3 Ways to Prevent Another “Dr. Death” Incident
Dr. Christopher Duntsch, colloquially known as “Dr. Death,” botched operations on nearly three dozen people. These adverse events resulted in the deaths of two patients before criminal proceedings finally put an end to his power. With such poor outcomes, why was Duntsch allowed to operate on so many patients before intervention came?
The answer is complicated. It lies in Texas tort reform, which shifted the balance of power from the patient seeking to sue for malpractice to the practitioner starting in the 1990s. Healthcare systems in the state currently face more risk of being sued by a practitioner than from a malpractice suit.
“Duntsch was allowed to move from hospital to hospital, despite having really poor outcomes,” says Robert Oshel, former Associate Director for Research and Disputes at the National Practitioner Data Bank. “The easiest thing for them to do was just to pass the problem along to somebody else, so he was able to get privileges at the next hospital.”
Here’s what went wrong to empower this nightmare and what healthcare organizations can learn from the shocking tragedy.
Prioritize the Patient
Healthcare organizations have found ways to skirt reporting laws when it comes to practitioners at their facilities. They may let a problem practitioner know that they’re going to be investigated, allowing them time to resign their privileges so the facility is under no obligation to report they resigned while under investigation. Or administrators may agree to end the investigation with no findings if the practitioner agrees to resign immediately after. These situations are very difficult to investigate and prove, Oshel says.
There must be an understanding that the needs of the patients come first and that reporting potential problems is always the right course of action.
“Follow the law on reporting problem doctors to the medical board,” says personal injury lawyer and patient safety advocate Kay Van Wey, who represented several of Duntsch’s victims. “Do not make decisions based on fear of a lawsuit from a disgruntled physician.”
Do More Than Your Due Diligence
Medical staff services personnel at receiving institutions should do more investigating than the minimum requirements. If a practitioner has ever been under investigation—even if the investigation didn’t produce anything substantial—medical staff services professionals have an obligation to learn more. “Err on the side of caution when it comes to patient safety rather than giving the physician the benefit of the doubt,” Van Wey says.
Although the final decision lies with peer review boards, medical staff services professionals must stand up for patient safety in their recommendations. “Push the people that make the decisions as hard as they can to make the right decisions in the interest of protecting patients,” Oshel says.
A comprehensive, healthcare-oriented background check can help spot red flags. Medical staff services professionals can include the report to make their case for or against a practitioner.
Advocate for Change
Duntsch continued to wield a scalpel, injuring dozens, because legal policies and medical systems incentivized the wrong decisions. Duntsch’s colleagues recognized his destructive behavior but received little to no attention from the Texas Medical Board. Reform is essential for preventing another incident like this from occurring. “There must be actual penalties and sanctions for hospitals that skirt the law in order to protect physicians,” Van Wey says.
Healthcare and medical staff services leaders can join patient advocacy groups to revisit and revise these systems. Legal changes take time, but the advocacy of local healthcare leaders sends a strong message about what healthcare systems will and will not tolerate when patient safety is at stake.
While “Dr. Death” has been convicted and faces life in prison, he’s not the only problematic practitioner who has injured patients. Medical staff services professionals must remain vigilant and keep patient safety at the forefront of their recommendations to prevent future tragic outcomes.