MY RETIREMENT
In Spring 2016, I was contacted by the Chief of Staff at my hospital, inviting me to meet to discuss with him what the Quality Assurance (QA) Department deemed were concerningly high complication rates in my surgical practice. Surprised by this, I asked what these concerning rates were, and received a list of 28 patients who had complications so that I could study their charts and prepare to meet with him. He would not provide the specific data, their rates of concern. This was against hospital Bylaws. I sent over twenty emails asking for their computation of my complication rates and for their specific concerns.
To discern the issues on my own, I hand-counted my surgeries from my office schedule for the duration of their review: 628 operations; and I studied the 28 patients with complications, calculating the complication rate, (28/628) at 4.5%, of which 10 (1.6%) had infections, and 15 (2.4%) had takebacks (unplanned returns to surgery). (See how office hand-counted rates are calculated) These rates were reassuringly similar to those widely published by other surgeons in my subspecialty of Gynecologic Oncology.
I was dubious that I had “increased complications, infections and takebacks” given that I had maintained a spreadsheet of surgical case data starting in 1996, and published nine surgical manuscripts describing techniques and prevention of complications.
My complication rates were, chronologically, 8.8%, 7.7%, 6.6%, 7.6%, 4.5%, 8.0%, 10%, 6.3%, and 7.0%. All normative for a Gynecologic Oncologist.
My infection rates were not reported in each manuscript, but occurred at rates of 1%, 1.3%. and 2%. All normative for a Gynecologic Oncologist.
My takeback rates in these manuscripts were 5.5%, 2.8%, 3.3%, 4.7%, 2.2%, 4.1%, 4.7%, 2.7%, and 3.7%, with variations depending on the procedures or diagnoses under scrutiny. Again, all normative for a Gynecologic Oncologist.
Dr. Anita Chandrasena was the Chief Medical Officer and was in charge of providing complication information, and made serious errors that ruined my career. With Dr. Chandrasena’s interpretation of my complication data, the Chief of Staff asked the Medical Executive Committee to authorize an Ad Hoc Committee (AHC) to formally investigate my patient care and possibly take action against my surgical privileges, repeatedly alleging that I had “increased complications, infections and takebacks.”
I would not find out their data or the source of their concerns until two years later.
The AHC did not have a Gynecologic Oncologist on it, so the members sent seven of my prior complications to be re-reviewed by an outside Gynecologic Oncologist, Dr. Julia Chapman, from Kansas. Each of these seven cases had already been reviewed by our hospital committee, so it appeared to me that the AHC wanted to see if Dr. Chapman could find further fault with my care. They were my most complicated cases, after all. 7/628 = 1.1%. (please, no one died!)
During my interview with the AHC, it became clear to me that the AHC already thought ill of my patient preparation, surgical skills, and outcomes. It seemed to me that they wanted to consider expelling me, but I did not understand why. Afterward, I wrote an angry letter providing written responses to Dr. Chapman’s critiques. Probably not smart; but very accurate.
Just after I met with the AHC, I performed a curative operation for what typically would have been deemed a terminal recurrence of the patient’s earlier cancer. All went exactly as planned, and the patient was cured, even to this day in 2023
Nonetheless, without querying me or any another Gynecologic Oncologist, Dr. Chandrasena made an emergency presentation to the Medical Executive Committee (MEC), with me absent from the room, asking that they summarily suspend my Sequoia privileges, convincing them that this complex case was in fact a “near miss.”
I was invited to the MEC meeting to explain my care of this patient and defend my privileges. One MEC member asked me if I knew what my complication rates were. I told them that I had asked Dr. Chandrasena over six times for this information. I directly asked her again for their rates and concerns about my practice. She refused again, saying the hospital lawyers advised against providing this information to me. I affirmed to the MEC that my tabulated practice data was normal for my subspecialty.
Whatever Dr. Chandrasena had told the AHC and the MEC, they all believed her, and not me, and they voted to immediately suspend my privileges from the hospital. I had to cancel 22 patients planned surgeries and refer each of them to other Gynecologic Oncologists.
None of this made sense to me.
My patients did well and were happy with my care. They donated to the hospital in a volume second only to that inspired by the six-person cardiovascular physician group. My referring physicians, office and Operating Room folks that I worked with loved me and I loved them, all of them. We were effective and efficient and safe. It brought joy to me how we provided really generously thoughtful, robust, and thorough patient care. 27 of my 60 peer-reviewed publications were on laparoscopic and cancer surgery. I taught advanced laparoscopic procedures at international meetings with my peers. I created and taught 19 surgical courses attended by 2,600 surgeons from around the world. In fact, at that course, I taught the lecture “Complication: prevention, recognition and management”!!!
Hospital bylaws allow for an appeal of the expulsion in a trial-like setting called the Judicial Review Committee (JRC). I hired a lawyer to defend me. To prepare for the JRC meetings, Sequoia was required to provide me with a copy of my entire internal file, which would include their statistics and concerns, finally.
Finally, two years later….information.
Studying their internal documents, finally, in 2018, I found out why good colleagues in my home hospital voted to expel me. They were given seriously wrong information.
Reviewing the AHC meeting minutes showed that they knew I had 628 total cases. Their data confirmed a 4.5% complication rate (28/628 = 4.5%). 1.9% were infections, and 2.4% were takebacks. (See how Sequoia counted calculations.)
Why did they not know these were normal rates in my subspecialty of Gynecologic Oncology?
The Sequoia records contained tables comparing my complications with the National Surgical Quality Improvement Project (NSQIP) data base. NSQIP is a national database that aggregates data from 1 million surgeries a year, submitted by 700 hospitals, including Sequoia, to establish standards of care and reduce complication rates. NSQIP data is accurate and indisputable, but the NSQIP database combines all Gynecology surgery data together, even though 95% of Gynecologists are General Gynecologists, and 5% are Gynecologic Oncologists, like me.
A Gynecologic Oncologist is a Gynecologist who has taken 2-3 years of extra surgical training, and been board-certified to operate on patients with Gynecologic cancers, including the elderly, more obese, more sick and frail patients. General Gynecologists refer their higher risk non-cancer as well as their cancer patients to us for surgical care. As a result of these higher risk patients and procedures, Gynecologic Oncologists’ have, on average, twice the complications that non-cancer Gynecologists have.
Dr. Chandrasena knew it was improper to compare Cancer Gynecologists with General Gynecologists, and tried to get comparison data from national NSQIP offices who referred her to already published data. The file showed that instead of obtaining the appropriatel comparative data, she told the AHC and the MEC that such data was “not available outside of research” and then persisted in saying that my complication were not normative.
I found all of the Sequoia NSQIP tabulations show I had 4.5% complications, 3.3% infections, and 2.9% takebacks, very safe rates in subspecialty Gynecologic Oncology. (See how Sequoia NSQIP data is tabulated)
It gets worse:
The records contained another table presented by Dr. Chandrasena’s to the AHC and MEC labelled “MIDAS Inpatient takeback rate.” This calculation is not a takeback rate, but a census and billing formula. As the CMO, Dr. Chandrasena knew or should have known that this MIDAS ratio was a census and billing ratio, not an actual takeback rate.
But she was undeterred by her willful ignorance and told all my good colleagues and the hospital administrators that my takeback rate was 20% compared to other Gynecologic Oncologists’ ratio of 4%. (See how the MIDAS is calculated). This is true, but the MIDAS ratio is very high in surgeons who perform 85% of their operations by laparoscopy (me), and others who perform only 40% of their operations by laparoscopy.
The Chair of Anesthesiology at the MEC meeting, who practiced with me for many years, told her that such a terrible rate was not possible over the three years under review. A 20% takeback rate would mean that one patient needed a takeback to the OR every single week for over 3 years, when I only had 15 in three years.
The record shows that Dr. Chandrasena repeatedly, firmly alleged to the MEC and AHC that my takeback rate was 20%. This is why good colleagues voted to expel me: they believed her representation and the MEC voted my expulsion.
It stays worse:
Dr. Chandrasena insisted to the “trial” 14 time, under oath, that I had a 20% takeback rate. She affirmed that it was accurate nine times under oath. Of course the AHC, MEC and JRC members believed in Dr. Chandrasena’s authority, believing her QA computer-generated rate comparisons and never imagining that she had no idea what the MIDAS ratio was.
None of this had to happen. Had Dr. Chandrasena shared her information with me early on, I could have alerted her to compare me with other gynecologic oncologists. I would have provided her with the NSQIP journal articles about Gynecologic Oncology practice data. I could have shared with her that there is only one way to calculate a takeback rate, and to trust the NSQIP data.
Each of the doctors and nurses who did routinely work with me wrote wonderful letters (read letters from my colleagues) and gave testimony of my patient care. They were not believed.
She had convinced everyone, and I was formally expelled.
Expulsion from a hospital automatically result in a review by the Medical Board of California. To defend my license before the MBC, I obtained a new lawyer who consulted with a respected gynecologic oncologist, and a former chief of staff from a large hospital. They critically reviewed my cases and found that I met or exceeded the standard of care with one minor deviation.
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They concurred that such minor deviations occur in about 3 to 5% of any surgical practice, and are routinely addressed at monthly hospital QA meetings for both educational and quality improvement purposes.
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They concurred that there was no justification for my expulsion in their detailed factual representation of my practice.
Having spent a very significant portion of my retirement savings on defense costs, at the age of 66, unable to practice locally, after three years of emotional hell, I gave up. I surrendered my license and asked that the MBC stipulate that indeed we did have a strong defense, but in order to save money on both sides they would accept the surrender of my license. The MBC agreed with that stipulation but it was not included in the final MBC report that was disseminated to all doctors in California, to my deep dismay.
Am I suing? You bet. Read my writ.
I am also publishing this story in our peer-reviewed journal so that other doctors don’t go through this hell.
Nowadays, I play a lot of tennis.
But trust me: I was really better at surgery.
