Address to the 2005 Congressional Forum-U Tube Presentation
"A major debate is raging concerning whether US citizens should
relinquish control of their health care system to the Federal Government. The following case was presented to the 2005
Congressional Forum on “Bad Faith Physician Peer Review”.
Let me begin by asking you to "imagine" you are a husband in the
delivery room. Your wife is in labor, you feel helpless, but you've prepared for this moment months in advance. You've read
books and articles on babies. The nursery is ready, colors and furniture carefully, lovingly picked out and painstakingly
arranged. The baby's name has been chosen and you can't wait for the new arrival. Yet as you and your wife prepared for this
moment, little did you know that the hospital's economically conscious CEO had chosen not to provide an on-call C-section
crew for emergencies. Your wife and baby begin to experience difficulty. As medical personnel rush in and out
of the room, you get an uncomfortable feeling that a C-section will be necessary. But there is no emergency C-section team.
The dream that started to unfold moments earlier begins to slip away.
An hour and a half delay occurs. You must now wait until
the O-R crew finishes a surgical case and sets up for the C-section. You try to reassure your anxious wife, but you know it's
useless. After this seemingly endless and agonizing delay, all your dreams are shattered. Tragically and needlessly,
your child is born severely and permanently brain-damaged. You find yourself a part of a scene that even most obstetricians
never encounter during their entire careers. Yet, because this hospital CEO chose illegal, avaricious shortcuts, your family
and your baby become victims of a senseless tragedy; a tragedy which will forever change your lives. You will go home with
many unanswered questions, only to spend many days fielding inquiries about the baby from well-meaning friends.
You learn later that had the C-section taken place when the obstetrician
had requested it, in all likelihood, the baby would have been born healthy; you also learn that a state law mandates that
all hospitals providing OB services, must be capable of responding to any C-section request within 30-minutes (decision to
incision). Additionally, you learn that the Director of OB had challenged the CEO's unlawful position throughout
the previous year; had reminded the CEO of the state law; provided opinions from the American College of Obstetrician-Gynecologists
(ACOG), and even requested that the hospital submit to an unbiased "Voluntary Review of Quality Care" which the American College
offers. The CEO refused.
Because of the CEO's actions, and obligated by state law, the
Director of OB had already reported the CEO and the hospital to the State Board of Health and Joint Commission (JCAHO).
The Virginia State Board of Health (VDH) in response, and one year before the birth of your baby, conducted an ineffective,
weeklong investigation in which the CEO stated un-categorically, that the hospital could perform any requested C-section within
30 minutes as required by law. But that didn't happen the night you and your wife anxiously waited. You learn the CEO retaliated
against the Director of OB by initiating "Bad-Faith Peer Review" and suspended him one month prior to the birth of your baby;
not because of medical or surgical complications or because of substandard or negligent medical care; but because he was "disruptive"
–"disruptive" of the hospital's efforts to cover-up numerous violations (or their untoward consequences); of the hospital’s
efforts to bypass laws and regulations (laws and regulations implemented to protect your wife and baby). You could have never
anticipated that anyone was capable of such villainy.
This true case took place at Community Memorial Healthcenter (CMH),
a 90-bed, Level I, Joint Commission (JACHO) accredited community hospital in Southside Virginia. Southside Virginia
is a medically high risk, underserved, economically depressed, rural community near the North Carolina border. This area of
Virginia has one of the highest teen pregnancy and pre-term birth rates in the state. Group B Strep vaginal colonization rates
at 40% are 6 times the national average of 7% and result in commensurate Group B Strep perinatal morbidity unless mothers
receive appropriate antibiotic prophylaxis during Labor. Also, this hospital is the only hospital within 1 to
1 ½ hr driving time of this area. In 1998 I was appointed Medical Director of Obstetrics, a position that the joint
commission (JACHO) and State Hospital Licensing Regulations prescribe to oversee OB standards, policies, and quality of care.
After relocating from Fairfax, Virginia, I noted the hospital’s
C-section rates were unjustifiably higher and vaginal birth after C-section (VBAC) rates were lower than state and national
averages, increasing medical costs. It also quickly became evident to me that medical services at CMH were substandard
in many areas; many medical policies were out of date or unsatisfactory.
However, this case is by no means an isolated example of negligence
limited to this hospital or just to hospitals in Virginia. The birth of this innocent child took place in November 2001. A
random review of only 21 cases involving negligence, from hospitals throughout the United States, already litigated specifically
for unnecessary delays in starting C-sections, revealed that similar hospital negligence resulted not only in severe and permanent
newborn brain damage, but also in judgments and settlements totaling nearly an astronomical $200 million. What
may be more remarkable, and, frankly, of greater concern, is the absence, incompetence, and abject failure of hospital oversight
by state and federal agencies, whose primary function, absurdly enough, is oversight.
Now imagine state oversight agencies “pouring salt in this
family’s fresh wounds” by further refusing to act even after this child suffered permanent brain damage as a direct
result of this CEO’s criminal negligence and despite receiving official transcripts of the CEO's sworn testimony taken
down during my Peer Review Hearing. During this sworn testimony, the CEO admitted his negligence and confirmed all of
my original allegations reported to state officials a year earlier. Had the oversight agency taken the allegations seriously
and instituted remedial actions, they would likely have prevented this infant’s tragic injuries.
In one final act of irony, Governor Warner (now Senator Warner)
insensitively and flagrantly dismissed this innocent family’s irreparable pain and ongoing suffering by actually appointing
this same CEO to the Virginia Executive Board of Health, the state agency charged with hospital oversight whose duty, of all
things, is to insure the public’s safety. As a result, and because of a politically-influenced criminal justice
system favoring those that are well-connected; a system that persistently refuses to prosecute the gross criminal negligence
of the privileged; and in addition to the incompetence or inaction of oversight agencies, substandard hospitals such as Community
Memorial Healthcenter continue to maintain their undeserved joint commission accreditation; and patients continue to suffer
unnecessary injuries or death in US hospitals. It is also, by the way, almost always much less costly to practice good
medicine from the start, unimpaired by witless bean counters and useless manipulators, who impede patient safety.
The purpose of my testimony comes down to asking: who has the
courage to step forward with integrity to protect our most vulnerable citizens? Should licensed and specialty-certified physicians
or "economically conscious" CEOs and politicians, be responsible for medical decisions and medical policies in U.S. hospitals?
Physicians and hospital medical staffs no longer have the autonomy to carry out their medical obligations, but still carry
the legal and ethical burden and their patients still suffer the medical consequences.
I will finish with a brief quote by the obstetrician, Oliver Wendell
Holmes (nephew of the jurist) who with Semmeilweis, was co-discoverer of childbed fever. Dr. Holmes’ words regarding
expectant mothers capture more poignantly what I have tried to convey. The essence of his words and feelings are equally valid
for any one of us, at any age, in any hospital when we are suffering, frightened, and so vulnerable. They should serve as
a warning, not just to physicians, but to anyone who compromises or obstructs any doctor’s efforts to render life saving
medical care to any patient:
"The woman about to become a mother, or with her newborn infant
upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her
aching limbs…
God forbid that any member of the profession to which she trust her life, doubly precious at that eventful
period, should hazard it negligently, unadvisedly, or selfishly!"
