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An Unprecented Disaster, or Just the Tip of the Iceberg?

Lessons from a Recent Medical Scandal

On July 10, 2015, Farid Fata, M.D., an oncologist and head of Michigan Hematology and Oncology (MHO), was sentenced to 45 years in prison for "horrific and unprecedented" crimes against 553 patients over nine years, i.e., deliberately prescribing unnecessary anti-cancer chemotherapy for some patients and treating others too aggressively with it. The charges? Defrauding Medicare and Blue Cross and Blue Shield out of what turned out to be $34 million. Yet a closer look at the series of events leading to his successful prosecution for these crimes, thanks to the thorough investigation of veteran Detroit Press reporter Laura Berman, suggests that the great odds against that success were just as unusual; the implications are sobering. 

The unusual circumstances:

1. Fata went on vacation.

2. While Fata was on vacation Monica Flagg, recently diagnosed with myeloma (cancer of the bone marrow) and treated with chemotherapy by Fata, had an (apparently unrelated) accident that led to her hospitalization. She was given a fairly comprehensive set of blood and urine tests while there, apparently standard practice for admitted patients.

3. Soe Maunglay, M.D., an oncologist employed by Fata, visited Flagg in the hospital because he was filling in for Fata. Although he had decided to leave MHO, he had given several weeks notice, perhaps longer than usual.

4. Maunglay studied Flagg's medical record, noting her normal test results, which ruled out the kind of cancer that Fata had diagnosed. Because routine blood and urine tests are the main sources of diagnostic information for myeloma and because the treatment was known not to have an immediate curative effect for this disease, Maunglay was able to determine from this information alone that she had not had myeloma prior to her treatment.

5. Maunglay was already suspicious of Fata because 1) Fata took measures to keep him from monitoring his work and 2) did not follow Maunglay's advice to seek quality certification and then lied about having obtained it to his employees. Quality certification might have involved monitoring of the work done at MHO by outside professionals.

6. Maunglay's suspicions were increased when Fata agreed to take his advice to moderate the levels of chemotherapy drugs he was administering, rather than defending his dosing decisions, suggesting he knew that he was doing the wrong thing.

7. Maunglay had a support system: George Karadsheh, MHO's office manager, filed the complaint under the False Claims Act, perhaps motivated in part by the reward provided by the Act. Maunglay's wife, also a doctor, served as a knowledgeable sounding board.

8. Fata chose not to move aggressively against Maunglay. Some employers in the same situation choose to harass potential whistleblowers, to deny them credit for their work, to give them poor evaluations, to try to damage their professional reputations via their connections, and even to fire them. They often consult lawyers to develop measures to undermine and to discredit their potential accusers. Many whistleblowers' careers have been permanently ruined through these measures. Fata not only did none of those things, but admitted his guilt and apologized for committing the crimes that he was charged with in open court, perhaps going against his defense attorney's advice.

On the other hand, there were compelling reasons that this case might not have proceeded to successful prosecution:

1. There was a large power differential between Fata and his accuser: Fata was a major figure in his field, having trained at Memorial Sloan-Kettering Cancer Center and built a clinic serving 1700 patients, while Maunglay was just beginning his career.

2. Fata shored up his image by creating a fundraising charity, the Swan for Life Foundation.

3. Fata anticipated resistance with certain shrewd measures, e.g., he made a practice of hiring employee doctors early in their careers and took steps to keep Maunglay from monitoring his work.

4. Heavy doctor turnover at Fata's clinic suggested that many of such employees simply left to go elsewhere when they detected problems.

5. Maunglay had been at the clinic only 11 months when he discovered problems with Flagg's case.

6. Symptoms of myeloma are vague and not specific to the disease, so that patients with other, milder, health problems can appear to have the disease. Since they might not understand their blood test results or even be allowed to see them, they might be inclined to take a doctor's word that they have cancer if they have those symptoms.

7. Flagg had a strong cancer family history, which also apparently made her afraid to contest her diagnosis and treatment.

8. Many non-medical staff members, such as nurses, had remained employed by the clinic for years, suggesting that they approved of Fata's diagnosis and treatment decisions.

9. No routine audits by insurance companies (or Medicare) had turned up anything suspicious.

10. Fata was consistently successful at deflecting attempts by individuals to prove his misconduct. Although Fata was sued for malpractice by four patients, three of these cases were dismissed and a fourth, which alleged a missed diagnosis, was settled out of court. RN Angela Swantek's formal complaint, based on firsthand observation of work at MHO, was dismissed by the state under murky circumstances.

In sum: 1) Malpractice is unlikely to be suspected when the side effects of a certain treatment are normally horrible, 2) doctors are extremely unlikely to question their colleagues' judgment and, if they do, tend to take the path of least resistance (and the one most favorable to their careers), 3) in order to make criminal charges for mistreating patients stick to a doctor, one has to prove insurance fraud, and 4) if the doctor who is accused of malpractice fights back, s/he is very likely to prevail. So is there any rule in place to protect patients against a doctor who overdiagnoses and overtreats cancer?

Two Memorial Sloan Kettering Cancer Center professionals (Snyderman & Korenstein, 2017) approach the issue of trying to develop measures to prevent medical overdiagnosis/overtreatment in a manner that suggests that it will at least be an uphill struggle, in apparent response to a paper suggesting a focus on low-hanging fruit. It does not look as though internal reform in the medical world will fix this problem any time soon.

The take-home message?  Perhaps a patient's best defense is getting a second opinion.

REFERENCES

Berman L (2015) Whistleblower: how doctor uncovered nightmare. The Detroit News: 10 Jun 2017. Retrieved 25 Feb 2017 from http://www.detroitnews.com/story/news/special-reports/2015/06/10/whistle-blower-doctor-uncovered-medical-nightmare/71027690/

Berman L (2015) One nurse's gutsy attempt to protect patients. The Detroit News: 6 Feb 2015. Retrieved 2 March 2017 from http://www.detroitnews.com/story/opinion/columnists/laura-berman/2015/02/05/berman-gutsy-nurse-whistle-blower/22964301/

Brand-Williams O (2015) Cancer doctor get 45 years for "huge, horrific" crimes. The Detroit News: 10 Jul 2017. Retrieved 25 Feb 2017 from http://www.detroitnews.com/story/news/local/oakland-county/2015/07/10/farid-fata/29955103/

Lipitz-Syderman A, and Korenstein D (2017) Reducing overuse -- is patient safety the answer? JAMA 317(8):810-811. Retrieved 8 Apr 2017 from http://jamanetwork.com/journals/jama/article-abstract/2605779

Phillips D (2013) Accused doctor has history of malpractice suits. Macomb Daily News: 8/13/13. Retrieved 28 Feb 2017 from http://www.macombdaily.com/article/MD/20130813/NEWS01/130819841

Unknown author. ClickonDetroit. Retrieved 28 Feb 2017 from http://www.clickondetroit.com/news/michigan-cancer-doctor-farid-fata-pleads-guilty-to-16-counts_20151201033528331

Copyright © 2017 by Dorothy E. Pugh.  All rights reserved. 

 

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