little nonprofit, The Patient Safety League, so that we can officially try to help victims of medical errors, warn the public about doctors with all degrees of disciplinary actions, and monitor state agencies like the Medical Board of California and the Department of Public Health, both of which are not properly protecting us. We started our website due to the lack of information on the Medical Board’s website. Consumers can check our website HERE. Right now we’re existing hand to mouth, and it often costs us a lot of money from our own pockets to do our job. Ironically, a doctor recently reached out and helped us come up with the money we needed to get us to the upcoming Medical Board meeting in northern California next month. Tax-deductible donations can be made to the Patient Safety League on their website.
This article was originally published in a shorter format on CityWatchLA. Special thanks to them for all the work they do helping people stay informed.
UPDATE, JAN. 22, 1:48 P.M.: We now know how the parents of the late Alex Smick feel about the “discipline” the Medical Board of California imposed on Dr. Daniel Joseph Headrick for the 22-year-old’s overdose death while in the physician’s care.
The Smicks hate it. They hate that it took four years for the board to come to a decision, and they hate the decision, which is that Headrick is receiving nothing more serious than a public reprimand.
You can watch the Smicks tell the board exactly how they feel here:
ORIGINAL POST, JAN. 15, 5:54 A.M.: In the recent documentary The Long Way Back: The Story of Todd “Z-Man” Zalkins, Dr. Daniel Joseph Headrick says on screen it is amazing the title character survived years of drug abuse, which only became worse after Z-Man’s close friend Bradley Nowell of Sublime died from an overdose.
Headrick, who operates Tres Vistas Recovery in San Juan Capistrano, has gone on to guest on Zalkins’ podcast, and both appeared together on a radio program dedicated to kicking substance abuse.
However, the same Dr. Headrick is being disciplined by the state medical board for the overdose death of a young man who was under the physician’s care. That is, finally being disciplined, and not nearly harshly enough, according to the family of 22-year-old Alex Smick, who died on Feb. 23, 2012. Tim and Tami Smick went on to become statewide activists for medical malpractice victims and their families.
A public reprimand over Headrick’s treatment of Alex Smick becomes effective Thursday, according to the Medical Board of California. Evidence shows the doctor’s medical license should be subject to probation or revocation proceedings, according to Eric Andrist, whose 4patientsafety.org website tracks medical malfeasance cases up and down the state.
“The medical board is not doing their job to protect us,” says Andrist, whose website includes the opinions of three medical experts highly critical of Headrick’s contributions to Smick’s death. Andrist says that case and others are prompting his group to soon expose numerous misdeeds by the Medical Board of California when it comes to disciplining doctors.
Click here for the medical board’s discipline of Headrick, who before operating Tres Vistas Recovery was the lone physician and CEO at Mission Pacific Coast Recovery Center at Mission Hospital in Laguna Beach. Based on the signatures Headrick and his Irvine attorney Raymond J. McMahon put on an acceptance letter from the medical board on Dec. 1 and Dec. 4 respectively, they agree with the findings of the public reprimand. That includes this of the doctor:
“You failed to write a comprehensible order for the level of overnight monitoring for a patient, failed to ensure that a nurse would provide that level of overnight monitoring and failed to ensure that the nurse documented the reasons for administering as needed (PRN) medications, that you ordered for the patient, as more fully described in the Accusation.”
According to Smick’s mother, Alex injured himself skateboarding at age 18, and his primary care physician suggested he go to a pain management specialist in Long Beach. That led to back injections and prescriptions of Vicodin, Oxycontin and even morphine. But he did not get better, Tami Smick says, he became an addict.
“He admitted to using opiates, benzodiazepines, sedatives, cannabis, cocaine, amphetamines, hallucinogens and tobacco,” say state medical board investigators, who add that CURES, California’s drug prescription monitoring system, shows that Alex Smick got scripts for Ativan, a sedative and anti-anxiety agent used to control seizures, and Dalmane, which treats insomnia, within a month of his Feb. 23, 2012, death.
“He just kept getting pain medications,” his mother said 11 months after her son’s death. “Alex knew he had a problem.”
According to medical board investigators, he was treated as an outpatient by a pain specialist on Feb. 15, 2012, when he received scripts for MS Contin, which is time-released morphine, and the highly addictive pain reliever hydrocodone. The following day, Smick overdosed on multiple medications, including MS Contin and the anti-anxiety drug Xanax, and was admitted to Downey Regional Medical Center near his parent’s home. He was then transferred to Pacific Hospital in Long Beach, where a new doctor prescribed more Xanax.
Somewhere along the way, Smick was diagnosed with major depression disorder with postpartum onset, which is actually a female condition, notes his mother, who partly blames that mistake for the additional problems and malpractice her son would face. She says that after his Feb. 22, 2012, discharge from the Long Beach hospital, he on his own arranged to have an ambulance take him to Mission Pacific Coast Recovery Center.
He was interviewed by the admitting nurse there at 5 p.m. and said, “I did not try to kill myself. I was in so much pain that I took too many pills,” according to the medical board. Smick went on to tell of having overdosed on 10 tablets of 2mg Xanax and 40 tablets of MS Contin. He said he used Xanax 3mg tabs for two years. The nurse logged the drugs he said he’d taken, noted his mood was neutral and filed out a checklist of his mental health status dimensions that showed they were unremarkable, according to medical board investigators, who add his vital signs were in normal ranges, and he was allowed to keep his regular clothes and luggage, with no notation from the nurse that either was searched.
Headrick diagnosed the patient as being dependent on opiates, cannabis and benzos with major depression and suicidal ideation. Smick was also diagnosed with Axis III disorders of lumbar disc disease, a T12 compression fracture and mild leukocytosis (slightly elevated white blood cell count). His EKG, urinalysis and metabolic panel all came back normal, and while he tested positive for opiates and cannabis, he surprisingly came up negative for benzos. His vital signs were taken at 9 p.m. and 11 p.m. on Feb. 22, according to the center’s records, which show he received medications to relieve his back pain.
However, according to medical board investigators, Headrick’s written notes from that day did not include any laboratory test results, and “leukocytosis” seemed to have been added later using a different pen. In a note dictated after Smick’s death early the following morning, Headrick said the patient had a positive toxicology screen for cannabinoids and opiates, and at 5:30 p.m.—hours after the young man’s death—the doctor wrote him orders for inpatient detoxification, inpatient rehabilitation and the taking of vital signs with a note that Headrick was to be notified about them, according to the probe.
“Detoxification medications” were also ordered—again, after the patient’s death—for moderate withdrawal symptoms, some to start “now,” report board investigators, who added there were also orders for “as needed” medications for nausea and vomiting and that scripts were written for the anti-convulsion medication Lyrica, the anti-depressants Elavil and Zoloft, a Lidoderm patch, the pain medication Toradol, the muscle relaxer Robaxin, Catapress for hypertension/high blood pressure and the anti-anxiety drug Librium. Another EKG and laboratory tests—including a complete blood count, metabolic panel, urine drug screen and breath test—were requested.
The record shows Smick got Lyrica at 5 and 10 p.m.; Librium at 5 p.m.; the anti-seizure Phenbarbital at 9 p.m., anti-anxiety Sertraline at 9 p.m.; and the pain reliever Buprenorphine at 11 p.m. It also shows Smick was able to go to sleep without distress.
The bottom of the page on his medical records has the time written as 3:30 (a.m., presumably) and hours slept as “8” and the notation “slept through the night,” according to investgiators, who tellingly add: “In light of the fact that A.S. was discovered dead at 6:20 a.m., it is difficult to see how the record could be accurate. Further troubling is the fact that Lyrica, Robaxin, Clonidine and Librium were noted as having been administered at 7 a.m. on Feb. 23, 2012, after A.S. was found dead.”
Nurses said they discovered Smick lying “supine” (face up) on his bed with rigor mortis at 6:20 that morning. However, the dictated record of a doctor, who came from the Emergency Department of Mission Hospital to assist in resuscitation efforts, observed the deceased had “obvious lividity with pooling of the blood in the anterior aspect of the body,” adding that, “The sheets were wet indicated [sic] that there was fluid there, which may have been either vomitus from which he aspirated and the fluid was noted on his face and eyes.”
This evidence indicates a Smick suffered a seizure, according to the state board, which also cites Orange County Sheriff-Coroner records that suggest there was evidence the patient had been turned over from the prone to the supine position. The coroner found no evidence of trauma or extra pills in the room, saying the cause of death was “[a]cute poly drug intoxication due to the combined effects of buprenorphine, sertraline, norsertraline, bupropion, amitriptyline, lidocaine, chlordiazepoxide, methocarbamol and tetrahydrocannabinol.” It was noted that none of the substances were at toxic levels. Furthermore, examination of Smick’s heart revealed left ventricular enlargement but no evidence of atherosclerosis.
Medical board investigators found notably absent from the coroner’s toxicology report any metabolites of Lorazapam, Flurazepam, Alprazolam and Phenobarbital, some of which center records show Smick received within the prior 24-36 hours.
Headrick’s public reprimand is for failure to maintain adequate and accurate records and unprofessional conduct/repeated negligent acts. His use of multiple medications “was unsupported by the medical records since withdrawal from opiates or benzodiazepines were not demonstrated, nor was insomnia or pain consistently proven,” states the medical board. “There was no indication for prescribing Zoloft since a diagnosis of major depression was excluded due to drug abuse. Elavil is an obsolete medication with many problematic adverse effects. Phenobarbital is similarly a medication belonging to an earlier generation of physicians due to its risks. The interacting side effects of these many medications are unpredictable.”
The “unpredictable consequence constitutes negligence,” according to the board, which also damned: the simultaneous administering of sedatives such as Phenbarbital, Lyrica and Librium with the opiate Buprenorphone; the simultaneous ordering of 10 medications without a record of symptoms supporting a diagnosis; and only ordering vital signs of a new patient when he was awake as opposed to every two hours.
The state nursing board previously cited Mission Pacific Coast Recovery Center registered nurse George Gappmayer for “failure to exercise the degree of professional judgment expected of a vocational nurse.” He was fined $1,000.
The mistreatment of their son led Tim and Tami Smick all the way up to Sacramento, as demonstrated by their support for Prop. 46, the Medical Malpractice Lawsuits Cap and Drug Testing of Doctors Initiative that was on the Nov. 4, 2014, ballot.
[embed-1]At the press conference that May 2, 2013, day, Tami Smick, with her husband by her side, accused Headrick of prescribing “a toxic combination of medications” that led to the death of her son. His blood pressure started to drop, yet he was unmonitored and unchecked for more than six hours, charged the Downey teacher.
“When a nurse checked him in the morning, he was dead. He’d been gone so long that he was already in rigor mortis. … Our beautiful son was left to die in his bed. No one checked on him. They left him alone and he went to this place for help and they left him for dead.”
Tim Smick, a home-building contractor, said he could not understand why, when there is a serious injury or death on one of his jobs sites, the police and the California Occupational Safety and Health Administration (Cal OSHA) show up, but no one did at the hospital where his son died. (Except for the coroner, who merely carted the victim away.)
But learning the cause of death from that coroner led the Smicks to fight for justice for others. That’s when the Smicks learned the Medical Injury Compensation Reform Act (MICRA), which Gov. Jerry Brown signed in 1975, capped non-economic damages at $250,000 in medical negligence lawsuits brought in California. Supporters of Prop. 46 argued that, with inflation, the cap should have been raised to $1 million.
“We can’t fight this,” Tim Smick said that day. “This system is so jacked up. There is no defense. In our case, we are up against the Goliath of insurance companies and doctors. The doctor actually had an insurance adjuster call our attorney to call us and say to watch what we say, really, or he is going to sue us. So I’m the victim now for causing our son’s death? This system is broken.”
Proposition 46 went on to be soundly defeated at the polls, thanks mostly to the tons of money poured into the no campaign by the health insurance industry.
The Smicks settled a malpractice lawsuit against Headrick, the terms of which weren’t disclosed.
Headrick is listed as the owner and medical director of Tres Vistas Recovery.
MATT COKER
Matt Coker has been engaging, enraging and entertaining readers of newspapers, magazines and websites for decades. He spent the first 13 years of his career in journalism at daily newspapers before “graduating” to OC Weekly in 1995 as the paper’s first calendar editor. He went on to be managing editor, executive editor and is now senior staff writer.
Tracy Lystra at her home in Aguanga, Calif. In 2013, Lystra sued her Fallbrook, Calif., OB-GYN, Anthony S. Bianchi, alleging that he had sexually harassed her — which Bianchi denied. Lystra said the lawsuit was settled for $150,000 but that her attorney’s subsequent complaint about the doctor to the Medical Board of California was rejected based on a review of the evidence and “mitigating circumstances.” In the meantime, Bianchi received two probation terms for alleged sexual misconduct with three other women. (Heidi de Marco/California Healthline)
The doctor instructed his patient to stand in front of him. He cupped her crotch and inserted his fingers into her vagina through her clothes, moving his hand repeatedly to her rectal area. Then he squeezed her breasts, according to a formal accusation filed by the Medical Board of California.
The patient, accompanied to the appointment by her 4-year-old granddaughter, asked why that was necessary to diagnose a urinary tract infection, according to the documents. He told her to let him do his job.
In three other cases, the board alleged that the family doctor, Ramon Fakhoury of California’s Inland Empire, touched patients’ genitals for no medical reason. In 2016, the board handed him 35 months of administrative probation, requiring him, among other things, to have a chaperone when treating females.
Fakhoury did not admit to the allegations, according to his attorney, and criminal charges against him were dropped.If he successfully completes probation next year, he’ll be able to practice without restriction.
The Medical Board of California put family physician Ramon Fakhoury on 35 months of probation after several patients alleged he had touched their genitals for no medical reason. Until he completes probation, he must have a chaperone present when treating female patients. He did not admit to the allegations. Previously, he faced felony sexual abuse-related charges, which were dismissed after a jury deadlocked.(Courtesy of the San Bernardino County Sheriff’s Department)
With a mission of patient protection and doctor rehabilitation — not punishment — California’s medical board and those in other states make decisions under laws and norms that can seem discordant in the #MeToo era.
California is often cited as one of the more rigorous states in overseeing doctors. But, according to the medical board, very few sexual misconduct complaints are reported to the board in the first place, historically under 200 a year. Even fewer result in a formal accusation against a doctor. And when discipline is found to be warranted — typically in fewer than 20 cases a year — the board tends toward leniency, sometimes granting a few years of probation even in instances of severe misconduct, according to a California Healthline analysis of medical board records.
More than a third of doctors sanctioned by California’s board in cases that alleged sexual misconduct received probation in the past 10 years — some more than once. The terms of probation often required temporary chaperones, as well as psychotherapy and courses in “professional boundaries” and ethics. (Through probation, the medical board can only place conditions or restrictions on a doctor’s license in civil proceedings; it does not take criminal court actions.)
“They love giving second chances” to physicians, said Marian Hollingsworth of San Diego, a frequent critic of the California medical board. “It makes you wonder where their priorities are. … Their first loyalty is supposed to be patient safety and that doesn’t always happen.”
The recent, shocking reports about years of abuse by USA Gymnastics doctor Larry Nassar and University of Southern California gynecologist George Tyndall — as well as national exposés about physician misconduct by the Atlanta Journal-Constitution and the Associated Press —have only intensified concerns about whether sexual abuse is taken seriously enough in medicine.
Nassar, accused of abuse by scores of girls and women under the guise of medical treatment, is now serving what amounts to a life sentence. Prosecutors are considering criminal charges against Tyndall in more than 50 cases, and the state medical board has suspended his license while seeking revocation. He has denied the allegations.
Larry Nassar sits in court on Feb. 5, in Charlotte, Mich., before being sentenced for three counts of criminal sexual assault. Nassar, accused of abuse by scores of girls and women under the guise of medical treatment, is now serving what amounts to a life sentence. (Scott Olson/Getty Images)
And just last week, 17 women sued Columbia University and its affiliated hospitals, alleging that the facilities engaged in covering up decades of sexual abuse by one of its OB-GYNs.
Research has shown that many doctors who sexually exploit patients, like other perpetrators of abuse, don’t stop with one victim. They “perpetrate such behavior for years before being stopped,” said the authors of one study.
Against this backdrop, California Gov. Jerry Brown in September signed landmark patient protection legislation requiring doctors who are on probation for sexual and other serious misconduct to notify patients of their status and the terms under which they must practice. It will take effect next July. The bill had failed twice before.
“It’s time,” said the bill’s lead author, Sen. Jerry Hill (D-San Mateo). “The #Me Too movement has really made it very clear that there are individuals even in the most respected professions who abuse their authority.”
Even as sexual abuse complaints filed with the medical board rose significantly in the past year to coincide with the rise of #MeToo, board officials say they plan no major changes in how the board dispenses discipline in sexual misconduct cases.
The #MeToo movement “has not changed us,” said the board’s executive director, Kimberly Kirchmeyer. Cracking down on sexual misconduct has always been “one of the board’s top priorities,” she said.
Digging Into The Records
California Healthline examined all 135 cases of alleged sexual abuse investigated by the board that resulted in sanctions from July 2008 through June 2018. (The analysis did not include discipline based on proceedings in other states.)
More than a third of sanctions were for sexual misconduct with more than one victim, and the vast majority of alleged perpetrators were men accused of exploiting women.
Doctors’ licenses were revoked in 39 cases and voluntarily surrendered in 38. Several doctors received public reprimands — a minor sanction.
The largest share of sanctions — 49 cases, or more than a third — were for probation.
According to the board’s disciplinary guidelines, the minimum probation period is seven years for a doctor found to have engaged in sexual misconduct — whether it is a sexual relationship with a patient, sexualized touching during exams or inappropriate sexual conversation.
But those “minimums” were not applied in more than half of the probation cases, according to the California Healthline analysis. The guidelines allow exceptions based on “mitigating circumstances,” the age of cases, the quality of evidence and other factors.
Kirchmeyer noted that the board treats every case as unique and places a high value on a doctor’s remorse and acknowledgment of wrongdoing.
In eight cases, California Healthline found, a doctor sanctioned for sexual misconduct had previously been sanctioned for similar misconduct.
Dr. Patrick Mark Sutton, a Pasadena obstetrician-gynecologist, received probation twice — the first time for four years after investigators alleged sexual misconduct in 2002. In 2011, he was placed on probation again — this time for three years — following allegations that he improperly rubbed a patient’s thigh and engaged in inappropriate sexual conversation.
He denied all sexual misconduct allegations in 2002 and 2011, admitting only to medical record-keeping violations in both cases.
This September, after he had completed mandated ethics and “boundaries” courses, the medical board filed a new accusation against Sutton, saying that he had called a patient “hairy” and asked the patient, who was naked from the waist down under a drape and in stirrups exposing her genitals: “Do you enjoy orgasms? You are a very beautiful woman.” That case is pending.
Sutton’s lawyer, Gary Wittenberg, said in an emailed statement that “the allegations in the pending Accusation are untrue and we will prove that in court.”
In several cases, the board granted probation knowing the doctor had been convicted of misdemeanor criminal charges stemming from sexual abuse investigations.
Fakhoury, the Inland Empire doctor, had faced felony sexual abuse-related charges but was not convicted due to a hung jury, according to San Bernardino County Superior Court records.
His lawyer, Courtney Pilchman, told California Healthline that the criminal charges were dismissed afterward, and that the doctor “did not stipulate” to — or admit to — the medical board accusation.
By contrast, Ohio’s medical board, upon learning of California’s sanction, in 2012 revoked his state license.
The number of disciplinary actions taken over the decade is strikingly small given the size of California’s practicing physician population of more than 100,000. Alleged victims of sexual abuse by physicians are significantly less likely to come forward than sexual abuse victims in general, some research indicates.
However, numbers provided by the medical board suggest that many of the complaints that are filed — whether by victims themselves or other sources — do not result in formal accusations against doctors. From October 2013 through June 2018, 838 complaints were designated by the board as possible sexual misconduct. During that same period, 74 accusations were filed. (Multiple complaints could be filed about one doctor.)
Experts and lawyers familiar with the board offered various explanations: Some complaints may be false. Doctor sexual misconduct can be hard to prove by “clear and convincing evidence,” as required in medical board cases. Accused physicians often hire experienced lawyers who aggressively fight back, leading to delays and deals. Victims may decline to testify or present poorly as witnesses.
Some victims, for instance, have psychiatric disorders or believe that they were engaging in a “consensual” relationship, according to medical board documents.
Board staff have worked hard to treat alleged victims sensitively, Kirchmeyer said. Expert reviewers are instructed to read complaints as if the person is telling the truth, she said, and the board plans weeklong training sessions to help investigators work better with alleged victims and prepare them for testifying.
The cases often drag on. It can take years for victims to come forward in the first place — and more time for cases to wind their way through the state’s complex bureaucracy. Evidence can go stale.
“Physicians have to have due process,” Kirchmeyer said. “Anyone can make a complaint about anyone at any time.”
Tracy Lystra at her home in Aguanga, Calif.(Heidi de Marco/California Healthline)
‘Slap In My Face’
Facing what they see as an uphill battle, lawyers from the state Department of Justice, who handle administrative hearings, will sometimes pre-emptively recommend probation — even in serious sexual misconduct accusations — to avoid the possibility a doctor will get no sanction at all from a judge, said Laura Sweet, a former deputy director who retired in 2015.
Sweet, who worked for the medical board for 23 years, said the legal process focuses on the doctors and does not always give sufficient weight to the pain of alleged victims. “You’re sending a message that’s potentially minimizing what the victim endured.”
That’s how Tracy Lystra sees it, too. In 2013, Lystra sued her Fallbrook, Calif., OB-GYN, Anthony S. Bianchi, alleging that he harassed her with comments about her body and how she aroused him, whispering into her ear as she lay on a gurney before surgery that she looked like a “sexy librarian.” She said the case, which also alleged medical negligence, was settled for $150,000 in 2016. Bianchi, who could not be reached for comment, denied the allegations in court documents.
Through her attorney, Lystra filed a complaint to the medical board shortly after settling with Bianchi. This past July, she received a letter from the board saying it would not be able “establish grounds for discipline” against Bianchi in her case, “considering all the evidence and mitigating factors.”
Ultimately, she learned that the board had received complaints from other women.
In 2014, Bianchi had been put on five years’ probation after the board accused him of making inappropriate sexual remarks to two patients, telling one he dreamed of having oral sex with her and couldn’t stop staring at her breasts. After learning of these cases, another woman came forward, alleging Bianchi several years earlier had blocked his office door with a chair, inserted his fingers into her vagina, exposed his penis and asked her for sex.
The board’s penalty was another five years’ probation. But the two probation terms overlap — and Bianchi, who agreed not to contest the allegations as part of the settlements in each case, could go back to work as an OB-GYN without restrictions in 2021. In the meantime, he is not allowed to treat female patients.
Learning that Bianchi received such a light punishment — and that the board would not take action on her own complaint — was crushing, Lystra said, noting that it had been so difficult to get anyone, including her family, to believe her.
“I really wanted him stopped. It was so disappointing when medical board responded the way it did,” Lystra said.“It was a slap in my face.”
Methodology
In its analysis, California Healthline requested every sanction for sexual misconduct issued by the Medical Board of California over the past 10 years, the name of each doctor involved and his or her license number. The board responded with 181 actions against 175 doctors from fiscal year 2008-09, beginning in July, through fiscal year 2017-2018, ending in June. (The records were designated by the board as primarily for sexual misconduct but often included other allegations.)
California Healthline used the board’s document lookup search on its website to review its available public records on each doctor. California Healthline mentioned sanctions outside the 10-year period when records showed the doctors were repeat offenders.
The analysis excluded cases in which the board took action in response to sanctions issued by other states’ medical boards for sexual misconduct outside California.
For each sanction, California Healthline determined the number of alleged victims identified in the board’s accusations, their gender, type of sanction, length and terms of probation, type of alleged sexual misconduct and whether the board took note of any previous or concurrent criminal proceedings.
California Healthline also requested the number of complaints the board received alleging sexual misconduct, and how many formal accusations the board filed each year after the allegations were investigated and merited disciplinary action. The board did not have data for all 10 years, but provided the number of complaints received and the number of accusations filed from October 2013 through the end of the 2017-18 fiscal year.
“Unproven but profitable”. That’s the headline of a recent Journal published by the American Medical Association, exploring the explosive growth of stem cell clinics across the country, including here in San Diego County. The clinics offer questionable “breakthrough” cures for a wide range of health problems.
In May, NBC 7 Investigates first reported on these “surgery-free” fixes that were drawing hundreds of local potential buyers to free seminars. In one seminar, attendees were not told that the costly procedures, sometimes costing up to $6,500 per injection, have not been FDA-approved, nor were they told the procedures do not have scientific support for their claims.
The only proof provided to patients are testimonials from patients who say the products were miracle workers.
Investigating Claims Made By Local Stem Cell Clinic
[See video on website.] NBC 7 Investigates went undercover at a stem cell clinic to see if the clinics are promising legitimate results. NBC 7’s Mari Payton reports. (Published Wednesday, May 23, 2018)
Now, the claims made by these clinics have gotten the attention of the California Medical Board and has led to the creation of a task force to review the clinic’s practices. The task force was formed as a result of an inquiry about the industry from the chairman of the U.S. Senate Health, Education, Labor, and Pensions Committee.
Currently, the only stem cell-based products approved by the Food and Drug Administration (FDA) are for transplant procedures. But these clinics are offering something different. Clinics advertising through Stem Cell Health Centers offer stem cell injections that they say are a “cutting edge treatments” that offer “regenerative cures”.
NBC7 Investigates has found newspaper and broadcast advertisements for free seminars running nearly daily in San Diego, making stem cell health claims without providing specific information about what procedures are performed.
Advertisements for Stem Cell Health Center seminars can be seen in the local newspaper nearly daily.
The ads list hotels hosting these seminars from Oceanside to Chula Vista, all centered around how to “restore your pain-free life”.
NBC 7 Investigates spoke with a registered nurse and a patient advocate who agreed to attend two of these stem cell sales presentation seminars, one in Mission Valley and the other in Rancho Bernardo.
Attendees, working with NBC 7 Investigates, walk into a Mission Valley stem cell seminar on September 25, 2018.
At both locations, Chiropractor Doctor Jared Taylor pitched to the crowd stem cell injections, costing at least $5,000 each, through the Create Wellness clinic in La Jolla. After the seminar, Taylor would not comment on the claims and treatments offered in the seminar. Create Wellness is owned by Acupuncturist Roya Nikzad, who did not return NBC 7 Investigates’ calls for comment.
In May, NBC 7 Investigates found another chiropractor, Michael Van Derschelden, using similar sales tactics at a Carlsbad hotel seminar. Van Derschelden told the audience of mostly senior citizens, some in wheelchairs, that he’s a specialist in regenerative medicine at West 2 North Medical Solutions in San Marcos. After the seminar, Van Derschelden refused to answer questions surrounding the claims he made to seminar attendees.
Promises of Pain Relief
For Actor Ed Hollingsworth, pain relief is top of mind. Hollingsworth has serious back, spine, knee and shoulder injuries, so he agreed to attend a stem cell sales seminar in Mission Valley and relay what was said to NBC7 Investigates.
“I heard a lot of anecdotal things,” Hollingsworth said. “[I] didn’t see a lot of proof. It concerns me the fact that it is so expensive. Like for me, with all the different areas, it would cost me conservatively maybe $30,000 to get all the different [treatments].”
His wife, patient advocate Marian Hollingsworth, said the sales pitch included numerous promises for pain relief.
“They talked about an I.V. infusion [offered] for somebody with cystic fibrosis. And that this woman is [now] off her meds,” she said. “Now this is somebody who was turned down for a lung transplant. So that’s a pretty hefty claim.”
NBC 7 Investigates found orthopedic problems are the primary draw for the clinics but not the only claim of relief promised by the chiropractors in the sales seminars.
The underlying “science” of the claims made in these seminars is that the injections “take advantage of your body’s ability to repair itself naturally,” according to the clinic’s advertisements.
“They didn’t really say what is in it exactly, besides stem cells from birth waste,” Marian said. “And that seemed kind of farfetched.”
While Marian and Edward attended the seminar in a hotel conference room, NBC 7 Investigates Producers sat in the hotel lobby. The couple texted Producers about the different claims made by Dr. Taylor. Some of the claims made involved “cures” for a range of ailments, including Alzheimer’s and Parkinson’s disease.
“[They] said only one shot was needed, with pain relief in two to four weeks with no downtime,” one text read.
“Stem cell therapy helps with COPD–lung disease,” Marian Hollingsworth texted. “They claim [to have] FDA clearance.”
Outside of the Mission Valley hotel conference room where the seminar was held, Create Wellness Clinic Director Melody Darvish sat and shared information with attendees as they left the presentation. After attendees left, NBC 7 Investigates asked her what the term “FDA clearance” meant but she would not tell us.
“I think you have all the information you need,” Darvish said.
NBC 7 Investigates asked the FDA about the term “FDA clearance” versus “FDA approved”.
Stephanie Caccomo, a spokesperson for the FDA, said the term “FDA Clearance” only applies to medical devices, not treatments. And that the stem cell procedures offered by these clinics are neither approved or cleared.
NBC 7 Investigates also asked Dr. Taylor about the fact that on the day of the Mission Valley stem cell seminar, September 25, his chiropractor license was expired.
Doctor Jared Taylor’s license was expired on September 25, 2018, the day of the Mission Valley stem cell seminar. The license has since been renewed.
Taylor said his license wasn’t suspended and that he had “sent his paperwork through the mail.” According to California’s Department of Consumer Affairs website, Taylor’s license, issued out of Utah, had expired in February after the “licensee failed to pay renewal fees”. NBC 7 Investigates found no previous disciplinary actions are taken on Taylor’s license and since the seminar, his license has been reinstated.
The website for Create Wellness, the La Jolla clinic Taylor works for, states his role is to consult with potential candidates for stem cell therapy and to “utilize functional medicine for customized healthcare.”
Stem Cell Health Centers
NBC 7 Investigates has found a common thread with all of the stem cell seminars and advertisements for these treatments, a group called Stem Cell Health Centers. Stem Cell Health Centers has used similar advertisement campaigns involving chiropractors and acupuncturists in 14 states, including California.
Digital forensic experts confirmed what NBC 7 Investigates found, that Stem Cell Health Centers’ website has done a good job of hiding the creators of its domain. The domain was created in July 2017 with a private registration invoked immediately.
Materials on Stem Cell Health Center’s website link to a 40-year-old Salt Lake City acupuncturist named Regan Archibald.
On the website, an e-book written by Archibald is offered for free and referenced often titled “The Stem Cell Breakthrough”. In the book, he claims Stem Cell Health Centers has seen, “well over 25,000 [stem cell] cases with over a 90% success rate.”
Archibald also states in the book that his own life experiences and injuries led to his discovery that, “stem cell therapy could repair and enhance”.
NBC 7 Investigates contacted Archibald to find out more about Stem Cell Health Centers and he said he has nothing to do with what other clinics are claiming at seminars, including here in San Diego. “This is simply a website where individuals and clinicians can reference many of the studies that I’ve found to be helpful. I’ve been able to learn from Arnold Caplan Ph.D.”
Dr. Arnold Caplan of the Case Western Reserve University and a noted expert in the field of stem cell research told NBC 7 Investigates, “I do not know this guy but am VERY (sic) supportive of your efforts to strip away the unsubstantiated claims made by many online”
When asked about Archibald’s role with Stem Cell Health Centers, the advertising campaign and for proof behind claims made in his book and elsewhere, Archibald stopped responding.
On YouTube, Archibald provides a video tutorial or “how to” for anyone interested in starting a stem cell practice.
Stem Cell Clinics Across the Country
Leigh Turner of the University of Minnesota Center for Bioethics said the rise in stem cell treatment offers here in San Diego can be seen across the country.
“We’re talking about hundreds of these across the United States,” Turner said. “By my count, it’s over a thousand at this point.”
Other experts NBC 7 Investigates spoke with provide similar figures on the number of stem cell clinics.
Turner notes the clinics are expanding rapidly, with different owners and clinic names, all making similar promises. He believes it’s up to both state and federal agencies to investigate this further, but so far they have largely ignored the issue.
“If someone has set up shop in San Diego or San Francisco or somewhere else, that company can market stem cell treatments for years with no evidence behind what they’re doing and no one’s going to come knocking on their door,” Turner said.
But that may be changing, at least here in California. Recently, the California Medical Board announced they are setting up a task force to investigate the claims made by these stem cell clinics, among other things.
Its impetus was a letter from U.S. Senator Lamar Alexander (R-TN) to the Federation of State Medical Boards, in which he voiced concerns that “recent reports indicate some patients have been harmed by unproven or investigational treatments received at stem cell clinics.”
The Federation was asked to create a “best practices” list for state medical boards to review when dealing with these types of clinics. The result is 11 recommendations that range from reviewing a clinic’s marketing materials to physicians being required to support health claims made with documented evidence.
A spokesperson for the California Medical Board said they are now reviewing the Federation’s recommendations but there is no date set for when the task force will get to work.
NBC7 Investigates has learned the California Attorney General and San Diego County District Attorney’s offices have both received information on various stem cell clinics and their practices. Neither office would confirm or deny that any active investigation is taking place.
November 28, 2018 | JW August, Mari Payton, Tom Jones | NBC San Diego
Tammy Smick of Downey, sits in the bedroom of her son, Alex, who died in 2012 from a lethal combination of prescription medications while being treated at an Orange County drug treatment center. (Photo by Nick Agro, Orange County Register/SCNG)
Philip Ganong, his wife and their 34-year-old son built a fast-growing, multimillion-dollar empire on urine.
They collected it from drug addicts at their chain of Southern California sober living homes. They created labs to test it. And they charged insurance companies to analyze it.
But the success story was a scam, according to prosecutors, who have accused the Ganongs of fraud. They say the family used a network of doctors and others to bilk insurers out of as much as $22 million for tests that were unnecessary or never performed.
The Ganongs have pleaded not guilty and are awaiting trial.
But the allegations raised in the Ganong case highlight what a growing number of critics say are chronic shortcomings in the oversight of California’s multi-billion-dollar drug rehabilitation industry.
Among the complaints:
Drug counselors and others can run sober living homes and some types of treatment centers without passing any kind of criminal background check. Even people convicted of drug crimes are allowed, under current state law, to get a license to own and/or operate drug and alcohol rehab centers.
Addicts and families considering rehab have no easy way to check the records of treatment centers, recovery homes or their owners or staff.
The state lags behind others in adopting reforms to crack down on treatment center operators who exploit vulnerable addicts and focus more on profits than on effective care.
California is “the wild, wild west right now,” said Kansas Cafferty, a commissioner with the National Certification Commission for Addiction Professionals.
In a state with about 1,800 licensed recovery centers and an unknown number of unlicensed sober living homes and testing labs, Cafferty is among many who believe California needs to get better at rehab regulation.
“There (are) a lot of places committing crimes that authorities are trying to enforce, but they can’t keep up with it.”
Just following the rules
Marlies Perez, chief of the California Department of Health Care Services’ Substance Use Disorder Compliance Division, which licenses rehab treatment centers, said her agency can only do what the state Legislature allows.
She would not say whether her department needs more authority, or if it is doing a good job protecting consumers.
“We’re not going to quantify our functions,” Perez said. “Our role is to provide oversight. That is, once again, exercise the authority that we have” and work with other regulatory agencies when appropriate.
Carol Sloan, the health department’s spokesperson, said state codes list specific causes for denying a treatment center license. Reasons include prior revocation of a license and failure to comply with fire codes. Other than that, applications from would-be operators and counselors generally aren’t screened by the state.
Drug counselors in California are certified by industry-related agencies to work in recovery programs. And once certified, they’re governed by a code of conduct written by the certifying agency that could make them subject to discipline for such things as sexual misconduct or drug abuse.
But officials and critics say neither the third-party certification organizations, nor the state health services agency, are routinely notified by law enforcement or state officials when treatment center operators or their workers are convicted of crimes or disciplined for license violations.
Stalled in Sacramento
It’s not a new problem, and California legislators have fought about it for years. Still, they’ve made only halting progress in beefing up licensing standards and rehab monitoring. That’s partly because of industry lobbying, and because of fears that tighter rules will raise treatment costs or limit the number of rehab beds just when the nation’s opioid crisis is cranking up demand.
This year, State Sen. Pat Bates, R-Laguna Niguel, introduced a bill to reform the system, but it stalled in committee. Today, she describes the state’s oversight of rehab operators, sober living homes and counselors as “troubling.”
Senator Pat Bates speaks during a drug overdose awareness memorial at Crown Valley Park in Laguna Niguel earlier this year. (Photo by Drew A. Kelley, Contributing Photographer)
“There is significant resistance … to looking at a (rehab operator’s) background,” Bates said. “There’s a culture about giving these people a second chance.”
Still, she insists that background checks and tougher licensing requirements for counselors, employees and rehab operators are vital. “It’s something we need to pursue.”
The Ganongs – who ran sober living homes in Los Angeles, Orange and San Diego counties – could face decades in prison if found guilty of running fraudulent urine-testing operations.
Since they were charged in May, the Ganongs apparently have shut down their recovery homes, according to one of their attorneys. Phone numbers for some of their operations are disconnected.
But there are no state rules that required them to do that. And even if they are convicted and sentenced to prison, the Ganongs still could legally own sober living homes in California. There’s no law preventing it.
At least one family member already has worked in the rehab business with a drug-related criminal record.
Prosecutors say William Ganong served as corporate secretary of the family’s sober living homes and a director of one of the drug testing labs named in the county’s fraud case. In 2006 and 2008, records show, he pleaded guilty to two misdemeanors involving being under the influence of a controlled substance and driving under the influence.
William Ganong (Photo courtesy of OCDA)
This summer, when prosecutors charged William Ganong and his relatives with fraud, he faced a series of new misdemeanor charges filed in 2014 and 2015 for allegedly possessing an opium pipe, driving under the influence, speeding and giving false information to police. William Ganong could not be reached, and his attorney did not respond to interview requests.
A lawyer representing Philip Ganong, the 64-year-old family patriarch, did talk.
In what might be a statement about the general weakness of rehab regulation and oversight, Kate Corrigan indicated a key part of her client’s defense could be to cite the law itself.
“There was great effort to comply on his part,” Corrigan said.
“But it’s not an area that has a good definition of what you can do and what you cannot do.”
Who is the doctor?
Tammy Smick lost her 20-year-old son, Alex, nearly six years ago, after he was admitted to an Orange County treatment program. The coroner’s office concluded he died of acute intoxication from the combined effects of several drugs. State records show the drugs were ordered during Alex Smick’s treatment.
Tim Smick, looks down on a photo of his late son, Alex, during a rally calling on the Medical Board of California to crack down on doctors whose overprescribing of medications has led to death or serious injuries, at the Capitol in Sacramento, Calif., Monday, March 11, 2013. (AP Photo/Rich Pedroncelli)
Alex Smick and his girlfriend, Tarra. (Photo courtesy of Smick family)
Alex Smick shows off a tattoo. It’s a likeness of his grandfather, left, and his grandmother. (File photo BILL ALKOFER, ORANGE COUNTY REGISTER/SCNG)
Tammy Smick of Downey, looks at photos of her son, Alex, who died from a lethal combination of medications while being treated at a Laguna Beach treatment center in 2012. (Photo by Nick Agro, Orange County Register/SCNG)
Dozens signed a poster for Alex Smick during a rally on February 23, 2013. (File photo BILL ALKOFER, ORANGE COUNTY REGISTER/SCNG)
Alex Smick was an avid golfer. (File photo BILL ALKOFER, ORANGE COUNTY REGISTER/SCNG)
Alex Smick and his girlfriend, Tarra. (Photo courtesy of Smick family)
Four years later, following an inquiry, investigators recommended that the state medical board discipline the doctor who ordered the drugs, Daniel Headrick. The formal accusation filed by the state attorney general’s office alleges Headrick engaged in “repeated negligent acts” in connection with the medications he ordered for Alex Smick.
Records also show a nurse was cited and fined $1,000 by a separate state agency because he was late in logging in Smick’s medication records, posting the information a half-hour after he was found dead.
Headrick denies the state’s allegations involving him, said his attorney, Raymond McMahon. The care Headrick provided was proper, McMahon added, and any issues involving Alex Smick’s treatment “relates to nursing care, not physician care.”
State officials declined to comment on the progress of Headrick’s case. Tammy Smick said the attorney general’s office and the Medical Board recently told her they have agreed to settle the case, without providing details. Potential penalties range from suspension or revocation of Headrick’s license to probation or a public reprimand, according to the accusation.
After their son’s death, the Smicks settled a malpractice lawsuit against Headrick, the terms of which weren’t disclosed.
Tammy Smick, center, flanked by her husband, Tim left, and son, Chris, called on the Medical Board of California to crack down on doctors whose overprescribing of medications has led to death or serious injuries during a rally at the Capitol in Sacramento in 2013. (AP Photo/Rich Pedroncelli)
Tammy Smick, a Downey teacher, threw herself into activism after her son’s death, retelling his story and focusing on issues such as overprescription of opioids and California’s cap on medical malpractice payouts, which she argues undercuts doctor accountability.
“Our goal is bringing awareness to medical malpractice (in) the opioid industry and detox centers,” she said.
Since Alex Smick’s death, Headrick has opened a drug treatment center, Tres Vistas Recovery in San Juan Capistrano, where he is listed as owner and medical director.
Addicts or their families considering using that rehab can learn about the state allegations involving Headrick, but only if they know where to look. In October 2016, details of the Headrick case were posted on the Medical Board of California website.
Tammy Smick believes it’s not enough. She says people considering rehab wouldn’t necessarily know to turn to the Medical Board website. She believes there should be an easier, centralized way to get official disciplinary records on rehabs, their operators and key staff.
State health officials say even when a doctor’s license is revoked, he or she can still operate a treatment center and profit from it, though they could not provide medical care to patients.
California lags other states
Smick is not the first to raise the issue of transparency. A state Senate report in 2012 found a host of oversight problems in the recovery industry, including poor monitoring of rehab centers and inadequate information sharing related to treatment center operators.
Other state officials have pointed to financial abuses in the industry that authorities say bleed millions from public and private pockets. Part of the concern is tied to so-called “junkie hunters,” people who recruit addicts from around the country and bring them to rehab centers in California in return for kickbacks.
One area of the rehab industry – sober living homes – has virtually no oversight.
The homes, where addicts often live for a few months after leaving formal rehab, aren’t required to submit any records of their operations. This is true, in part, because operators aren’t claiming to provide medical treatment and the people living in them, recovering addicts, are protected under the Americans with Disabilities Act.
The state’s findings from 2012, and a follow-up report in 2013, have sparked debate about how to regulate the industry. But that debate hasn’t prompted big change, and critics complain that California – which has about 1,800 licensed rehab centers, including more than 1,100 in Southern California – is falling behind other big states in vetting and licensing rehab centers.
“The big issue is, what do the licensure laws look like?” said Michael Cartwright, CEO of American Addiction Centers, one of the nation’s largest for-profit treatment chains. “Are they standard? Do they follow good guidelines other states follow? No, they do not.
“Time and time again, the problems get worse and worse,” Cartwright added. “Progressive states like Massachusetts, Pennsylvania, New Jersey … are making serious progress.”
Some of the biggest changes are taking place in Florida.
Like California, Florida has become a hotbed of out-of-state addict recruitment and scandals related to widespread fraud and dangerous patient care. In June, Gov. Rick Scott signed a package of reforms aimed at cleaning up the industry.
The new regulations call for background screenings for all owners, directors and clinical supervisors of sober homes. They clarify laws to make kickbacks illegal and empower state regulators to make unannounced visits to sober homes. They also allow state prosecutors to use racketeering laws to crack down on patient brokering and fraud networks in the industry.
In addition, licensed treatment centers in Florida have been prohibited from referring addicts to sober living homes that have not met the standards of a voluntary, third-party certification process.
Other states are taking actions as well.
In Pennsylvania, as part of the state’s response to the opioid crisis, lawmakers authorized funding for 45 “Centers for Excellence,” treatment facilities that combine medical, behavioral and job training services for 11,000 addicts. And the governor is pushing for the state to begin regulation of sober living homes.
Coming to America
Tonmoy Sharma worked as a psychiatrist in the United Kingdom before losing his license in 2008 for allegedly dishonest and unprofessional conduct in connection with research involving patients.
With a map of ambitious plans for expansion as a backdrop, Tonmoy Sharma, founder and CEO of Sovereign Health, an addiction treatment company, talks about the recent FBI raid earlier this year in San Clemente. (File photo by Mindy Schauer, Orange County Register/SCNG)
He also was accused of employing titles he did not possess – “Ph.D.” and “professor” among them – and “fell significantly short of the standards to be expected of a medical practitioner undertaking medical research on human subjects,” documents from the United Kingdom show.
Sharma said he believed he had obtained proper ethics clearances when he did his research, and that his course of study was equivalent to a Ph.D. so he was justified in using the title. A spokesman said he no longer practices psychiatry.
After moving to Southern California, Sharma built a chain of drug treatment centers, Sovereign Health, with nine centers in California and four other states with 743 beds. He also has centers that treat people for mental illness.
But before starting his businesses in the United States, Sharma’s background wasn’t widely known to California regulators.
His application to run rehab centers sparked no criminal or disciplinary background check. His application to run mental health care facilities did bring scrutiny from the state’s Department of Social Services, which oversees other types of group homes, and he was allowed to operate. There is no indication that the Dept. of Social Services alerted any other state agency about Sharma’s licensing issues and other problems in the United Kingdom.
Today, Sharma and Sovereign Health are under investigation by the FBI.
Tonmoy Sharma, founder and CEO of Sovereign Health, an addiction treatment center, shows reporters photos from the FBI’s recent raid of his company, He feels he is being unfairly targeted by the government. (File photo by Mindy Schauer, Orange County Register/SCNG)
Sharma says he has done nothing wrong. He contends the FBI investigation was sparked by an ongoing legal battle he’s waging with the insurance provider Health Net.In June, federal agents raided his offices and confiscated records and computers. Documents related to the FBI’s search warrant have been sealed, so the focus of the investigation is not public.
The health care giant has accused Sharma’s company of billing fraud worth more than $33 million. Sharma has responded by accusing Health Net of improperly cutting off payments for patient care.
Separately, the Dept. of Social Services is seeking to revoke Sharma’s license to run group homes for the mentally ill over allegations that proper consent was not given to perform genetic and HIV testing on children, among other problems.
But even as he battles law enforcement, the state and at least one major insurer, Sharma is among those who argue that there is “no quality control” in the state’s rehab industry.
“You will find treatment centers in Orange County like Starbucks,” he said.
“Yesterday, a tire shop; today, a treatment center. You don’t require background checks. You don’t require any skill to do this. That’s the problem.”
Business model
Court documents accuse the Ganongs of creating a network of rehab-industry companies that fraudulently exploited the testing of addicts’ urine.
This, according to prosecutors, is how they did it:
In December 2011, Pamela Mae Ganong, now 61, of La Jolla created Ghostline Labs Inc. to submit urine testing claims to insurance carriers. The next month, Ganong hired physician Suzie Schuder to run the lab, which conducted urine tests.
Suzie Schuder was charged with four counts of insurance fraud and conspiracy to commit insurance fraud. Her maximum sentence would be 17 years, eight months. (Booking mug courtesy of OCDA)
In January 2012, Pamela Ganong, Philip Ganong, and their son, William Ganong named themselves officers of the William Mae Corp., which ran sober living homes in Orange County, Bakersfield, Los Angeles and San Diego.Prosecutors allege some of the tests were not covered by the laboratory’s certification or were not necessary, and that Schuder received $21,884 from 2012 to 2013 to run the laboratory and write prescriptions. Schuder has pleaded not guilty to fraud. Her attorney did not respond to requests for comment.
The company advertised on Craigslist and word of mouth among drug users to get clients, according to a court declaration by the District Attorney’s Office.
Yet within a year the company, operating under the name Compass Rose Recovery, mushroomed from 12 employees to nearly 100. That growth sparked interest from insurance giant Anthem Blue Cross, which suspected the company’s sudden success might be a result of something more than smart business, records show.
During this period, the Ganongs also formed Compass Rose Staffing, which referred recovering addicts for temporary jobs with nonprofits. But hundreds of recovering addicts from the Ganongs’ sober living homes also were employed at the Ganongs’ various companies, and prosecutors say those workers were required to take frequent urine tests as a condition of their continued employment.
The staffing company “was just a front to facilitate the collection and testing of urine,” Pamela Angle, an Orange County District Attorney’s Office investigator, wrote in May.
Pamela Ganong and William Ganong also submitted insurance claims worth more than $1 million for testing on their own urine, Angle wrote in a court declaration. The lab charged between $400 and $1,500 for each test.
Records allege that over a three-year period the Ganongs’ urine business billed insurance carriers $22 million and collected $15 million. William and Philip Ganong recruited doctors who treated addiction and allegedly bribed those doctors into writing drug testing prescriptions, according to documents.
Carlos X. Montano, 61, of Newport Beach, was charged with three counts of insurance fraud and conspiracy to commit medical insurance fraud, and his maximum sentence would be 16 years, eight months. (Booking mug courtesy of OCDA)
The Ganongs and other defendants are scheduled to appear in court on Feb. 13.One physician, Carlos X. Montano of Costa Mesa, received a flat fee of $2,000 a month and $150 per prescription, prosecutors allege in court documents. Montano also is charged with fraud. His attorney, John Barnett, declined to comment on the case.
Staff writers Jordan Graham and Teri Sforza contributed to this article.
With the news full of stories about sexual misconduct, it’s worth mentioning the perpetrators who have hidden in plain sight – with the blessing of the Medical Board of California and the Legislature. These are doctors who are allowed to practice even after being found responsible for sexual misbehavior.
The state medical board has disciplined more than 450 doctors in recent years for crossing the line with patients. Surprisingly, board investigators are not required to notify law enforcement of a sexual assault complaint. They can quietly investigate without any warning to the public, and doctors usually stay on the job throughout the investigation, which usually takes about three years.
Some physicians do have their licenses revoked if the accusations are found to be true, but others are discreetly put on probation, ordered to take behavior classes and to have a chaperone in the examination room.
But their patients are never told. They have to look up the doctors’ records themselves.
What is also surprising is that a license revocation is rarely permanent. Doctors can petition for reinstatement within a few years. At least three doctors found responsible for sexual misconduct have had their licenses reinstated, and two of the cases involved underage girls.
In one notable case, Dev Gnanadev, the current board president, sat on the panel that reinstated the license of a physician who had assaulted four women, including a minor. Records show that doctor, Hari Narayana Ma Reddy of Victorville, had also pleaded guilty to misdemeanor battery after being charged with felony sexual battery of the minor.
There was never an inquiry into Gnanadev sitting on the panel by either the state Department of Consumer Affairs, which oversees the medical board. An investigation is not likely now since the new consumer affairs director, Dean Grafilo, used to work for the California Medical Association, the doctors’ lobbying group of which Gnanadev is a former president.
In some cases, the medical board doesn’t bother to follow its own discipline guidelines for sexual misconduct cases, which say that physicians should get a minimum of seven years probation, even when the relationship is consensual. Last year, a physician was given just less than three years on probation for unwanted sexual contact with five female patients.
State legislators have been complicit in the protection of these doctors, due in part to strong-arming by the medical association. In 2016, lawmakers failed to pass Senate Bill 1033, which would have required doctors on probation for egregious cases to notify their patients. Just last summer, an effort to insert a similar requirement failed when legislators watered down the proposal so that only a handful of doctors would be covered.
Will there ever be a bill to protect patients from assault by doctors? Not if the current mindset persists. Until then, patients must look up their doctors on the medical board’s convoluted website before every single appointment. And if there is a problem, patients should go directly to the police.
Marian Hollingsworth, who lives near San Diego, is a volunteer advocate with the Patient Safety Action Committee and Consumers Union. She can be contacted at marian.hollingsworth@yahoo.com.
There are a handful of physicians in California who have been put on probation for serious offenses like drug abuse or sexual misconduct.
More than 110,000 doctors are licensed in California. One California senator says about 600 are on probation, Los Angeles has the most with 164. But one legislator tried to make it a requirement for doctors to tell their patients if they have been in trouble, but that language in a bill up for a vote Friday was removed.
Eric Andrist lost his sister Cali to what he says were medical errors. He says not enough is being done to discipline bad doctors. Andrist testified in front of the State Medical Board which includes several doctors.
The board is in charge of disciplinary action and looking into complaints against physicians.
“We can’t have doctors policing doctors,” Andrist said. “The conflict of interest is just too great.”
Every four years the medical board must have their authority renewed by the legislature. It is an opportunity for lawmakers to evaluate whether the board is doing the job of protecting patients.
California Senator Jerry Hill, D-San Mateo, tried to add language to legislation requiring doctors to tell patients if they are on probation or have been disciplined by the board.
“At the end of the day they’re there for consumer and patient protection,” he said.
He says the California Medical Association, which represents 43,000 doctors across the state, lobbied to have it removed.
“It’s absolutely ludicrous that this provision’s been taken out of the bill,” Andrist said.
The group declined to be interviewed, but has repeatedly argued that forcing doctors to tell their patients about their probation status would unfairly put doctors out of business without giving them due process.
Gov. Jerry Brown has the final say. He has until Oct. 15 to sign the legislation.
To see if your doctor has been disciplined or is on probation, you have to look them up on the Medical Board’s website.
More than 110,000 doctors are licensed in California. One California senator says about 600 are on probation, Los Angeles has the most with 164. Lolita Lopez reports for the NBC4 News on Friday, Sept. 15, 2017.
Patient advocates looking to reform the maligned Medical Board of California were dealt a blow this week as the Legislature passed a bill to renew the watchdog agency for four more years without significant change. The board was created to protect patients from dangerous doctors, but as the NBC Bay Area Investigative Unit reported, patients can wait years for the board to deliver justice.
The medical board is set to expire at the end of the year unless the governor signs a bill to renew the state agency. It’s a process that usually runs smoothly, but this year it’s coming down to the wire for the Legislature to pass a bill renewing the board.
Doctors on Probation
The major issue that essentially put the medical board on life support stems from a contentious battle over disciplinary disclosure requirements. Under current law, doctors do not have to notify their patients when the medical board places their license on probation for offenses including deadly medical errors, drug use, and sexual assault against patients.
Probation info about a doctor’s past is posted on the medical board’s website, but critics say it’s difficult to navigate. State Sen. Jerry Hill of San Mateo authored SB 798, which would have forced doctors on probation to tell their patients directly, however the state Assembly gutted that plan before passing the bill on Wednesday.
“There are some in the Legislature that would rather support and protect doctors than patients,” Hill told NBC Bay Area.
The California Medical Association, which represents 43,000 doctors across the state, posed the main opposition against Hill’s disclosure requirement. The association argued that forcing doctors to tell their patients about their probation status would unfairly put doctors out of business without giving them due process.
The Medical Board and Patient Protections
The Medical Board supports SB 798 and maintains that the bill will allow the board to protect patients, despite the lack of disclosure requirement. A spokesperson for the board told NBC Bay Area that the new law will still allow the agency to investigate complaints and “continue to have the same value it’s always had.”
But some critics argue that without major reform, the state should disband the board completely and start from scratch.
State data provided to the Investigative Unit shows that that the average case takes the medical board 909 days to sanction a doctor. The process allows nearly all of those doctors continue practicing during the investigation.
“We need the medical board, but it’s not working for us, it’s working on the doctors behalf, they’re doing things to keep the doctors in practice,” patient advocate Eric Andrist told NBC Bay Area.
Eric Andrist is an outspoken critic of the medical board, which he says failed to issue any disciplinary action after his sister Cali became the victim of medical errors.
“It’s crucial that doctors tell their patients when they’ve been placed on probation. It’s absolutely ludicrous that this provision has been taken out of the bill,” Andrist said.
California is home to nearly 111,000 practicing doctors. More than 609 are practicing while serving probation. Los Angeles county has the most doctors on probation with 164. In the Bay Area, Alameda tops the list (16), followed by Santa Clara County (14), and Contra Costa County (12).
Gov. Brown has until Oct. 15 to decide whether he will renew the medical board. If signed, SB 798 will also require the board to restructure its process for investigating complaints over the next year, however it is unclear what that restructure will look like.
Patient advocates looking to reform the maligned Medical Board of California were dealt a blow this week as the legislature passed a bill to renew the watchdog agency for four more years without significant change. The board was created to protect patients from dangerous doctors, but as the NBC Bay Area Investigative Unit reported, patients can wait years for the board to deliver justice. Investigative Reporter Bigad Shaban reports in a video that first aired on Sept. 14, 2017. (Published Thursday, Sept. 14, 2017)
September 14, 2017 | Bigad Shaban, Jeremy Carroll, and Kevin Nious | NBC Bay Area
Above: Kevin Antario Brown, a doctor who sexually assaulted eight female patients and an undercover detective while working at three medical facilities in Los Angeles and Glendale, Calif., listens as he is sentenced to 12 years and six months in prison, at the Los Angeles Criminal Justice Center in Los Angeles Friday, Dec. 16, 2011.
She decided to check the records of the doctor who did her colonoscopy.
“And I about fell over, because he was about to start a 30-day suspension and seven years probation for a decades-long history of drug and alcohol abuse,” she said. “But what finally got the attention of the medical board, is that he went after a patient with a hatchet.”
Hollingsworth discovered that the medical board had investigated this doctor before.
“And in the early 2000s he was recommended for the medical board’s diversion program that they had at that time, and he had failed some other diversion programs he had tried voluntarily,” she said. “He had also failed the medical board version, and nothing was ever done.”
Any disciplinary action taken against a physician in California is listed on the medical board’s website.
Not required to tell patients
But the website is not exactly user-friendly.
In fact, someone searching for a doctor’s public records needs to navigate through multiple screens, and be willing to sort through pages upon pages of legal documents, before they can discover exactly why a particular doctor was disciplined.
But even if a doctor is punished for being drunk on the job, they’re not required to tell patients about it.
A bill (SB 798) in the state legislature would have changed that.
It would have required doctors to notify patients in writing if the medical board put them on probation for a serious offense, like sexual misconduct with a patient, or operating under the influence of drugs.
CMA officials did not agree to be interviewed for this story.
In an email, Joanne Adams, CMA’s associate director of communications, said such patient notification “would erode the fundamental right to due process by basing notification on accusations, rather than a finding of fact.”
“Anyone that’s on probation, has either stipulated with the medical board that they did commit the conduct they’re accused of, or that the board could at least prove its case, or at least certain elements of its case,” she said.
Gramme said the CMA is dead wrong on this one.
“I think they’re trying to make it sound like there’s a good reason, but I don’t think they have a good reason,” she said. “They just don’t want to have to tell their patients, because it would harm their business, and it would be embarrassing, and that’s just not a good enough reason.”
A unique perspective
There are an estimated 137,000 licensed physicians in California. Each year on average, the medical board puts 124 doctors on probation.
The failed bill would have applied to a subset of those doctors: some 40 a year.
In other words, the CMA lobbied to kill a measure that would have affected about two-one-hundredths of one percent (.02 percent) of all doctors in the state.
San Diego physician Jeoffry Gordon has a unique perspective on this issue.
He not only spent 35 years in private practice, but he also served on the state’s medical board for eight years back in the 1970s.
Gordon said the board has an obligation to protect patients from bad doctors.
“And to put their names on our website is not adequate,” he said. “I think each physician ought to be responsible for notifying his patients that he’s not been morally responsible.”
Marian Hollingsworth has become a crusader for more public disclosure. The bottom line? She thinks the medical board does not have its priorities straight.
“The investigator in my case actually told me that it’s the medical board’s job to make sure doctors remain in practice for as long as possible,” Hollingsworth recalled. “And I said, ‘Well, I thought it was to protect patients.’ And she goes, ‘Oh, that too.’”
May 14, 2017 | Bigad Shaban, Jeremy Carrol and Kevin Nious | NBC Bay Area
If your doctor was disciplined for harming other patients, would you want to know?
In California, the state Medical Board is responsible for protecting patients from dangerous doctors. More than 600 physicians and surgeons across the state are currently on probation for a wide-range of violations including sexual assault, insurance fraud, and medical negligence that has resulted in the deaths of patients. Despite the severity of such violations, the Medical Board does not require doctors to notify their patients of their probation status. According to the board, disclosing such details would “harm the patient-doctor relationship.”
The Medical Board has come under fire in recent months for what some are calling a lack of oversight. In February, several patients and their families gathered at the state capital to express their anger and testify before legislators.
“My sister was dead,” said an emotional Eric Andrist. Overcome with pain and anger, Andrist recounted losing his sister, Cally, to what he described as “poor medical care.”
“She, too, was dead from gross medical errors,” he explained to lawmakers.
Is Your Doctor on Probation?
Nearly 110,990 physicians and surgeons currently practice medicine in California. More than 600 of those doctors are on probation, according to the most recent data available from the Medical Board. Their offenses include deadly medical errors, drug use, and criminal convictions. Probation details for those doctors can be found on the Medical Board’s website, but it’s up to patients to find locate the information since doctors are not required to notify them directly of their probation status.
“Those doctors have [historically], a 30 percent recidivism rate,” state Sen. Jerry Hill, D-San Mateo, told NBC Bay Area.
Hill chaired the February hearing that centered on the Medical Board. He is now proposing major reforms to boost patient protections. His legislation includes a proposal to require doctors to directly notify their patients if they are practicing while on probation.
Medical Board President Dev Gnanadev, however, believes forcing all doctors to disclose their probation status would do more harm than good.
“If I go to a doctor … and if the person says to me, ‘Oh by the way, I’m on probation,’ there goes whatever trust I had – completely gone,” Gnanadev said during the hearing.
Medical Board Executive Director Kim Kirchmeyer also testified, explaining why her colleagues on the board worry about the implications of forcing all doctors to disclose their probation status.
“They didn’t want it to interfere with the patient-physician relationship,” Kirchmeyer said. “They were afraid it would have an impact on the time frame that the physician would be able to see the patient … because so many questions would come up at that time.”
Still, Sen. Hill found the board’s argument difficult to accept.
“When a doctor goes on probation, they have to notify the hospital they’re affiliated with, they have to notify their insurance company, but they don’t have to notify the most important part of the health care continuum, which is the patient,” Hill said.
Last week, the Medical Board released a letter, revising the agency’s stance, saying it now supports doctors disclosing their probation status to patients in cases of sexual abuse and criminal convictions. But the board’s proposal would not require some doctors who were disciplined for negligence to notify their patients.
“It’s speaking out of both sides of their mouths, and it really shows how little physicians at the medical board want patients to be informed.”
“The Medical Board continues to fail in its primary mission, which is patient protection,” Consumer Watchdog Executive Director, Carmin Boulder testified during the hearing.
MEDICAL BOARD AND DOCTOR DISCIPLINE
Despite the board’s revised stance on probation, it continues to face criticism over its process for disciplining doctors.
Each year, the board receives more than 8,000 complaints concerning physicians and surgeons, with only a few hundred of those complaints resulting in discipline. But even when investigators determine a doctor acted inappropriately, it takes an average of 909 days from when a complaint is submitted before a physician faces any kind of penalty. State regulations allow nearly all of those doctors to continue to see patients in the meantime.
“The system was set up to fail,” investigator Michelle Veverka testified. Under the current system, Medical Board investigators work in conjunction with the Attorney General’s Office to bring cases against doctors. However, Veverka says that partnership leads to inaction.
“We had to investigate and prosecute these matters being in two separate agencies,” Veverka said. “It has made it very difficult and very cumbersome.”
NBC Bay Area first exposed the communication breakdown between the Medical Board and the Attorney General’s Office last year when it profiled Mario Gusman.
Mario was an avid runner who believes a misdiagnosis by his doctor left him a multiple amputee.
“It’s like they steal your life away from you,” Gusman told NBC Bay Area.
Gusman filed a complaint with the Medical Board who recommended the Attorney General’s office discipline his doctor. However, the Attorney General’s Office decided not to pursue the case, citing “insufficient evidence.”
Hill’s legislation, which includes language to restructure the investigations process and require doctors disclose their probation status, is expected to be the subject of debate during a Senate committee on Monday. A final vote on the bill, however, is likely months away.
“The California Medical Board has really broken down in a number of areas,” Hill said. “In some cases, it could be life or death.”
Senator Pat Bates speaks during a drug overdose awareness memorial at Crown Valley Park in Laguna Niguel earlier this year. (Photo by Drew A. Kelley, Contributing Photographer)
William Ganong (Photo courtesy of OCDA)
