In what can only be described as a disaster due to organizational failure, a pathologist working at the Veterans Health Care System of the Ozarks has been charged with involuntary manslaughter (see: Former Arkansas VA Doctor Charged With Involuntary Manslaughter In 3 Deaths). Below is an excerpt from the article with the details:
A former pathologist at an Arkansas veterans hospital was charged with three counts of involuntary manslaughter in the deaths of three patients whose records he allegedly falsified to conceal his misdiagnoses. According to federal prosecutors, Dr. Robert Morris Levy, 53, is also charged with four counts of making false statements, 12 counts of wire fraud and 12 counts of mail fraud, stemming from his efforts to conceal his substance abuse while working at the Veterans Health Care System of the Ozarks. Levy was suspended from work twice — in March 2016 and again in October 2017 — for working while impaired, before he was fired in April 2018. A June 2018 review of his work examined 33,902 cases and found more than 3,000 mistakes or misdiagnoses of patients at the veterans hospital dating to 2005. Thirty misdiagnoses were found to have resulted in serious health risks to patients. The three deaths came as a result of incorrect or misleading diagnoses. In one case, according to prosecutors, a patient died of prostate cancer after Levy concluded that a biopsy indicated that he didn't have cancer....Levy used 2-Methyl-2-butanol, a chemical substance that intoxicates a person "but is not detectable in routine drug and alcohol testing methodology," the statement said (see: tert-Amyl alcohol).
When I began writing this note, my mind turned first to the possible absence or inadequacy of a surgical pathology quality control program at this particular VA hospital. Such a program would include periodic peer review of the surgical pathology reports of the accused pathologist (see: Peer (case) review in anatomic pathology can drive improved proficiency). However, I then began to focus more on the facts in the case such as 14 years of what can only be described as overt malpractice on the part of Dr. Levy plus two suspensions for working while impaired.
I came to the conclusion that the major problem at this particular VA was that Dr. Levy's supervisors and colleagues probably watched him stagger to his microscope for many years and kept silent. The fact that he "cleverly" masked his impairment by imbibing a rare form of alcohol is no excuse. Whatever form of alcohol he was drinking, there is no way to disguise the physical impairment associated with excess alcohol consumption. So what lesson should we take away from this case of an impaired pathologist?
I think that indictment of the pathology leadership and hospital executives of this hospital should also be considered -- they are surely accomplices and enablers of this Dr. Levy. The prospects of this happening are highly unlikely. The last thing that senior VA administrators and probably the legal apparatus want to happen is a prolonged media discussion of inadequacies of the VA system. They will willingly "sacrifice" Dr. Levy (now) but don't want the investigation to extend in a wider fashion. It could get out of hand and substantive changes could be demanded by the public of the VA to improve quality and save lives.
In my opinion and, as I have blogged in the past, the military healthcare systems and the VA are not amenable to change (see: Why the Military and the VA Healthcare Systems Are Not Amenable to Change). By the way, Graham Grieve, the FHIR architect, disagreed with this particular blog note posted in 2014 and responded with the following comment.
I think you're wrong to say that this is a feature of the military and not of companies. It's a feature of bad management or workers, and can occur in either, or any other context. What we can say is that the nature of competitive business is more likely to expose the deception quicker, and so it's less tolerated. One consequence of this is that if you replace the existing system with a new one, it will soon come to look like the old one, whoever runs it.
He has a good point but I think that there are unique features of the military healthcare system and the VA that distinguish them from other organizations such as federal oversight/politics and the military chain of command.
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