A Complete and Total Failure – Part One

I recently finished listening to a podcast about a Texas neurosurgeon, who was so incompetent and injured so many people that he is now serving a life term for elder abuse and assault as a result of a surgery gone wrong.  The doctor was Dr. Christopher Duntsch and the podcast was called Dr. Death.  It was both mesmerizing and horrifying.  I have never heard of a surgeon who seriously injured so many people in such a short period of time.  The question, which is explored in the podcast but never really answered, is how could this person have ever gotten in this position and stayed there long enough to do the damage he did.  In this post and the one to follow, I want to discuss the entities that failed the public so badly and without which this tragedy could not have reached the magnitude it did.  In the third post, I will discuss the final betrayal of the patients of Dr. Death.

Wondery poster

Before Dr. Duntsch began his first job at a prestigious hospital in a well-to-do section of Dallas, he graduated from college, went to medical school, where he obtained both an MD degree and a PhD, took a neurosurgery residency, and then participated in a fellowship to get further training in spine surgery.   His academic credentials were impressive and he received glowing reviews from the doctors at his residency and his fellowship.  Given how quickly he demonstrated complete incompetence at his first job, you have to ask, “What were they thinking in giving him these glowing recommendations?”

The first failure of the system, which is supposed to protect us, was that it allowed Dr. Duntsch to complete a neurosurgery residency.  Based on later events, it is clear he was completely unqualified and that should have been obvious to the people he trained under.  It also appears that, because he spent a lot of time in the lab, he did very few surgeries during his residency.  Instead of the thousand or so surgeries performed by the typical neurosurgery resident, he did only about 100.  This is a stunningly low number.  He should have been required to do more surgery.  Had he done more surgery, perhaps he would have learned more.  Had he done more surgery, perhaps his lack of competence and temperament would have become so obvious that the system could not have covered for him.  On top of lack of surgical experience and incompetence, he was suspected of using cocaine and sent to a rehabilitation facility for a few months before being allowed to return to the residency program.  How is a person who is suspected of being under the influence of cocaine while operating get allowed back into a neurosurgery residency program?  As it was, when prospective employers called about Dr. Duntsch, the people at the residency program never mentioned any problems, even after they had to have known how incompetent and potentially impaired he was.

The second failure took place at the hospital where he got his first job.  Almost immediately, he began to experience horrific surgical outcomes.  The first patient he operated on was left with chronic pain when he operated on the wrong part of his back.  When he took the patient back to surgery to address the chronic pain, he left him partially paralyzed.  Soon after that, he operated on one of his best friends and turned him into a quadriplegic.  Another of his patients bled to death as a result of his not recognizing that he had severed an artery.  The hospital quickly realized he was a problem and revoked his privileges to perform surgery there.  It sent him off to find another job as a spine surgeon.  In order to avoid a potential lawsuit with him, the hospital agreed that, if ever questioned about his time there, it would simply say that there were no issues with him.  Although required by law to do so, the hospital did not report Dr. Duntsch to the National Practitioners Data Bank.  Had it done so, Dr. Duntsch may have found it difficult to find other employment as a spine surgeon.

By now a pattern was emerging that would continue and would allow Dr. Duntsch to hurt more people.  Everyone who came into contact with Dr. Duntsch was looking out for themselves first.  If protecting themselves from criticism, or a lawsuit, or public exposure meant letting Dr. Duntsch move on without consequences, so be it.

Next week, Dr. Duntsch moves on again and again before finally being stopped.

Posted in disclosure of medical mistakes, Doctors, Hospital Negligence, Hospitals, Lawsuits, medical errors, medical ethics, Medical Malpractice, medical mistakes, Medical Negligence, never events, Secrecy, Surgical Errors, tort reform |