At War in the Wards
Queen of Angels defends an outside probe of unexpected deaths. But doctors decry the bypassing of traditional peer review.
By Charles Ornstein
Times Staff Writer
July 10, 2003
When state health inspectors looked through the files of thoracic surgery patients at Queen of Angels-Hollywood Presbyterian Medical Center last year, they spotted a big problem.
Some cases in which patients had died or experienced severe complications hadn't been reviewed by a panel of physicians, as required by law, to determine if the care was proper.
That suggested, at the very least, that surgeons might not be learning from mistakes. At worst, it could mean bad doctors were practicing unchecked, endangering patient lives.
The findings by the California Department of Health Services startled the owner of Queen of Angels, Tenet Healthcare Corp., the nation's second-largest for-profit hospital chain.
With Tenet's blessing, the hospital's governing board hired outside experts to extensively review unexpected deaths and complications, usurping the medical staff's traditional role.
The doctors saw a dangerous precedent: Corporate administrators, who were intruding into so much of modern medicine, would now presume to judge patient care after the fact.
Some said Tenet was trying to mend its image as federal investigators probed allegedly lax oversight of patients and finances at some of the chain's other hospitals.
Tenet and hospital leaders portrayed themselves as having taken a principled stand in defense of patients.
"This was a governing board taking the steps they needed to do to assure that there was quality in the practice of medicine," said Albert Greene, the hospital's chief executive. "Where hospitals have gotten in trouble in this country is where the governing board has failed to step in."
The ensuing battle at Queen of Angels has become a marker in the national struggle between physicians seeking to retain autonomy and health-care corporations striving to avoid costly or embarrassing lapses in care.
At the 434-bed medical center, a presence in Hollywood for 75 years, the fight has cracked open a window into a private world-exposing the lengths to which both sides will go in the name of protecting patients.
So far, three former presidents of the medical staff have resigned, a fourth doctor has sued the company, and the medical staff, in a vote, has expressed no confidence in the hospital's leaders. Saying his staff has been threatened, the hospital's chief executive officer has beefed up hospital security and hired a driver for his protection.
"It's not normal," said Dr. Hagop Bezikian, a staff member about 12 years. There's "lots of gossip, lots of suspicions. No one knows what's going on. No one knows what will happen next. This is not a hospital anymore. It has become something different."
Among the 16 cases that state inspectors examined, three troubled them. Each involved Dr. Moneim Fadali, a four-time president of the medical staff who had been seeing patients at Queen of Angels for 25 years.
According to the inspectors' report, completed last August, the surgeon had operated on a very ill 73-year-old woman despite another physician's order that the woman receive "supportive care only." She died about two weeks later.
The doctor had performed surgery on a 57-year-old woman with metastatic breast cancer who died nine days later. And he had opened the chest of a man in his 60s with cancer who later experienced serious complications.
Patients sometimes fare poorly or die despite doctors' best efforts. What disturbed the inspectors was that "there was no documentation or other evidence to indicate that these cases were discussed, presented or subjected to scrutiny by any committee of the medical staff," according to the report from the state health department.
Inspectors Fault Board
Ultimately, the inspectors said, the hospital board was at fault for failing to take responsibility for patient care.
Fadali insists that the care he provided was appropriate, and a committee of fellow physicians agreed after reviewing the cases in light of the state report. "In God's name, I would have done the same to my own mother," the doctor said.
But the hospital governing board saw the report as "a flashing red light telling us that there was potential danger," said Michael Woo, chairman of the board and a former Los Angeles city councilman.
The board concluded that it could not rely on the hospital's doctors to police themselves. Instead, it hired physician experts from Mercer Consulting's San Francisco office to review questionable cases.
After scrutinizing dozens of files, Mercer identified major problems that hospital doctors didn't, administrators said. In particular, four top members of the medical staff-including Fadali-were found to have provided inferior care, including unnecessary procedures and overly aggressive treatment, according to interviews and a summary prepared by the hospital for The Times.
The hospital did not notify patients whose care may have been substandard, because the state requires peer review to be done confidentially. Queen of Angels chief Greene said the hospital did, however, report Fadali and one other physician to the Medical Board of California, which can issue sanctions.
The medical staff was outraged, saying the hospital had no authority to commandeer a peer review process they insist was well run. In September, doctors at their quarterly meeting voted that they had no confidence in the hospital administration, saying officials' actions "threaten the integrity of the hospital." Just two doctors dissented.
Physicians quit leadership positions; many began taking their patients elsewhere.
In a September letter to Tenet executives, physician leaders portrayed the dispute, in grandiose terms, as a clash between good and evil.
"The medical staff stands tall and gentle, considerate and dignified, certain of its integrity, sincerity of purpose and dedication," they wrote, "all the while abhorring the malicious targeting and the malignity and spite that characterizes the present hospital administration's dealings with the medical staff."
Peer review in medicine dates back more than 1,000 years-by some accounts to northern Syria, where doctors went over notes on each other's cases.
The practice has evolved considerably, but the core idea remains: Only doctors who practice under similar circumstances can judge a colleague's performance. These days, reviews are kept secret, to encourage candor and minimize lawsuits.
Administrators at Queen of Angels, its physician leaders say, violated that tradition by inserting themselves into the process.
Although hospitals occasionally consult outsiders to make sense of a particularly difficult case, hiring a team to scrutinize all questionable cases is extremely rare.
"As a matter of policy, we don't want hospital administrators or laypeople controlling clinical decisions and/or making clinical judgments," said Charles Bond, a Berkeley lawyer who represents doctors in disputes with hospitals.
Others who study peer review said a hospital board must intervene when patient care appears to have suffered.
If peer review is not done properly, it can "threaten a hospital's existence," said Dr. Stanley Klein, a surgeon at Harbor-UCLA Medical Center near Torrance and expert in the process.
Queen of Angels chief Greene said the hospital tried to be abundantly fair: It hired expert doctors, not bureaucrats, to review the cases in which patients had died or suffered unexpected complications.
Nonetheless, he said, one quality-assurance employee received anonymous death threats on voice mail. The cars belonging to Greene and another administrator were scratched, and their tires slashed. In response, Tenet hired security guards to stand watch outside the hospital's administrative suite.
Complicating matters for Tenet, a public scandal was erupting elsewhere.
In October, the FBI disclosed that two doctors at the firm's Redding Medical Center in Northern California had performed an unusually high number of heart procedures that may have been unnecessary. Days later, the company revealed that U.S. regulators were auditing its hospitals to determine if they had overbilled Medicare.
"My feeling is that Tenet is under very, very tight scrutiny from the government and they want to do something to show that they are monitoring their doctors," said Dr. Steven Ho, a Queen of Angels kidney specialist who resigned in February to protest the hospital's actions and is now reapplying.
Tenet officials say their activism at Queen of Angels was unrelated to the company's other problems-and in fact began before the federal investigations came to light. Their sole motive was protecting patients, said Gus Valdespino, who, until April, oversaw Queen of Angels and other Southern California hospitals for Tenet.
"The responsibility that we have as the owners to help oversee the quality of care is something I take very seriously," he said.
Tenet's consultants didn't find fault with the hospital's 800 rank-and-file doctors. Instead, they zeroed in on four leaders who had themselves vetted physician applicants and reviewed problematic cases.
According to interviews and hospital documents obtained by The Times, the leaders were Fadali; Dr. Medhat Mansour, a former medical staff president; Dr. Osamah El-Attar, the former chief of cardiology; and Dr. Andrew Yee, currently president-elect of the medical staff.
Yee attended medical school in Guadalajara, Mexico. The others were educated in Egypt, arriving at Queen of Angels in the 1970s. The four physicians didn't socialize much outside work, but together they ran many of the hospital's medical operations, apparently with broad support-although some doctors quietly hoped for a greater say.
Mansour, a urologist at Queen of Angels for 27 years, was the first to go. He resigned in November, the same day Greene told a physician committee that the doctor had "demonstrated an extensive pattern of substandard and dangerous patient care," according to a report filed with the state medical board.
In an interview, Mansour declined to discuss his situation in detail, saying only that any time an organization undertakes a "witch hunt" they "can always find something. There's nobody perfect."
Fadali, the four-time medical staff president, resigned in February. Although the outside reviewers had not completed their study of his charts by then, his wife told him: "Enough is enough. One day you'll get a heart attack."
He said all of the doctors criticized by administrators serve without problems at other area hospitals. He and several colleagues suggested that the hospital was retaliating against outspoken doctors who, among other things, opposed the hospital's sale to Tenet in 1998 and supported a nurses union.
"The only bad ones are the leaders?" Fadali said. "These leaders have been honorable physicians doing very good care for many, many years."
El-Attar chose to stay and fight.
The hospital governing board had voted in January to remove him from the staff. At a meeting with the medical staff, Greene told the hospital's physician leaders that the board considered El-Attar a danger to patients, according to minutes prepared by the hospital and filed in court.
Greene said three consulting cardiologists had reviewed the charts of 17 randomly selected patients treated by El-Attar. They "found none of the care in those 17 cases to be acceptable. None."
El-Attar missed a patient's heart attack, misinterpreted echocardiograms and ordered "a large number" of unnecessary procedures, Greene told doctors at the meeting.
Doctor Sues Hospital
Three months later, El-Attar sued the hospital, seeking to prevent administrators from kicking him off the staff or imposing restrictions on his practice.
"I think the different accusations against me are not right, so I am fighting," said El-Attar. Last month, Tenet sued him, saying he had refused to vacate his office at Queen of Angels. Both cases are pending.
Because Yee's problems were considered less serious than the others, he was required to attend a medical training course at UC San Diego and undergo proctoring, but was not suspended. Through an assistant at his office he declined to comment.
In the meantime, hospital officials say they are trying to put the turmoil behind them. Some physicians remain wary. Others are hoping that, with time, the tension will dissipate.
"Physicians will tend to go to a place where this is not happening," said Shobhana Gandhi, chairwoman of obstetrics and gynecology, who is pleased with the new leadership on the medical staff. But eventually, "this will go away and physicians will start coming again."
Staff researcher Tracy Thomas contributed to this report.