Does Doctor Negligence Often Go Unreported? –National Practitioners Data Bank

Are doctors relocating all over the United States?

Congress created the National Practitioners Data Bank in 1986, passing a piece of legislation whose mission entailed improving the quality of healthcare, reducing abuse and fraud and protecting the public.

A vast online repository, it includes information about adverse actions by practitioners and medical-malpractice payments from lawsuits.
“…it is a workforce tool that prevents practitioners from moving state to state without disclosure or discovery of previous damaging performance,” its Web site states.

According to a yearlong investigation by MedPage Today and the Milwaukee Journal Sentinel, the system is seriously flawed. As many as 500 practitioners reprimanded by their state’s medical boards continue to treat patients in other states by obtaining new licenses, the investigation found. The offenses: everything from misdiagnoses to sexual harassment.

“The pattern that emerges is both disturbing and damning: physicians who are “caught” in one state slip through the bureaucratic net in another, where they are free to practice without any disclosure,” states the report, titled “States of Disgrace: A Flawed System Fails to Inform the Public.” “Yet the 500 identified in the yearlong investigation by MedPage Today and the Milwaukee Journal Sentinel most likely underestimates the scope of the problem. It focuses only on those cases where at least one agency took some sort of public action.”

What’s more: the investigation covered a five-year period (2011 to 2016), most likely underestimating the scope of the continuing problem even more. The problem stems from a loophole in the law.

“The same legislation that created the tool shrouded it in secrecy,” the report states. “Public versions of the database don’t include physicians’ names or other identifying information. That makes it impossible to determine what happened in cases where reporters asked officials why physicians with license problems in other states were allowed to practice in their state unfettered.”

The data bank discloses that fact on its Web site, stating, “Note: This file does not include any information that identifies individual practitioners or reporting entities. The file is designed to provide data for statistical reporting and analysis only.”
The report also found the data bank is underused.

“It’s a highly flawed system,” Dr. Robert Wachter, the University of California San Francisco’s chairman of medicine, told MedPage Today and the Milwaukee Journal Sentinel. “It has created a patchwork of accountability.”

David Loewenstein, the data bank’s director, admitted the information does not paint the entire picture of a particular practitioner’s background.
“We by no means hold ourselves out to be the all-encompassing definition of good and bad practitioners,” Loewenstein told MedPage Today and the Milwaukee Journal Sentinel. “We’re a data point, to be used along with others.”

Dr. Gary Weiss, of Colorado, treated a patient with multiple sclerosis who later died. A complaint was filed with the state’s medical board. Dr. Weiss relinquished his license but had another one in Florida and practiced there without a word from the wiser on that state’s medical board. The patient, a 63-year-old woman, was said to have had progressive multifocal leukoencephalopathy, or PML, not multiple sclerosis, and the drug prescribed to her was natalizumab, which treats multiple sclerosis but increases the risk of PML.

“Over the months PML went undetected, Weiss continued the woman on the drug and her condition deteriorated, according to a complaint filed with the state’s medical board by four neurologists from the University of Colorado School of Medicine,” the report states. “The physicians wrote that the woman became forgetful and had trouble speaking. She soon had to use a wheelchair and eventually went to a nursing home.”
Since then, two patients in Florida initiated lawsuits with similar stories.

Dr. John Siebert, of New York, was accused of having sex with a patient, which resulted in a license suspension for three years. Dr. Siebert, who also has a license in Wisconsin, never was reprimanded by that state’s medical board and went on to become an endowed chair at the University of Wisconsin-Madison.
Dr. Jay Riseman, of Missouri, was called a danger to the public by Illinois’ medical board but still practices medicine, despite facing 12 lawsuits. Dr. Riseman also has a license in Kansas.

Dr. Julie Sullivan, of California, got in trouble with Texas’ medical board for failing to administer a funduscopic exam on a patient with an aneurysm history. The patient was instead discharged:“Less than six hours later, the patient went to an emergency room where a CT exam showed a ventricle colloid cyst in the man’s brain,” the report states. “He then suffered a fatal cardiac arrest on the way to another hospital.”

California’s medical board has no records about the incident.

Patient advocate Julia Hallisy, who founded the Empowered Patient Coalition, said such negligence by doctors does not always mean it is reported to the data bank.
“The numbers you’re showing are not anywhere near the real numbers,” Hallisy told MedPage Today and the Milwaukee Journal Sentinel. “If something goes wrong in a surgery, or you get an infection, or your 80-year-old mother is given the wrong medicine, you may never know that came from this doctor, their impairment, their lack of skill. People who want to make the case that we have bigger fish to fry: this is bigger than we know.”