When the system fails

Several years ago, a complaint was filed against my license to practice medicine in the state where I was working at the time.

As I’m sure you can imagine, when I first received the notification about the complaint it was quite unnerving.  My head swam trying to guess what I had done to warrant it.  When I picked up the certified letter from the board of licensure, I tore into it as quickly as I could to find out why someone had urged them to consider action against me.

To say that the substance of the complaint was frivolous would be an understatement.  It would be imprudent to go into much detail, but I am not being unfair when I describe the complainant’s case against me as ridiculous.  It was weightier than “I didn’t like his smile,” but only just barely.  The board dismissed it as without merit by unanimous vote at their first opportunity.

However, I was still made to submit a written response to the complaint and provide the patient’s complete medical record for scrutiny.  The board still reviewed the materials and took the trouble to vote on it.  As preposterous as the complaint itself was, it was still treated with seriousness.

And I will never be totally free of it.  Every time I apply for privileges at a new hospital, I complete a lengthy questionnaire that includes some question or another about whether any formal complaint has ever been submitted against my license in any state where I’ve ever practiced.  Ditto every time I apply for licensure in another state.  And I must provide documentation that verifies the board’s decision, and that no discipline was enacted against me.  (I keep copies of these materials on hand so I can just photocopy them when need arises.)  It is remarkably tedious.

All for a complaint that was wholly devoid of merit, and that any layperson would have been able to recognize as such on its face.  (I hope I always practice in a way that obviates any potential for more complaints.)

This is in addition to all the hoops I must jump through in order to maintain my license, my board certification and my privileges at the hospitals where I am on staff.  On a periodic basis I have to submit a tally of the ongoing medication education I have received to all the various entities that supervise my capacity to practice, and must be able to provide documentation if necessary.  Every few months I have to take some online learning module or another to confirm that I know how to competently handle some aspect of hospital practice.  And of course I must take re-certification exams every decade in my specialty and subspecialty in order to keep the American Board of Pediatrics’s imprimatur.

Keeping all of that in mind, perhaps you will understand my utter and appalled bafflement at the grisly crimes of one Kermit Gosnell.  (Thanks for the topic suggestion, Alexios.)  For those of you unfamiliar with his ongoing trial, Dr. Gosnell (it pains me to type his title) is accused of running an abattoir of an abortion clinic in Philadelphia.  You can read about details from Conor Friedersdorf  here, but before you click the link you should be aware that those details are incredibly gruesome and disturbing.  Some of the less grisly charges:

One woman “was left lying in place for hours after Gosnell tore her cervix and colon while trying, unsuccessfully, to extract the fetus,” the report states. Another patient, 19, “was held for several hours after Gosnell punctured her uterus. As a result of the delay, she fell into shock from blood loss, and had to undergo a hysterectomy.” A third patient “went into convulsions during an abortion, fell off the procedure table, and hit her head on the floor. Gosnell wouldn’t call an ambulance, and wouldn’t let the woman’s companion leave the building so that he could call an ambulance.”

Much of the conversation surrounding Gosnell’s serial crimes (and I use that term advisedly) has focused on the meta-narrative and why it hasn’t garnered more attention in the national media.  I have no interest in discussing that aspect of things.  I’ll leave it to another post of Conor’s and to Kevin Drum, for the interested.

What I cannot fathom is how he was able to do what he did to those people (infants and women alike) for so long.  Via the  link to the first Friedersdorf piece:

The Department of State, through its Board of Medicine, licenses and oversees individual physicians… Almost a decade ago, a former employee of Gosnell presented the Board of Medicine with a complaint that laid out the whole scope of his operation: the unclean, unsterile conditions; the unlicensed workers; the unsupervised sedation; the underage abortion patients; even the over-prescribing of pain pills with high resale value on the street. The department assigned an investigator, whose investigation consisted primarily of an offsite interview with Gosnell. The investigator never inspected the facility, questioned other employees, or reviewed any records. Department attorneys chose to accept this incomplete investigation, and dismissed the complaint as unconfirmed.

There is much more depth to the litany of abject failures described in the grand jury report.  Every single one of them stupefies me, and in aggregate they represent one of the most monumental failures of regulatory bureaucracy I have ever seen.

Gosnell’s crimes are ghastly, and beggar my attempts at commentary.  I hope they find an appropriately deep pit into which to cast him.  I have no special insight as a physician into what he did.  Monstrosity requires no expertise to recognize.

But one reason I hope this story gets lots and lots of attention, in Pennsylvania if not the nation as a whole, is that I hope many, many, many people lose their jobs.  I hope some are brought to trial for their own negligent, incompetent and/or indifferent contribution to the mutilation and murder of women and infants.  I hope that the brightest glare of media scrutiny shines on every single person who was charged with overseeing the practice of medicine in that city and state, and that a full accounting of their failures is made.

Do I find it terribly wearying to comply with the rules and regulations and bylaws that prescribe and proscribe my professional activities?  You bet.  Do I think there is some room for making it less tedious, onerous and time-consuming?  Indeed I do.  (I question whether I really need to pass annual online exams about the proper storage of chemical materials, for example.)  Do I have my gripes with the ABP about its new maintenance of certification process?  I will gladly enumerate them over a friendly beer or two.

But I dot every last “i” and cross every last “t” demanded of me, knowing that doing so is my part in keeping the patients in my and my colleagues’ charge safe.  I comply not only because I must, but because at heart I know that my compliance is part of a system dedicated to securing the well-being of people who make themselves vulnerable in our care.  I photocopy the report from the board of licensure when asked because I know I’m being asked for reasons more important than my convenience, no matter how nettlesome I find it at times.

I do my part because I take seriously my obligations.  And from within this system of regulations and guidelines I raise my finger in angry condemnation at those who so blatantly failed in theirs.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. I am not being unfair when I describe the complainant’s case against me as ridiculous. It was weightier than “I didn’t like his smile,” but only just barely.

    The Franco-philes will stop at nothing to destroy you, Doc.

    More seriously, I wonder why there isn’t a nationwide public Yelp-style site that rates and reviews medical/dental/etc. providers – on the one hand, there would be a LOT of the frivolous griefer-style complaints, like you got, for any given provider (see YouTube comments for a million depressing examples), but on the other hand a few reports of “blood on the furniture and walls…” might have steered additional victims away from this reputed abattoir, and drawn law enforcement attention to it more quickly.

    I know if I simply want to find a new Primary Care Physician, it’s still not easy to really find much public info about whether he or she is well-liked and competent – remind me to tell you sometime about the crazy thing a PCP that I picked at random out of a directory (based solely on geographical proximity and assumptions about linguistic compatibility), said to me on my initial visit.

    • There are scads of physician-rating websites, and Angie’s List also rates physicians. I think this is a little bit unfair, since HIPAA prevents any kind of detailed response to a complaint. But it’s the lay of the land, and my general view is that if you’re doing right by your patients you’ll generate far more positive word of mouth than you’ll need to counteract whatever negative effect you get from some random negative online review.

      In addition, on a more local level, there are lots of “mommy-type” discussion groups and bulletin boards and such.

      And I shudder to think of what some fellow physician said to you. I would so love to believe my profession wasn’t rife with asshats, and I lament that I know all too well how wrong that belief would be.

      • I didn’t even think about Angie’s List for physicians, interesting. And I have seen a few other sites too, I didn’t mean to imply they don’t exist at all. It’s just that when I was looking, none of them seemed to have achieved the market domination to cause any one of them to have enough reviews to be useful – a handful of reviews don’t help, all it takes is one griefer (or one irrationally-optimistic person, or one sockpuppet/plant) to skew the whole thing. You need numbers for the signal to reliably pierce the noise (frankly, if I saw just one comment about “blood on the furniture/walls” I’d probably assume it was a prank). Maybe Obamacare will centralize this piece 🙂

      • Oh, and what that doc said wasn’t anything dangerous to my health, just wildly-inappropriate to say to a patient, particularly on first meeting.

        Frankly, it was more dangerous to him – some people might have hauled off and popped him in the nose for saying something like that. I wonder if he was on drugs.

        • Asshatery ranges all over the spectrum, from the flagrantly insulting to the jaw-droppingly insensitive to the genuinely dangerous and incompetent.

      • interestingly (or not) yelp caters to the difficulties of reply and online reputation management for physicians by offering business packages to small practices and individual doctors that go up to and including shooting videos for them. it’s reasonably priced, especially compared to some of the more ahem predatory marketing outfits that tend to prey on physicians, who despite some of their beliefs are generally hapless in this area. (similar outfits do this for lawyers, church groups, and small non-profits as well.)

        all you can really do is reach out to the person online and give them an avenue of contact back to you. twitter is absolutely fabulous for this, fwiw.

        that said, outside of a few areas – generally cosmetic dentistry, cosmetic dermatology, cosmetic plastic surgery – i can’t see dumping resources into yelp being that helpful for a group or individual md practice. i might make an exception for general pediatrics as that’s more of a “shop around” experience than most other healthcare providers, though obviously not as much as a cash for services outfit like most of the cosmetic groups listed above.

    • “More seriously, I wonder why there isn’t a nationwide public Yelp-style site that rates”

      “The doctor botched the operation and led to a hysterectomy, and after receiving too much ketamine from the unlicensed she no longer remembers thing so well. But there’s plenty of off street parking, and the waiting room in quite spacious and well lit with current magazines, so we’re giving it two stars.”

      • “I really appreciate how he was able to separate my conjoined twins, but he later went to CPAC and ranted about the President. Two Stars.”

        • *raises eyebrow*

          Well, since we’re going there…

          Let’s say I needed a highly-skilled pediatric neurosurgeon for one of my children. If there was one who was clearly the very best at treating the condition at hand, I would go to him even if I found his social views repellant. However, assuming there was a small number of elite pediatric neurosurgeons at a handful of hospitals, I would actually consider it relevant and important information if one of them had blithely lumped relationships like mine with pederasts and animal rapists.

          • I was probably a bit more shirty in my response than necessary, particularly since it was you I was responding to. Apologies proffered.

            That said, considering how very much of my practice is dedicated to the ineffable factors of personality and attitude, the way a physician speaks to or about certain patients is germane to a review. “I felt disrespected because I’m poor” is weighty, and deserves mention no less than “He failed to diagnose a pneumonia despite examining my child on three separate occasions.”

          • No, it was my fault. The “this doctor deserves blog posts that doctor doesn’t” meme is running around and I should have known better than to drop it here. The fault was mine for turning a funny joke into a debatably unfunny barb.

          • And you guys say *Canadians* apologize too much? Seriously. Doctor, heal thyself.

            (Oh, and insert beta male comment here.)

          • And poutine. Contrary to the myths grown up around it, poutine was invented by a Canadian cardiologist to drum up business.

          • Tod is a Dodger fan. The rest of you are forgiven.

          • Pulled pork poutine is one of the most delicious things in the world. I don’t care what it does to my arteries.

      • To make a serious yelp comment, it’s one thing to weigh the upsides and the downsides of a particular experience that is fundamentally a leisure experience. Everything from parking, to ambiance, to how often the busboy refilled your water glass is likely to be as important to the audience out there searching for information as it is to you.

        Heck, that even makes sense for Angie’s List level stuff when it comes to people charged with staining your deck or replacing carpet. “I knew what I wanted, I communicated what I wanted, and here’s whether I got what I wanted.”

        When it comes to medical care, however, I don’t know that the average layperson has the competence to accurately judge. It seems just as likely to me that an Alternative Medical Provider would get four stars as a Mainstream Medical Provider would get fewer. “When I came in, there were windchimes gently ringing and I immediately felt at ease. His bedside manner was amazing! He took great care to explain to me that these essential oils were used by grave robbers in the 17th century who didn’t understand that the protection it gave them was the jumpstarting of their immune systems! Four stars, he’s got a patient ‘for life’!”

        It makes sense to talk about expectations and delights/disappointments when it comes to Chinese Food.

        I don’t know the extent to which these things are relevant to fatty liver tissue.

        • This strikes to both the fundamental flaw of such review sites and the tension that always exists vis-à-vis patients as customers.

          I know full well that there are times when the proper practice of medicine will result in an unhappy person leaving my office. I try as hard as I can to mitigate that, and to communicate effectively and attentively. Some days I’m better at it than others. But there are times when the only right thing to do is something other than what a patient/parent wants. That means you’re left with, in essence, a dissatisfied customer.

          And since I can’t go on Angie’s List and violate federal law explaining that, say, a patient’s symptoms simply didn’t indicate that an antibiotic was warranted or that a blood test to search of an implausible or questionable diagnosis would be useful, that leaves me with a bad review for appropriately-rendered care.

          The only thing one can do is take comfort in knowing that one has delivered good care and that almost everyone leaves happy and comforted, and to trust for the best.

          • Doc,

            Do you think other information should be available? Should I be able to (am I able to?) look up how many complaints have been filed against a provider and what their outcomes were? Or is that confidential? To me, that’d be far more useful information than what the crazy lady down the street thinks.

          • In every state where I have been licensed, the board of licensure has made publicly available any disciplinary action taken against a licensee. Cases like mine, in which no wrongdoing was found and in which no action was taken, are typically not reported. (That said, my general sense if that boards tend to start scrutinizing you a little more closely if you get lots of complaints, even if each complaint in and of itself is thin beer.) I think this is just as it should be.

            The only thing you won’t get from this kind of public information is what a doctor’s bedside manner is like, unless it’s outright abusive. Boards don’t typically discipline physicians for being jerks (though in more extreme cases non-disciplinary “letters of guidance” or some such are sent out; to what degree this kind of thing is publicly available varies by state, I think). If you’re wanting to know about the quality of a given provider’s patient interactions, you won’t find it from the board. Which is also as it should be, since that’s not the kind of thing boards should be able to monitor.

        • To an extent.

          There was supposedly “blood on the furniture”. That’d be a definite red flag.

          Also, more info is generally better. Reading an “essential oils” woo-comment would tell me that that doctor is probably not for me, four stars or no.

          Ah, what the hell. I’ll tell y’all what that doctor said to me, encrypting for the faint of heart, because it’s a little bit off-color.

          I had recently switched to the company HMO plan to save some $, which meant that I had to choose a Primary Care Physician. I hadn’t even been to a doctor in many years, but I wanted to go because I was getting pain/numbness/weakness in my thumbs (I’ll ruin the suspense of that part: = keyboard RSI from long work hours, basically).

          So, I picked a guy at random from the directory because he was close, and because his name indicated we’d probably be speaking the same language (please don’t construe that as a knock on anyone who is ESL – it’s just that if all other factors are equal, you use the filters you have; I live in an area with many non-English speakers, so speaking the same language in a medical setting, versus navigating potential language difficulties/ambiguities/misunderstandings, seems like a plus. Had I the choice between a good ESL doctor, and a bad doctor with flawless English, I would obviously choose the former).

          It’s a simple-enough complaint, I figure any random doctor can probably take a first pass at the problem, and I need to find a PCP anyway.

          On my initial visit, I explain my problem, and he responds that maybe I should stop svfgvat zl jvsr.

          I look sort of dumbfounded and confused, thinking I must have misheard/misunderstood him; so he repeats himself, this time with an illustrative hand gesture.

          Now, maybe he thought this was an ice-breaker of a joke – “ha ha, hey, we’re all guys here, right?” And I want to make clear that I have no issues with the described act in and of itself: whatever makes the socks of consenting adults roll up and down is A-OK by me. And there is nothing wrong with off-color jokes amongst friends who know one another well.

          But you just do not say something like this to someone you just met. A patient. A first-time patient.

          What if I were really religious and/or viewed this as some sort of perversion? You’ve now just cast aspersions and insulted me and my wife, by those lights.

          It is highly unprofessional and speaks of really, really bad judgement, to the point of speculative mental illness or drug abuse on the doc’s part.

          I finished the appt., weirdly enough. I was too stunned to do anything else. The whole thing seemed unreal.

          So, if you saw a review that said the doctor said that to someone on their initial visit, would that be good info to have before you schedule an appointment?

          • “Also, more info is generally better. Reading an “essential oils” woo-comment would tell me that that doctor is probably not for me, four stars or no.”

            This is why I never go off just the star ratings. Someone might love the Indian place on the corner because all their food is mildly seasoned and palatable to their sensitive tongue. Me? I’d hate that. If all I saw was a four-star rating without the why behind it, it is almost meaningless.

            With doctors, the quality of care is first and foremost for me. Bedside manner matters if it impacts our ability to work together. Ambiance is a perk if it is positive and goes largely unnoticed if it isn’t, provided it doesn’t impact the other factors (a dirty examination room isn’t just ambiance but a factor in quality of care).

          • Oh, my God.

            There is no world in which that comment is anything other than wholly, egregiously unacceptable. Maybe, maybe, maybe if he legitimately thought your condition was related to that activity he could make very polite, respectful inquiries to that effect. But to just say that, outright?!?! No. No, no, no.


          • I needed to borrow Millicent’s umbrella for a whappin’. I really wonder if he was coked-up or something, it was just too bizarre.

          • Or a “You wait until this thumb gets better and see what I do to you.”

            That is just too weird.

  2. Oy, I feel sorry that a complaint was filed against you. I had a complaint filed against me for frivolous reasons. The ethics board dismissed it but it was scary at the same time.

    • The worst part was fearing that somehow they’d find me in the wrong, despite how patently idiotic the complaint seemed to me.

      Thankfully, no.

        • I thought you were retired. Would you be censured for not relaxing on your front porch enough? Forced to get a part-time job until you pass a remedial ‘What It Means To Be Retired’ test?

          • I’ve seen evidence of Tod’s so-called retirement firsthand and can attest that he isn’t very good at being retired.

            Maybe he’ll improve with practice. 😉

          • But when you tell the industry what to do, does it listen? That’s how you know it’s truly yours.

          • Dammit, all this time I thought they were my kids.

  3. My mother was once involved in a nasty and frivolous malpractice case as the anaesthesiologist on the surgical team. Case got to court, the hospital’s attorney walked over to the plaintiff’s table and put a check for 5 grand on the table and told them to get out of the courtroom.

    Case went away immediately.

  4. I first learned about this story from Tim over at DC, but I had’t heard about the off-site interview as investigation until your post. I’m not sure at this point how this story could get any worse.

    • “Pro-life” idiots are crowing — as if this is what all clinics are. Of course these are the same idiots who crowed when abortion doctors who cared for their patients, who ran clean and safe clinics were murdered, so I see no reason why we should listen to them.

      But yeah, it’s already “worse” (see Tim Mother-fisher Kowal for an example of moral failure).

      • Jeff, I haven’t read Tim’s piece. I actually decided not to because I prefer to avoid getting into arguments over abortion, about which people often feel strongly and about which I feel ambivalent at the best of times.

        That said, I consider Tim a friend, of sorts. He has always treated me with courtesy. Whatever your opinions of him, please refrain from outright insults, even if euphemistically framed.

  5. “But one reason I hope this story gets lots and lots of attention, in Pennsylvania if not the nation as a whole, is that I hope many, many, many people lose their jobs. I hope some are brought to trial for their own negligent, incompetent and/or indifferent contribution to the mutilation and murder of women and infants. I hope that the brightest glare of media scrutiny shines on every single person who was charged with overseeing the practice of medicine in that city and state, and that a full accounting of their failures is made.”

    This…. a thousand times this. Folks will want to talk about abortion, and there is room for that conversation. Folks will want to talk about the media handling, and there is room for that conversation. But this, to me, is the most important point. This was a failing on multiple levels and those involved should face consequences. Whether this guy was killing folks during abortion procedures, heart surgery, or routine check-ups, that it was allowed to go on for 17 years speaks to something very, very wrong with the system.

      • Jeff,

        It doesn’t have to be. It will be in some places… and I think there might actually be room for a productive conversation there… though I doubt that is what we’ll get.

        But here, we tend to do things slightly differently and, if I may, slightly better. Case in point… the good doctor’s post here. Some folks will say, “Well, you’re not REALLY discussing the case because you’re not talking about abortion.” And we can point those folks to the other 98% of the internet that will be talking about abortion.

        • Surely there are other cases of gross medical misconduct that have gone unreported. This one is extreme, definitely, but if we wish to discuss what happened and why, regardless of the procedure involved, surely there are better, less inflamitory ways.

  6. There are only three ways to regulate misconduct in a complex society where word-of-mouth has limited utility: criminally, contractually (through the tort system) and regulatorily. Each has their problems. The criminal justice system only works after the fact, and requires the attention of both the police department and the prosecutor’s office. Institutionally, neither organization is likely to focus on a doctor’s office. The tort system requires plaintiffs who can find counsel and navigate the civil court system; these were not the people being treated here. And the regulatory system requires bureaucrats and tax dollars, which are treated as anathema by conservatives and libertarians.

    Yes, I’m utterly appalled. But not entirely surprised. This is precisely the kind of thing we should expect to see when abortions are driven to stand-alone clinics which can then be easily targeted by anti-abortion forces, when pro-choice groups are mistrustful of state regulation because they are legitimately concerned that the regulations are not focused on women’s health, and when the very idea of the state as an agent that can serve the interests of the disempowered is relentlessly demonized.

    This is the world you wanted, libertarians: a weak, poor state captured by special interests. This is one price of making common cause with social conservatives. (And lest you think that you are exempt from failures in the public health system, vaccine use is falling.)

    • Please.

      The “Proper Authorities” were warned years ago. They performed an inadquate investigation and closed the case. There was no “on site” investigation. Much of this horror could have been prevented if the regulators/gov’t would have simply done the frickin’ jobs they are paid to do.

      But you never see gov’t employees brought up on charges of negligence or deriliction of duty do you? Qualified immunity and civil service rules assure no one gets punished. Sweet deal for them isn’t it?

    • This is certainly not something libertarians desire, I’m only an amateur neoliberal and even I know that. Libertarians would want abortion options so widely available and lightly regulated that Glyph’s yelp suggestion would have a hundred possible hits for people seeking to end unwanted pregnancies to choose from.

      The entire point of a weak state in a libertarian mindset would be that when it is captured by ideological forces (and sooner or later they’ll get a crack at it if they can dress up nice and walk on their hind legs to the debate podium) capture government for a time there’s little they have available to do to interfere in people’s lives.

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