MY RETIREMENT

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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 for a list of my patients who had complications so that I could study their charts and prepare to meet with him.

 

He put me in touch with Dr. Anita Chandrasena, the new Director of the Quality Assurance Department, which monitors patient complications, infections and other outcomes such as surgical takebacks. A surgical takeback is when a patient must be taken back to the operating room emergently to have something fixed. Dr. Chandrasena provided me with a list of 28 of my patients who had complications, but she would not provide the specific data, the rates of concern.

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 1.6% had infections, 3.8% had enterotomies, and 2.4% had takebacks. (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. My rates of 6.8%compliations, 1.3% infections and 2.7% takebacks in my 2021 publication on 2,266 laparoscopic hysterectomies in obese women was only slightly better than the rates described in my 2007 publication from my first 830 laparoscopic hysterectomies.

 

I sent repeated emails to Dr. Chandrasena and to the Chief of Staff asking for their computation of my complication rates and for their specific concerns. I sent them my own tabulations with references to the published rates from other Gynecologic Oncologists.

Before I could meet with them, Dr. Chandrasena and 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, alleging that I had “increased complications, infections and takebacks.” By every self-examination and calculation in my practice, I did not.

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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 complicated cases, after all.

 

In three of Dr. Chapman’s criticisms of my care, I disputed making any errors, because sometimes a surgeon does everything right, but the patient still has a complicated outcome. I concurred with four criticisms from Dr. Chapman, wishing I had done things differently in each. Even so, seven cases out of 628 total cases is still a safe rate.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 a letter to make sure that they had the tabulated practice complication data from the 28 (there were no more) patients, and with appropriate subspecialty comparison data. I also provided written responses to Dr. Chapman’s critiques. Apparently, the confident tone of my letter made them think I was unable to introspect or improve.

Just after I met with the AHC, I performed a curative operation on a patient who was referred to me by a younger Gynecologic Oncologist from out of town, for what typically would have been deemed a terminal recurrence of the patient’s earlier cancer. It required a planned consultation with a vascular surgeon who agreed to help if we needed him. All went exactly as planned, and the patient was cured, even to this day in 2022.

 

Nonetheless, without querying me or any another Gynecologic Oncologist, Dr. Chandrasena made an emergency presentation to the Medical Executive Committee (MEC) 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. I discussed the operation and said how it went precisely according to plan. One MEC member asked me if I knew what my complication rates were. I told them that I had asked Dr. Chandrasena 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, but Dr. Chandrasena told them that I manipulated the data to my benefit and gave no further information to them, or me.

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.

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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. The folks 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. The Chief of Staff had emailed me that I had 28 total complications. This was proof of a 4.5% complication rate (28/628 = 4.5%). 1.9% were infections, and 2.4% were takebacks. (See how the Sequoia AHC tabulated rates) 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 98% of Gynecologists are General Gynecologists, and 2% 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 and their cancer patients to us for surgical care. As a result of these higher risk patients and procedures, Gynecologic Oncologists’ practice standards have been set and published by by specifically analyzing the Gynecologic Oncology-only practices and/or procedures in the NSQIP dataset.

 

Dr. Chandrasena presented a table to the AHC and the MEC that comparing my NSQIP Gynecologic Oncology practice rates with those of Sequoia’s General Gynecologists and with the entire NSQIP database, with the conclusion that my practice needed improvement. Dr. Chandrasena knew it was improper to compare General Gynecologists with subspecialists, but instead of obtaining the available subspecialty Gynecologic Oncology comparison data, her slides said that such data was “not available outside of research.”

 

There are at least 12 NSQIP publications providing comparable subspecialty data. 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)

 

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. The word “takeback” in the title must have misled her, a pulmonologist, and not a surgeon, into thinking that this census and billing ratio was an actual takeback rate.

 

My MIDAS ratio is 20% compared to other Gynecologic Oncologists’ ratio of 4%. (See how the MIDAS is calculated) The discrepancy stems from my greater use of Outpatient Laparoscopy over Inpatient open-incision surgery, not from differences in complications. If this MIDAS ratio were a takeback rate, it would indeed indicate that I was a deadly awful surgeon, one who really, really must be expelled immediately.

 

The record shows that Dr. Chandrasena completely ignored Sequoia’s QA department rate of 2.4% and NSQIP’s rate of 2.9%, and firmly alleged to the MEC that my takeback rate was 20%. 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. It would have meant that I had one takeback every single week. Dr. Chandrasena repeatedly insisted it was 20%, and the MEC voted my expulsion.

 

Dr. Chandrasena insisted to the JRC under oath that I had a 20% takeback rate. The AHC Chair, convinced by Dr. Chandrasena’s presentation, testified to the JRC under oath that I had a 20% takeback rate and was too aggressive as a surgeon. 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 could have misinterpreted the MIDAS tables.

None of this had to happen. Had Dr. Chandrasina shared this information with me I could have alerted her to compare me with other gynecologic oncologists. I could have shared with her that there is only one way to calculate a takeback rate, and to trust the NSQIP data. At any university hospital, with more gynecologic oncologists, the QA department would have known better.

 

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.

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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.  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. 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 had to give 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 dismay.

Nowadays, I play a lot of tennis.

But trust me: I was better at surgery.