Thursday, November 14, 2013

No Dogs to Bark - Failure to Connect the Events Foreshadowing the Fall of the Upstate President

In Silver Blaze, Sherlock Holmes noted the important clue of the watchdog that did not bark.  In health care, nowadays watchdogs are absent, so who is expected to bark?  So, when cases of failed leadership of health care organizations appear, in retrospect they often appear to have been foreshadowed by various events which caused no reaction.. 

Last week we posted about the president of the State University of New York (SUNY) - Upstate Medical University who resigned his job after revelations that he was receiving hundreds of thousands of dollars in income from outside organizations which he had not properly disclosed, and which could have constituted conflicts of interest. 

Only days later, on November 20, 2013, James T Mulder, the Syracuse Post-Standard journalist who had done much of the relevant reporting, published an article summarizing previous events that in retrospect should have suggested that there were serious ongoing problems within SUNY - Upstate leadership. 

Claims that the University Fired Physician Whistle-blowers - the Case of Dr Stewart

According to the summary article,

Critics of [SUNYH - Upstate Medical University President Dr David R] Smith ... [said]  he ruled with an iron first and did not tolerate opposing views.

'It became clear once he knew who dissenters were, things would happen,' said Dr. James Holsapple, a former Upstate neurosurgeon who now practices and teaches in Boston, Mass.'Dissidents would not be tolerated.'

Holsapple cited the case of Dr. William Stewart, a neurosurgeon fired by Upstate in 2011. Stewart contends he was fired because he filed a complaint with the state Health Department, alleging misconduct by two other Upstate doctors. That complaint led to an investigation by the state which issued a report critical of Upstate.

Upstate contends Stewart was let go because he refused to cooperate with an investigation into a breach of confidential information, including patient records.

Holsapple calls the incident a ' ... clear example of Smith taking out a critic.'

In a pending lawsuit in federal court, Holsapple has accused Upstate of retaliating against him for speaking out against what he calls dangerous medical practices and other unethical activities at the Syracuse teaching hospital. Upstate has denied his accusations and called them 'baseless.'

In fact, Mr Mulder's article from April, 2011 about Dr Stewart's case noted that Dr Stewart

said his complaint ' ... made me an enemy of the regime.'

Although Upstate accused Dr Stewart,

 ... because he refused Upstate’s request that he cooperate in an investigation into an intentional breach of confidential information, including private patient care records.

Dr Stewart contended that he knew how to handle confidential information,

Stewart served 20 years as a member of the state Board for Professional Medical Conduct, which takes disciplinary action — including license revocation and suspension — against doctors. He chaired that board for three years in the late 1980s.

Stewart said he never disclosed any private patient information. 'I took the Hippocratic oath when I graduated from medical school,' he said.

Stewart said physicians are required by state law to report suspected cases of medical misconduct. Failure to do so is considered misconduct under the law.

Stewart said that’s why he filed a complaint with the Health Department, alleging that a resident neurosurgeon training at Upstate was allowed to perform complex spine surgery without proper supervision because the neurosurgeon who was supposed to be doing the operation was in another operating room with a different patient.

Furthermore, Dr Stewart alleged that Upstate sought to intimidate him,

Stewart said two private investigators hired by Upstate visited his office in December, but he refused to talk to them.

Claims that the University Fired Physician Whistle-blowers - the Case of Dr Holsapple

The case that caused Dr Holsapple to file a lawsuit against Upstate had some interesting similarities, but also some uniquely colorful aspects, as documented in an article from February, 2011, by Mr Mulder.  Dr Holsapple also alleged a major quality of care problem at Upstate,

 The suit charges Holsapple’s problems began in 2007 when he objected to a plan to have a single neurosurgeon supervise two spine surgeries in separate operating rooms at the same time. Holsapple thought the plan was risky for patients. At the time death rates following spine surgery at Upstate were five times higher than normal, the suit said.

The suit contends Dr. Ross Moquin, a neurosurgeon no longer at Upstate, was overseeing the two surgeries, according to the suit. While Moquin was with one patient, Dr. Walter Hall, then chair of the department of neurosurgery, and a resident doctor in training, began surgery on the second patient, the suit says. Neither Hall nor the resident were qualified to finish the operation, but Hall told the resident to complete the surgery because Moquin was busy with the other patient, according to the suit. Holsapple’s suit contends the patient suffered complications. It also accused the hospital of creating fraudulent documentation about the operation and billing fraud. 

Some of these charges appear to have been independently corroborated, at least,

That same two-room spine surgery case was cited in a recent state Health Department investigation. In a 68-page report issued in August, the Health Department said Upstate did not provide surgical services in a way 'that assures protection of the health, safety and rights of patients ... .'

Nonetheless, Dr Holsapple argued that the hospital punished him for his whistleblowing,

The suit says Hall stripped Holsapple of his job as residency coordinator in 2007 without any explanation, cutting his annual pay by $82,500. Hall also removed Holsapple as the department’s quality officer, according to the suit.

Dr Holsapple also contended that the hospital attempted to harass him after he left, and did so, as Dr Stewart also argued, using private investigators,

Holsapple contends Upstate continued the retaliation after he left. He said Upstate sent two investigators to his home in South Boston in November to intimidate and harass him and his wife.

The lawsuit suggested that Dr Holsapple was qualified to complain about quality issues,

Upstate hired Holsapple as an assistant professor of neurosurgery in 1994 after he completed his residency training there. In his suit he says he served as the quality improvement officer for the neurosurgery department, on the SUNY faculty senate and on the hospital’s medical executive committee alongside top Upstate executives, department chairs and other officials.

It also suggested that perhaps Dr Hall, the chairman of neurosurgery whose conduct figured in Dr Holsapple's complaint, was not so qualified to sit in judgment of Dr Holsapple,

The following year nursing staff discovered images of Nazi artifacts within the computerized medical records of Hall’s patients, the suit says.

Holsapple said in an interview the images were photographs of tank medals and other Nazi paraphernalia displaying the swastika.

The suit says a hospital investigation confirmed the Nazi images belonged to Hall and he was forced to resign as chair of the neurosurgery department.

Holsapple said in an interview Hall told hospital officials he bought and sold the Nazi memorabilia and stored the images on his computer. 'Some of the Jewish faculty were disturbed these icons were finding their way into the computer system,' Holsapple said.

A Cheating Scandal and Probation by an Accrediting Agency

Mr Mulder' November 10, 2013, summary article also reported,

The medical school was embroiled in a cheating scandal in 2011. An Upstate investigation found more than 100 fourth-year medical students cheated on quizzes in a medical literature course.

Last year the medical school was placed on probation by the Liaison Committee on Medical Education, an accrediting group. That group criticized the school for having an erratic learning environment. It also said the medical school's curriculum was out of sync, student complaints were being ignored and the dean was ineffective. Upstate fixed the problems and was taken off probation earlier this year.

Mr Mulder's article jogged by hazy memory into the recollection that I had seen several other examples of problems at SUNY - Upstate, but since the articles that illustrated them seemed to appear in isolation, I had just dumped them into the pile of  documents to be filed. A hurried search then revealed articles on the two whistle-blowers, and the cheating and probation issues above, and...

A Costly Merger?

I found a story from February 21, 2011, also authored by Mr Mulder, that suggested a merger proposed for Upstate University Hospital would lead to a big increase in health care prices,

 The cost to replace a hip, treat a heart attack and provide many other routine hospital services covered by Medicare is about 46 percent higher at Upstate University Hospital than at Community General Hospital.

Some experts fear a proposal to merge Upstate and Community into one hospital with one payment rate will raise Community’s prices to Upstate’s level and increase overall health care costs in Central New York. 


MVP Healthcare, a health insurer, is worried about potential price increases at Community.

'We need to know if the charges for services provided by Community General Hospital would increase as a result of the merger,' said Gary Hughes, a spokesman for the insurer. 'If the rates increase, we would be concerned how the merger would affect health care costs in the region, how that would affect the business community and individuals.'

At a recent public forum on the proposed acquisition, Dr. Douglas Tucker, of MVP, said blending Upstate’s high rates with Community’s could be 'catastrophic,' especially for patients with high-deductible plans who have to pay big upfront costs before their insurance coverage kicks in.

SEIU Local 1199, the union representing Community General workers, shares that concern. The union wants Community General to remain as a lower cost, private sector community hospital. The union also wants to remain at Community to preserve its members pensions and benefits. It does not want to see Community workers become state employees, who are represented by different unions.

Note that although the merger did occur in 2011, I could not find any documentation about its effects on costs since.


In the last two years, SUNY - Upstate Medical University has been accused of seeking a merger mainly to drive up its prices, and of independently driving out and attempting to intimidate two separate physicians for blowing the whistle about health care quality concerns.  The department chairman whose work was criticized by one of the physicians, and who subsequently drove him to leave was himself forced out of his leadership position over allegations of Nazi photographs found within his computerized patient files.  University students were involved in a big cheating scandal, and the university was placed on probation by its accrediting agency.  These stories generated lots of concerned and sarcastic comments online.  However, I could find nothing to suggest that they lead to any official investigations by SUNY leadership, state government, accrediting agencies (other than as listed above), Medicare, medical societies, etc  I could find nothing to suggest that any actions were taken by students or faculty at the school, or by independent watchdogs or other members of civil society. 

Yet in retrospect the sequence of events suggested major problems with the leadership of SUNY - Upstate Medical University.  The existence of these problems seems to have been confirmed by the revelations that the university president was accepting hundreds of thousands of dollars of outside income which he failed to properly disclose to the university, and which could have constituted major conflicts of interest.  The seriousness of the leadership problems was just underscored by the recent decision of the state Comptroller to audit the institution's contracts (look here for AP story), and the sudden resignation of the university senior vice president for administration and finance who apparently was receiving pay, admittedly which he had disclosed, from the same organizations who were paying the president (see story by Mr Mulder here.)

 One obvious conclusion is that bad leadership leads to lots of bad consequences.

Another is that here in these United States we lack any effective watchdogs who can spot major leadership problems at important health care organizations before they lead to bad outcomes. 

  In particular, our the leadership of our academic medical organizations do not seem to get any organized scrutiny from student, faculty or alumni groups, from government agencies, from accrediting organizations, from medical societies, or from community based civil society organizations  or health care watchdog groups.  Hoping that overworked local reporters or volunteer bloggers will not only be able to spot evidence of trouble in a timely way, and then make it visible enough to generate action is whistling past the cemetery. 

 IMHO, concerned citizens, hopefully including those in and in training for the health professions, need to set up organized civil society watchdog groups to hold health care leadership accountable, and to push for involvement by government, accrediting organizations, medical societies, etc. 


Anonymous said...

I could not agree with you more. This is repeating itself at many hospital/medical centers throughout the US. The leaders of these places are ruthless and shameless, and lthe BOD are hand picked puppets for the dictator.

Nazi paraphernalia on their computer system...from the Chair. That's a new one.

Your suggestions are good ones but have two chances of success: slim and none.

Anonymous said...

Great suggestion in the last paragraph. Scott

Anonymous said...

Ah Yes, another Upstate leader, Steve Brady, bites the dust.

I knew there had to be an HIT EHR angle to this. That industry is too corrupt to not have worked with these guys at Upstate:

Upstate Medical has a $22 million single-source contract with MedBest to provide technical support to implement an electronic-medical record and practice-management system, DiNapoli’s office said.

Anonymous said...

Don't you realize that there is a conspiracy of silence from all people at leadership positions, whether it be government, corporate, or medical center?

They do not want to know how bad it is. Thank the lord for the fiasco. But even that is instructive as to how the leaders make up the facts as they go along.

Even the Joint Commission is an agency that is there to give the illusion that hospitals are safe.

And the DOH, forget about it.

Steve Lucas said...

Sadly, this case is not isolated, nor does it exist in a vacuum. In today’s society the only issue is do you have enough to sue and can you stay ahead of the legal consequences.

I find myself after nearly a year of dealing with certain clergy coming to the conclusion that the only interest is in keeping those in power in power, keeping the money flowing, and avoiding a public legal suit. The results are struggling churches and congregations left without guidance.

Government falls into the same category as we learn more and more of cover ups, pay backs in the form of contracts, and we have all learned the new term of failing upward. Loyalty to the regime is the ultimate test for advancement.

Medicine is only reflecting what is happening in our broader society. The loss of any semblance of responsibility, the desire for personal advancement, and the quest for financial gain has left the public with a distrust of all of the professions.

Change will only take place when people, not institutions, are held responsible, and those people have a price to pay in their ability to hold future positions.

Steve Lucas

Roy M. Poses MD said...

Anonymous of 15 November, 2013, at 9:01 AM,

On Health Care Renewal we are very aware of what could be called a conspiracy of silence affecting discussion of many of the issues we talk about here.

One of our bloggers long ago coined his own term for this, the "anechoic effect." We have written extensively about it. Look here:

The anechoic effect has dampened discussion of cases and issues much worse than the case.

The anechoic effect is just the health care version of a very old phenomenon, the rich and powerful have long been able to quiet discussion of events and ideas that might make them uncomfortable.

A major reason we started this blog was to combat the anechoic effect by creating an electronic place where various kinds of recent unpleasantness can be discussed.

Anonymous said...

Whistling past the graveyard:

1. (idiomatic, US) To attempt to stay cheerful in a dire situation; to proceed with a task, ignoring an upcoming hazard, hoping for a good outcome.

2. (idiomatic, US) To enter a situation with little or no understanding of the possible consequences.

Describes the electronic medical record industry and hospital attempts to adopt the systems well.

Afraid said...

"Loyalty to the regime is the ultimate test for advancement." and the corollary, truth be damned.

Anonymous said...

I have been trying for years to get my complete and original medical records of a three level cervical fusion in 2010. I have reason to believe I may have experienced a problem during surgery or in post op.
Records requested twice. They appear incomplete and illedgable.
I am asking for help. I have a right as a patient to know what happened to me.