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Patel's disturbing record
Dr. Jayant M. Patel was a surgical star.
Just three years after he was hired by Kaiser Permanente Northwest in 1989, the HMO gave him the job of training its young surgeons.
Patel gravitated to the toughest cases, confidently rebuilding colons and removing tumors to become one of Kaiser's busiest surgeons. In 1995, fellow Kaiser doctors voted him a "Distinguished Physician of the Year."
But there was another side to Patel's work, one hidden from both his patients and many colleagues.
By the time Kaiser honored Patel, he had been involved in a string of problem cases, eight of which had prompted or would lead to malpractice or wrongful death lawsuits, an investigation by The Oregonian has found.
In four of those problem cases, Patel's patients died. One young man was left impotent. An elderly woman lost a kidney and became incontinent. Yet it took Kaiser until 1998 to begin investigating Patel and five more months to bar him from surgeries on the liver, pancreas and colon. State medical regulators did not discipline him until 2000.
Between the time Kaiser lauded Patel and the time it restricted him, he performed scores of operations -- including one in which an elderly patient bled to death after Patel severed an artery and vein during pancreatic surgery.
Patel resigned from Kaiser in 2001 and later surfaced at a hospital in Australia, where authorities are investigating his role in 13 patients' deaths and asking how he got the job given his troubled background.
But Patel also slipped through the cracks in Oregon's largely secretive system for spotting and disciplining problem doctors, The Oregonian found in reviewing his 12 years at Kaiser. His case highlights how hard it can be for patients to learn about a physician's track record -- and the risks that come with not knowing.
Because of confidentiality laws, patients have little opportunity to learn if their doctor is under investigation by a hospital or regulators. Patel's case also exposes deficiencies in a state law requiring insurers to report malpractice claims, which regulators screen for possible negligence. Kaiser asserts it is exempt from the law, although state regulators disagree. It did not report claims against Patel or its other doctors from 1991 to 2004.
Between 1994 and 1998, The Oregonian found, Kaiser settled five Patel cases and paid out $1.8 million in two of them. Those claims, had they been reported, would have triggered an investigation of Patel by the Oregon Board of Medical Examiners years earlier, said Executive Director Kathleen Haley.
Kaiser is the region's largest health maintenance organization, with a health plan covering 470,000 people in Oregon and Southwest Washington. The nonprofit defends its handling of Patel and said it has tightened procedures for tracking medical errors. A situation like Patel's would be discovered and corrected sooner now, Kaiser maintains.
The HMO acknowledged that Patel had been sued more frequently than other Kaiser doctors. Kaiser would not discuss those cases. It denied the allegations in court and moved to have Patel dismissed as a defendant.
"It's important to note that Kaiser Permanente's patient safety program doesn't hinge on waiting for someone to file a claim," Kaiser said in a prepared statement to The Oregonian. "We actively monitor for a long list of signs that might indicate a problem."
Now back in Portland, Patel, 55, has declined repeated interview requests through his lawyer, Stephen Houze. He faces possible criminal charges in Queensland, Australia, where he had landed the job as chief surgeon at Bundaberg Base Hospital with the help of six enthusiastic letters of introduction written by fellow Kaiser doctors.
"I can recommend Dr. Patel without any reservations whatsoever," wrote Dr. Edward Ariniello, Kaiser's former chief of surgery who hired Patel and, later, sat on the committee that restricted Patel's practice.
Ariniello did not respond to requests for comment. It is not clear how much the other doctors recommending Patel knew of his record; none would discuss the matter. Nor would most of the more than two dozen other physicians and nurses who worked with Patel at Portland hospitals and were contacted by The Oregonian.
The former chairman of the Michigan Board of Medicine, whom The Oregonian hired to examine medical records from Patel's patients, said his succession of bad outcomes should have prompted a review years earlier.
"As soon as you see one or two, you say, 'We better take a look,' " said Dr. Norman Bolton, who was chief of surgery at Sinai Hospital in Detroit. He called one 1995 case, in which Patel supervised a routine hernia operation where an unrelated vein was cut by mistake, "grotesque" and a "red flag."
"Certainly a result such as this should have called for an evaluation of the operating surgeon," Bolton said.
But it didn't -- for years.
Promise hid a troubled past
Patel arrived in Oregon from Buffalo, N.Y., in 1989 with a strong resume and rave reviews. A native of India, the 39-year-old Patel had completed medical school and early surgical training by 1977 before emigrating.
He had finished his surgical residency, taught surgery for five years and run the residency program at a prominent Buffalo hospital. He contributed to a medical textbook and published numerous articles with Dr. Raymond Hinshaw, a nationally known Rochester surgeon who praised him in recommendation letters.
At Kaiser, Patel built a reputation as knowledgeable, aggressive and brash.
"He boasted a lot about his surgical abilities," said Dr. Gerald Holguin, Kaiser's chief of anesthesiology from 1993 through 1999. "He was arrogant and full of himself, but there was a charming side to the man."
Patel and his wife, Kishoree, a Kaiser internist, settled into a sprawling Beaverton home they purchased for $420,000 in 1991. And while keeping a busy practice at Bess Kaiser Medical Center, Patel took on extra duties, running Kaiser's surgical residency program at Legacy Emanuel Hospital & Health Center and volunteering to screen fellow surgeons for national certification.
"He was very well liked," said Dr. Robert McFarlane, a retired Kaiser surgeon who worked with Patel on administrative matters. As a surgeon, McFarlane said, Patel was hard-working and "pretty aggressive," preferring such technically demanding operations as liver surgery and intestinal reconstruction.
He showed little interest in learning the new technique of laparoscopic surgery that emerged in the mid-1990s as a way to do abdominal surgeries with smaller incisions and less chance of infection, McFarlane said. "That effectively eliminated him from doing a lot of routine surgeries, like gallbladder," he said.
In late 1996, Bess Kaiser Medical Center closed. Patel then began operating on Kaiser patients at Providence St. Vincent Medical Center, where he brought a reputation as an articulate, knowledgeable and prolific surgeon -- "a go-to guy for major surgery" -- said Dr. Roger Alberty, St. Vincent's chief of surgery.
What neither Alberty nor Kaiser knew was that Patel had a disturbing secret in his past.
Kaiser never checked Patel's disciplinary record in New York when it hired him, the HMO told The Oregonian. And it turned out that Patel omitted an important detail.
In 1981, the University of Rochester dismissed Patel from its surgical residency program after patients accused him of altering records to make it seem as though he'd examined them when he had not. Patel entered data on five patients' charts without examining them and tried to coerce a patient into not cooperating with investigators, according to a statement of charges from the New York medical licensing board.
The board found Patel guilty of professional misconduct, fined him $5,000 and put him on three years' probation, which passed before he completed his residency in Buffalo.
The Oregon Board of Medical Examiners was aware of the misconduct finding but granted Patel a license in 1989 based partly on an enthusiastic recommendation from Hinshaw. In retrospect, Patel's problems in New York foreshadowed a pattern that played out over the next decade in Oregon and, later, in Australia.
Slipshod medical practice. A fudged resume. And disciplinary sanctions that went unnoticed.
A pattern of problems
The year after his arrival at Kaiser, Patel performed hernia surgery on a patient who claimed in a subsequent lawsuit that he'd been left sterile. Although the case was dismissed for procedural reasons, others like it soon followed.
In 1992, Patel and a resident he supervised operated on a 28-year-old man with ulcerative colitis, a severe bowel irritation. Residents, or young doctors in training, typically assisted Patel in the operating room and worked under his direct supervision.
The operation was to fashion a new colon for the patient, using his stomach lining. According to a 1993 lawsuit in Multnomah County, the doctors severed the urethra, the tube through which urine passes from the bladder. A few weeks after the operation, the patient said he began urinating from his rectum.
The patient, a restaurant cook who grew up in Portland, asked that his name not be used because the surgery and complications made him permanently impotent. He settled with Kaiser for more than $100,000 in 1994, two years into Patel's tenure as director of surgical residents.
The amount of the settlement is significant because the state medical board normally would investigate any malpractice payout of $100,000 or more.
In 1993, an error by Patel led to what Bolton, the surgeon hired by The Oregonian, called a "real tragedy."
Eighteen-year-old Ronela Tepei, a Romanian immigrant, came to Patel with abdominal pain and a family history of polyposis, a predisposition to colon cancer. Her father had died of colon cancer that spread to his pancreas two years earlier at 42, according to Tepei's mother, Tabitha Starkenburg. Tepei's uncle had died of the same cancer at 19.
Patel ordered a sigmoidoscopy, a test that can detect abnormalities in the lower colon. When Tepei's results came back normal, Patel told her she was healthy, according to Starkenburg, and medical records reviewed by Bolton.
The problem, Bolton said, is that a sigmoidoscopy was the wrong diagnostic procedure for a patient with Tepei's history. The standard was to order a colonoscopy, he said, a more extensive screening that examines the entire colon for the kind of polyps that are the first sign of cancer.
In younger patients, Bolton said, it's critically important to screen the entire colon because the polyps turn cancerous quickly. If polyps are detected, the patient's colon can be removed to prevent cancer from developing.
That never happened to Tepei. In 1995, while no longer a Kaiser patient, she died of colon cancer that had spread to her lungs and liver. She left behind a husband and an infant son.
Starkenburg blames Patel: "You can make a mistake, but I think he's responsible for my daughter's death."
After reviewing Tepei's records, Bolton agreed. Her death "is one you can point to that should not have happened," he said. "Had she gotten a colonoscopy, there was a darn good chance she would have lived."
Tepei's family sued, and Kaiser settled the case for $1.4 million, court records show.
In 1994, Patel removed part of Leatrice Fairchild's stomach because of ulcers. Fairchild's surgical wound came apart, causing infections and leakage that doctors could not control. She died two months later.
Patel missed the leak, Bolton said, though he noted that Fairchild's case was complex because she was extremely obese and her ulcer was large. Fairchild's family sued, and Kaiser later settled for $375,000.
Then, in 1995, three cases came along that would lead to lawsuits and settlements.
Three weeks after Patel operated on Gerald Tucker's inflamed pancreas in February, the 50-year-old died from massive internal bleeding and infection that had required three corrective surgeries, his medical records show.
Bolton, after examining the records, said that while Tucker's death does not necessarily reflect poorly on Patel's technique, it suggests a worrisome pattern that Kaiser should have noticed in the context of other bad outcomes. Kaiser settled the Tucker family's wrongful death lawsuit in 1999 for $900,000.
During gastrointestinal surgery in September 1995, Patel accidentally cut the ureter of a 79-year-old woman. Dr. Sanjeev Sharma, a medical resident in the operating room with Patel that day, described it as "awful." The ureter is a tube that links the kidneys to the bladder.
"I tried very hard to get him to realize there was a problem after the surgery," said Sharma, now a cardiothoracic surgeon in Stockton, Calif. The patient, Helen Brooks, "was leaking urine."
"I spoke up about Mrs. Brooks to Patel, and he said, 'It's OK, it's OK,' " Sharma told The Oregonian.
But it wasn't OK. Brooks' lawsuit said she became incontinent for three months, underwent three further surgeries and lost a kidney. She settled with Kaiser confidentially in 1997 and died the next year. Brooks' lawyer said he did not know whether her death was related to the operation.
On the same day as Brooks' surgery, Susan Tomberlin was on Patel's schedule for an outpatient hernia repair.
Tomberlin, then an unemployed data entry clerk, said she was in her hospital bed recovering when a nurse confided to her that something had gone wrong.
During the operation, the femoral vein from Tomberlin's right leg was inadvertently damaged, then deliberately severed so Patel could attempt a repair. Afterward, a potentially life-threatening clot developed.
Patel was supervising a resident during the surgery, but said in a sworn legal deposition later that he was responsible. Bolton described what happened as "grotesque." He said the severed vein was so far removed from the surgical area that cutting it isn't even considered a risk.
"It's almost impossible for me to think of a rationale that would allow this kind of complication to occur," Bolton said. "He was operating below where he should be. It's a big vein. Even when you repair it, the repairs don't do so well. She's in for a lifetime of trouble."
Tomberlin said she couldn't walk or pull on pants for six months because of excruciating pain. Kaiser settled her medical negligence case confidentially in 1997.
"When I saw another doctor, he said I was a walking time bomb from this. They said this could kill you if a piece of this blood clot gets loose," said Tomberlin. "When I mentioned that to Dr. Patel, he screamed at me like I was a 2-year-old and told me I wasn't to talk to anybody about what happened."
One doctor speaks up
Susan Tomberlin's case would have triggered an immediate review of the responsible surgeon at his hospital, Bolton said, especially with evidence of recurring problems in routine and complex surgeries.
Yet Kaiser didn't start its investigation of Patel for more than two years.
Kaiser said fellow surgeons began raising questions about Patel sometime in late 1997, but officials declined to be more specific. Though Patel "was the target of lawsuits more frequently than his fellow surgeons at Kaiser Permanente," the lawsuits did not trigger the practice review, Kaiser said. The HMO looked at outcomes in a sample of 79 Patel surgeries, most of them not problematic, before restricting him in June 1998.
Since 2000, Kaiser officials said, surgical outcomes are tracked by computers, and medical staff can complain anonymously through a national hot line. But during the 1990s, quality assurance largely depended on patients' complaints or doctors coming forward to report their own mistakes, Kaiser spokesman Larry Wheeler said.
"Without the rigor of today's systems, I suspect things happened that didn't hit the radar as quickly as they do today," Wheeler told The Oregonian.
The first blips might have been at Providence St. Vincent, where Patel's practice shifted after Bess Kaiser shuttered.
That is where Dr. Sally Ehlers spoke up.
Ehlers, now a general surgeon in Centralia, Wash., was a resident under Patel for three years. Ehlers said she had many concerns about Patel -- she described him as sloppy, arrogant and uncaring -- but worried that her own job could be on the line if she criticized Patel.
"If I had someone to complain to, I would have started complaining," she said. "But I didn't."
That changed when Patel stopped overseeing residents under a reorganization. In summer 1996, Ehlers, then at St. Vincent, decided to come forward about a patient whose care had troubled her for years.
The patient, Duane Feakin of Scappoose, had his colon removed by Patel in 1992 for ulcerative colitis. Infections and other problems forced several additional surgeries; in 1994, Feakin was hospitalized for 49 days.
Ehlers said a pathology report in 1996 indicated Feakin had Crohn's disease, which has similar symptoms to ulcerative colitis but sometimes can be treated without surgery. She said Feakin never should have had his colon removed and that Patel missed signals pointing to a diagnosis of Crohn's.
Ehlers said she warned Feakin that year to get away from Patel, and Feakin dropped him. Feakin confirmed the account to The Oregonian, provided his medical records, and gave Ehlers permission to discuss his case.
At a weekly, confidential meeting among St. Vincent doctors to discuss problem surgeries, Ehlers offered Feakin's case for discussion. She said the other surgeons were surprised. Later on, "Dr. Patel became very hostile and aggressive toward me," Ehlers said. "He knew I presented the case."
Ehlers believes the meeting was the first red flag for Alberty, the St. Vincent chief of surgery, who told The Oregonian his hospital began looking at Patel's record sometime afterward and well before Kaiser began its review.
St. Vincent evaluators first assumed Patel's high rate of complications arose from the difficult cases he tackled, Alberty said. But then a pattern emerged: clear problems with upper abdominal surgery involving the liver, pancreas and bile duct. Technical skill was not Patel's problem, Alberty said. Rather, it was poor judgment or carelessness.
"We weren't sure which -- maybe it was a combination, we didn't know," Alberty said. "But he didn't seem to understand he was getting into trouble on these big cases. . . . Things weren't matching up to our other major surgeons doing this kind of surgery."
While suspicions grew at Providence St. Vincent, Patel continued to operate.
On March 3, 1997, retired restaurant owner Marie Mesecher turned to Patel to treat her pancreatic cancer.
Bolton, who examined Mesecher's records, said such cases are inherently risky. The 73-year-old's tumor involved a critical vein and artery, and the operation shouldn't go forward until the surgeon is certain the cancer can be safely cut away. But in this case, Bolton said, the records show Patel committed too soon.
"He went right ahead and started cutting things -- until he saw the damage," Bolton said, calling it a clear case of malpractice. "This is very complicated surgery, but he did a really rotten job."
Mesecher bled so profusely that doctors had to give her more than three times her blood supply. A post-surgery report said blood "was pooling off the bed and onto the floor." Mesecher died that afternoon.
"We asked lots of people if (Patel) knew what he was doing at Kaiser and St. Vincent and were told he was a specialist and was great," said Mesecher's daughter, Sandra Ickert.
"I feel like I was lied to by a bunch of people."
Records kept confidential
Patients like Mesecher have no way to know if their doctor's competence is under review -- unless an insider like Ehlers divulges it.
In Oregon and other states, any information a hospital has on a doctor's performance, surgical mishaps or internal investigations is confidential by law. It cannot be disclosed, even in a court case. Investigations by the Oregon Board of Medical Examiners also are confidential until the board issues a formal complaint.
"It's easier to find out about your roofer or your lawyer than your doctor," said Greg Smith, a former intensive care nurse turned malpractice attorney in Salem.
State law requires any doctor who has information about another doctor's possible incompetence to inform the medical board within 10 working days. But only 8 percent of all new medical board investigations last year were the result of complaints by health care providers, including doctors.
Kaiser kept its own doctors in the dark about Patel, including some of those who later wrote the recommendation letters he sent to Australia.
"Most of the physicians who wrote the letters would not have known about corrective actions taken up to that point against Patel," Kaiser said in its statement to The Oregonian. "Such corrective actions are usually handled by a limited number of people directly charged with managing and monitoring a physician's performance."
Kaiser's practice review of Patel took five months. On June 25, 1998, the HMO banned him from pancreas and liver surgeries and colon reconstructions. Kaiser also required Patel to get a second opinion before any difficult surgery and said he must take classes on communication skills and preventing malpractice losses.
At that point, Kaiser reported its disciplinary action to the state board and the National Practitioner Data Bank, a confidential database available for licensing boards and hospitals to check a physician's background.
Kaiser insists that it acted responsibly in Patel's case. "We were the ones who did something," Dr. Maureen Wright, who oversees physician competence at Kaiser, told The Oregonian in May.
In its September statement to The Oregonian, Kaiser revealed more detail about Patel's departure, saying its physician group put him on probation in September 1999 after "instances of poor communication with patients." By late 2000, after the state board sanctioned him, Patel "was essentially no longer doing inpatient surgeries," the statement said.
Patel took a leave of absence from Kaiser in February 2001, then submitted his resignation on June 20.
Kaiser said the medical group's board was scheduled to discuss firing him the next day.
The furor in Australia surfaced last April. An Indian surgeon from Oregon -- "Dr. Death" in the Aussie media -- had botched scores of surgeries. Patients died, their stories sometimes gruesome.
In 2003, Patel had landed as surgical director of Bundaberg Base Hospital in Queensland after hiding his past.
His resume said he left Kaiser a year later than he actually did. Australian investigators found that he lied twice on his medical license application, indicating he'd never been disciplined. And he failed to submit the part of his Oregon license stating he'd been restricted from doing some types of surgery.
As questions mounted, Patel hurriedly resigned and returned to Portland.
An Australian commission investigating him has yet to issue its final report but said in July it will recommend charging Patel with murder or manslaughter in at least one case. Of 13 Patel patients who died from substandard care, investigators said, eight had operations Patel was restricted from performing in Oregon.
Anthony Morris, the commission's former chairman, issued a scathing report on "the Patel phenomenon" in September, noting that Queensland authorities were partly to blame for inadequately checking Patel's record. Among other things, the report said Patel performed unnecessary operations, removed wrong organs, sewed wounds that repeatedly burst or leaked and frequently misrepresented his patients' progress.
Morris pondered how Patel could have lasted as a chief of surgery for two years.
"Paradoxically, the very fact that Patel was not totally incompetent only added to his lethal propensities," Morris wrote. "A surgeon who was obviously incompetent would not have lasted so long, or done so much harm, in the position to which Patel was appointed."
In Portland, some who crossed Patel's path wonder what might be different if they had known more about his competence.
"It's upsetting that he got away with this kind of practice for so many years," said Paula Tucker, whose husband died after pancreatic surgery by Patel. "It wasn't a choice my husband had."
Vickie Boyle had her colon removed by Patel in 1995 and later ended up rehospitalized for infection and a perforated bowel. When she questioned Patel about what happened, he asked if she'd been "eating toothpicks."
Boyle said she approached another Kaiser doctor, who simply shrugged.
"I was told he was the best," she said.
Staff writers Andy Dworkin and Steve Woodward and news researchers Margie Gultry and Kathleen Blythe of The Oregonian contributed to this report. Susan Goldsmith: 503-294-5131; firstname.lastname@example.org; Don Colburn: 503-294-5124; email@example.com©2005 The Oregonian