Quackery of a different kind than I usually write about

I've spent a lot of time on this blog discussing failures of the medical system. Usually, such discussions occur in the context of how unscientific practices and even outright quackery have managed to infiltrate what should be science=based medicine (SBM) in the form of so-called "complementary and alternative medicine" (CAM) or "integrative medicine," in which the quackery of alternative medicine is "integrated" with SBM. However, as big a problem as the infiltration of unscientific CAM practices into medicine is, there is a threat at least as grave here in the U.S. (and, I presume, in many places in the world). What I am referring to is the utter ineffectiveness of most state medical boards in reining in quackery and bad physician behavior that endangers patients. A recent story about a prominent Detroit area oncologist named Farid Fata, MD who has been arrested and charged with administering unnecessary chemotherapy and of diagnosing patients with cancer who turned out not to have cancer in order to defraud Medicare has led me to think that now might be a good time to revisit this issue. Then I heard about an Ohio spine surgeon indicted for performing unnecessary surgeries to defraud insurance companies, and I knew that now is a good time to revisit the issue.

I've discussed this issue before with respect to various practitioners over the years. One that comes to mind immediately is Dr. Rolando Arafiles at the Winkler County County Memorial Hospital in Kermit, TX. Basically, a CAM-friendly physician was practicing substandard medicine, and two nurses reported him anonymously to the Texas Medical Board. Because Dr. Arafiles was a business partner with Winkler County Sheriff Robert Roberts, who left no stone unturned to discover who had complained about his good buddy, leading to the prosecution of the two whistleblowing nurses for violation of patient privacy, even though Texas law explicitly said that using patient information to report substandard care is not a violation of patient privacy. The entire medical establishment seemed to be trying to come down on the two brave nurses like the proverbial ton of bricks. Ultimately, the Texas Medical Board did the right thing, but it took a long time, and two responsible nurses who couldn't bear seeing Dr. Arafiles continue to betray patient trust. There are many other examples, such as that of Dr. Rashid Buttar, a North Carolina doctor known for using "alternative" treatments for autism and cancer who got off with a slap on the wrist for some truly horrendous violations of the standard of care.

And don't even get me started on the utter failure of the Texas Medical Board to put a stop to Dr. Stanislaw Burzynski's unethical abuse of clinical trials and use of an unproven cancer drug over 36 years or on how it took decades to finally put a stop to Dr. Mark Geier's autism quackery in the United States. So what about these recent cases have in common? It's that they were both busted by the feds. The relevant state medical boards in Michigan and Ohio (both states in which I hold a medical license) did not detect the medical misadventures and did, as far as I can tell, basically nothing to stop it.

Farid Fata, MD

To all appearances, prior to his arrest and indictment last week, Dr. Farid Fata was a hugely successful oncologist and businessman with impeccable medical credentials. According to his practice's website, after graduating from Lebanese University in 1992, he went to medical school at Cornell Medical College, did an internal medicine residency at Maimonides Medical Center in Brooklyn, NY, and then completed a medical oncology fellowship at one of the premier cancer centers in the world, Memorial Sloan-Kettering Cancer Center. In 2005, Dr. Fata founded Michigan Hematology Oncology (MHO), which rapidly grew to seven locations with 60 employees throughout some of the more affluent northern suburbs of Detroit. In addition, Dr. Fata has published 20 articles indexed on PubMed for which he is primary or co-author and has widely lectured at local hospitals. He's a member of the usual list of medical organizations, including the American College of Physicians, American Medical Association, American Society of Clinical Oncology (ASCO), and American Society of Hematology (ASH), plus the Memorial Sloan-Kettering Alumni Association, and Hour Detroit Magazine named him one of the "Top Docs" in oncology in 2006, 2007, 2008, 2009, 2011, and 2012.

So how did it all go so very wrong? What is Dr. Fata accused of doing? For that, I have to reference some local news stories, such as this one from WXYZ-TV:

And this story from WDIV-TV:

In this story, perhaps the most shocking example of patient mistreatment is the the man who had head and neck cancer and was treated inappropriately with chemotherapy while receiving radiation, leaving him disfigured. Perhaps the most useful way for me (and perhaps for you) to understand the full scope of the charges is to peruse a summary published on Medscape on Friday, the actual criminal complaint against Dr. Fata, and the memorandum in support of detention that characterizes Dr. Fata as a flight risk and asks the court to keep him in custody until trial. There are dozens of examples of wrongdoing described, and the activities of which Dr. Fata is accused fall into these general categories:

1. Administration of unnecessary chemotherapy to patients in remission
2. Deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment
3. Administration of chemotherapy to end-of-life patients who will not benefit from the treatment
4. Deliberate misdiagnosis of patients without cancer to justify expensive testing
5. Fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments
6. Distribution of controlled substances to patient without medical necessity

The details of the allegations, obtained from various employee whistleblowers, range from the mundane to the truly horrific, and the amount of money involved is truly staggering, $35 million. Some of the mundane examples include charges such as this:

68. The unlicensed doctors are generally assigned to examine Dr. Fata's patients and complete write-ups of their exam. Dr. Fata typically sees his patients for only a few minutes at the end of their typical 2-4 hour visit to the clinic. The rest of the patients' time is spent with the unlicensed doctors and other MHO staff. This arrangement allows FAta to routinely see between 50-70 patients per day while other doctors in his practice see between 5 and 10.

Not to mention upcoding the billing to collect as much money as possible from Medicare. The general pattern in the complaints is that Dr. Fata would see large numbers of patients per day but bill every patient at the highest possible billing code, even though he spent only 3-5 minutes with each patient. For those of you not in the medical field, there are generally five levels of patient visits for billing purposes, from quick visits designed to look at one problem to highly complex visits that take over an hour. Upcoding visits (billing for a higher level visit than is justified by what was actually done at the visit) is common, and not all of it is with nefarious intent, mainly because the billing guidelines are confusing and complex. However, when a physician consistently bills at the highest levels for every patient, there's no way that's anything but intentional:

79. Dr. Fata typically sees 30-60 patients in a single day. Because of the volume, unlicensed doctors and nurse practitioners divide up his load, examine the patients, and create courses of treatment. Dr. Fata see the patients for a cursory exam and often changes the course of treatment. EE-6 [one of the whistleblower employees] believes he bills the two highest level office visit codes under his own number.

The only thing that puzzles me here is how Dr. Fata could possibly have gotten away with this over so many years, if he is in fact found guilty. Medicare pays very close attention to the percentage of patients billed at each level. If a physician bills for every patient at level 4 or 5, that's a huge red flag.

Another mundane charge against Dr. Fata is that he ran a self-referral setup with an imaging company that he owned, much the same way that Stanislaw Burzynski required his patients to get their chemotherapy from a pharmacy that he owned:

81. According to EE-7, Dr. Fata opened a company known as United Diagnostics to perform medical testing. Since he opened United Diagnostics, the percentage of patients in his practice receiving PET scans she estimates has increased from 30% to 70%.

Another whistleblower reported:

64. EE-1 advised that all patients referred to MHO, even those referred only for hematology issues, are prescribed PET scans and blood tests. EE-1 advised that two MHO medical assistants questioned him about the practice of giving all patients PET scans, even those referred only for anemia or other hematology issues.

One notes that Dr. Fata also had a relationship with a pharmacy that he always liked to use for his patients when he prescribed oral chemotherapy agents. Indeed, in the criminal complaint Up until now, these charges are basically charges of running your standard Medicare scam, in which inflated bills are submitted for services rendered and there are incestuous relationships between imaging centers and pharmacies and the physician's practice. This sort of thing is sadly all too common. However, such shenanigans, although they are designed to enrich the doctors who run them and frequently lead to overuse of of services, don't necessarily grossly endanger patients (at least not all the time), as it's quite possible that the pharmacies involved can be qualified and that the imaging center provides quality imaging. If this were all that Dr. Fata were charged with and ultimately convicted of, he'd be a greedy bastard but not the monster he is accused of being. The charges go far beyond his being just a greedy bastard, though.

If the federal charges are correct, where Dr. Fata took it to the "next level" was in the brazenness and callousness of it all. His practices, the feds charge, grossly endangered and injured patients. For instance, in the complaint we learn that he appears to have been the living embodiment of an old (and rather offensive) joke about oncologists that goes something like this. Why do they nail the coffins of cancer patients shut? So that the oncologist won't keep trying to give them chemotherapy. Sadly, with Dr. Fata, that old joke appears not to have been (much of) an exaggeration:

46. In two instances, Dr. Fata directed that chemotherapy be administered to patients who had other serious medical conditions that required immediate treatment before he would permit them to go to the hospital.

47. In one instance, a mail patient fell down and hit his head when he came to MHO. Dr. Fata directed EE-4 that he must receive his chemotherapy before he could be taken to the emergency room. MHO administered the chemotherapy, after which the patient was taken to the emergency room. The patient later died from his head injury.

48. In the second instance, a patient came to MHO with extremely low sodium levels, which can be fatal. Dr. Fata again directed that the patient must first receive chemotherapy before being taken to the emergency room. MHO administered the chemotherapy and the patient was taken to the emergency room and hospitalized.

Consistent with the case above and that horrible old joke, Dr. Fata is accused of administering chemotherapy to patients with late stage and terminal cancer who could not conceivably have benefited from the treatment. For such patients and, of course, for patients who don't have cancer in the first place, chemotherapy can only cause harm because, depending on the specific regimen, it's very toxic.

Other charges against Dr. Fata's include ordering chemotherapy inappropriately for patients in remission and falsifying cancer diagnoses:

42. In addition, Dr. Fata falsifies cancer diagnoses to justify cancer treatments. Where a test falls in a "grey" area, he will diagnose cancer in order to start cancer treatment. EE-4 explains that it is easier for the doctor to do this for blood cancers, where the doctor has more discretion to interpret blood test results vs. tumors, for which is is harder to falsify diagnoses.

One of the whistleblowers quit because Dr. Fata had instructed her to falsify cancer diagnoses in order to justify ordering PET scans. While he was in the process of opening his imaging center, Dr. Fata also allegedly delayed PET scans that were actually medically indicated so that he could have them done at his new facility. He was also reported to become quite angry when his staff failed to follow through on these instructions.

As for chemotherapy, Dr. Fata is accused of not just of ordering it inappropriately for patients who had urgent medical conditions requiring attention before any conceivable need to give chemotherapy or for patients at the ends of their lives, but he is accused of ordering it inappropriately for many other reasons and, even when the chemotherapy was indicated, prescribing too much of it. For example, he is accused of routinely ordering "maintenance" chemotherapy for patients who did not need it. Indeed, medical assistant quoted Dr. Fata as telling patients that once they had chemotherapy, "they had to have it for the rest of their lives," which is utterly unnecessary for nearly all cancers. That's how he is thought to have racked up nearly $25 million worth of chemotherapy charges over the last couple of years. Finally, one offense that I hadn't thought of before but that I came across in an article yesterday is that Dr. Fata wasted chemotherapy drugs on people who didn't need them, harming those people, but also potentially denying those drugs to people who could benefit from them. There have been shortages of certain drugs, and one wonders how much of these drugs could have helped other people. Causing harm both to the patient through unnecessary treatment and to others through potentially making it harder for them to get the drugs they need is a double whammy on Michigan cancer patients.

Again, if these charges hold up, not only did Dr. Fata commit Medicare fraud (which is the least of the charges against him, as far as I'm concerned), he betrayed, endangered, and injured his patients. He betrayed the trust and enormous privilege given to him as a physician by society, all for money, all at enormous cost to his patients and society. Already, stories are coming out of patients who died under Dr. Fata's care whose families are now not sure whether they actually had cancer and died of chemotherapy complications or whether they died of their cancers. Hundreds of patients currently under treatment now don't know where to go.

Abubakar Atiq Durrani, MD

Abubakar Atiq Durrani, MD is a spine surgeon in the Cincinnati area who, if federal authorities are correct, suffers a similar lack of ethics as Dr. Fata. Instead of administering unnecessary chemotherapy to patients, Dr. Durrani is accused of doing unnecessary surgeries on patients through his private practice, Center for Advanced Spine Technologies (CAST), all to bill insurance companies and Medicare:

A federal grand jury indicted Abubakar Atiq Durrani on Wednesday on five counts of health care fraud and five counts of making false statements in health care matters, according to prosecutors.

Durrani’s fraud scheme resulted in serious injuries in some cases, with many patients treated by Durrani for back and neck pain left in worse pain because of unnecessary surgery, the indictment states. Durrani also would tell some patients the medical situation was urgent and that back surgery was needed immediately, according to the indictment.

“For cervical spine patients, Durrani would often tell a patient that there was a risk of paralysis or the head would fall off if the patient was in a car accident because there was almost noting attaching the head to the patient’s body,” the indictment states.

Dr. Durrani collected over $10 million from Medicare and private insurers for services rendered. Earlier this year, 88 of Dr. Durrani's former patients sued him for doing "criminal ... medically unnecessary, experimental spine surgeries" without informed consent in order to sell Infuse Bone Graft for Medtronic, for which Dr. Duranni is accused of taking kickbacks from Medtronic. Some of the civil complaints can be found at this link, as well as the response by Dr. Durrani's lawyer. There are also several patients of patients of his defending him in the comments. Since February, the number of patients suing has ballooned to 150.

As was the case for Dr. Fata, I think a local news report gives the flavor of what's going on:

The federal grand jury indictment can be found attached to this news story. The indictment lumps the charges into these categories:

1. DURRANI would persuade the patient that surgery was the only option, when in fact the patient did not need surgery
2. DURRANI would tell the patient the medical situation was urgent and that surgery was needed right away. He would also falsely tell the patient that he/she was at risk of grave injuries without the surgery
3. For cervical spine patients, DURRANI would often tell a patient that there was a risk of paralysis or the head would fall off if the patient was in a care accident because there was almost nothing attaching the head to the patient's body.
4. DURRANI often did not read or ignored the radiology reports written by the radiologists for imaging studies that DURRANI ordered (e.g., xrays, CT scans, and MRIs)
5. DURRANI would provide his own exaggerated and dire reading of the patient's imaging that was inconsistent with or plainly contradicted by the report written from the radiologist. At times, DURRANI provided false reading of the imaging.
6. DURRANI would dictate that he had performed certain physical examinations and procedures on patients that he did not actually perform.
7. DURRANI would order a pain injection for a level of the spine that was inconsistent with the pain stated by the patient or the imaging. DURRANI scheduled patients for surgeries without learning or waiting for the results of certain pain injections or related therapies.
8. DURRANI often dictated his operative reports or other patient records months after the actual treatment.
9. DURRANI's operative reports and treatment records contained false statements about the diagnosis for the patient, the procedure performed, and the instrument used in the procedure.
10. When a patient experienced complications resulting from the surgery, DURRANI at times failed to inform the patient of or misrepresented the nature of the complications.

There's also a rather strange, but interesting, twist in this story, namely that the five patients whose medical records were reviewed might all have Ehlers-Danlos syndrome, a connective tissue disorder in which the collagen that makes up certain connective tissue is too elastic and easily deformed. Most forms of Ehlers-Danlos syndrome are inherited in an autosomal dominant fashion. Dr. Durrani's attorney is arguing that the standard of care is different for these rare patients and that they did need surgery. Even if that's true, I don't see how it would absolve Dr. Durrani of charges that he documented diagnoses patients didn't have, procedures never done, and dictating procedures and charts months later. In any case, I will concede that, to me at least as a surgeon, Dr. Durrani's case strikes me as less clear-cut than that of Dr. Fata, but quite troubling nonetheless.

The problem

In the wake of these cases, I have heard many observations, some reasonable, some not, regarding what the problem is. As an example of the unreasonable, take a look at Debbie Schlussel's disgustingly racist take on Dr. Fata's case, where she accuses that "a significant percentage of doctors and other healthcare professionals who commit healthcare fraud are Muslims, Arabs, or both" and uses the opportunity of Dr. Fata's arrest as an excuse to rant against immigrants, Muslims, and Arabs. (It would probably blow her fragile eggshell mind to tell her that not all (or even most) Muslims are Arabs and not all Arabs are Muslim, but that's for another day.) One notes that she provides zero evidence to support her assertion that a disproportionate amount of Medicare and health insurance fraud is committed by "Muslims, Arabs, or both." Can anyone say, "confirmation bias"? Sure, I knew you could. I've also heard it also said that the problem is foreign medical graduates (FMGs). Never mind that Dr. Fata received all of his medical training and Dr. Durrani did his orthopedic surgery residency and multiple advanced fellowships at top-notch institutions right here in the good ol' U.S. of A. While it's true that we need good mechanisms to make sure that physicians who receive their medical training outside of the U.S. are trained up to the standards expected in the U.S., but if there's any evidence that FMGs are more prone to fraud that U.S.-trained physicians, I am unaware of it. Certainly Schlussel hasn't provided any such evidence.

One reasonable observation that is unavoidable from all this is that an impressive pedigree and having trained at top-flight medical schools, residencies, and fellowships are no guarantee against what Dr. Fata and Dr. Durrani are accused of having done. Dr. Fata, for instance, routinely won local "top doc" honors from the local magazine that does the list every year (every major city has one). Dr. Durrani was on the faculty at the University of Cincinnati ahd had a reputation as a

The real question that cases like this bring up is about state medical boards. Fraud almost never gets to the level of what Dr. Fata, for example, is accused of without a long prior history. Indeed, Dr. Fata apparently had that history, as is coming out now in local news reports, for example, this report from WXYZ-TV, which describes allegations of patient mistreatment going back years. Also revealed is that there is currently an open complaint against Dr. Fata with the Michigan Board of Medicine:

Interestingly, a search of the Michigan website for Dr. Fata's medical license reveals no open complaints against him. Similarly, neither the State Medical Board of Ohio nor the Kentucky Board of Medical Licensure websites has any notice of action against Dr. Durrani. The question is: Why not? Why is it that it took the feds investigating Medicare and health insurance fraud to discover—virtually stumble upon, actually—evidence of Dr. Fata's wrongdoing? Why is it, for example, that the North Carolina Medical Board has been unable to do much against Dr. Rashid Buttar and, even more egregiously, the Texas Medical Board hasn't been able to stop Stanislaw Burzynski? It matters not to me whether the offense is practicing pseudoscientific "alternative medicine" (as Dr. Buttar does, in my opinion), using unapproved and unproven cancer drugs (as Dr. Burzynski undoubtedly does), administering unnecessary chemotherapy (as Dr. Fata is accused of doing), or doing unnecessary surgery (as Dr. Durrani is accused of doing). What matters is that these physicians either administer treatments far outside of the science-based standard of care or are accused of doing so.

As I've pointed out before, one of the most contentious and difficult aspects of trying to improve medical care is enforcing a minimal, science-based "standard of care." Optimally, this standard of care should be rooted in science- and evidence-based medicine and act swiftly when a practitioner practices medicine that doesn’t meet even a minimal requirement for scientific studies and clinical trials to support it. At the same time, going too far in the other direction risks stifling innovation and the ability to individualize treatments to a patient’s unique situation–or even to use treatments that have only scientific plausibility going for them as a last-ditch effort to help a patient. Also, areas of medicine that are still unsettled and controversial could be especially difficult to adjudicate. The cases I've described above, with the possible exception of that of Dr. Durrani (and even then I'm not convinced yet) do not fall into these gray areas. So why can't medical boards protect patients against such doctors? Why did it take allegations of insurance fraud to bring in the feds, who acted rapidly to shut them down? Indeed, in the case of Dr. Fata, U.S. District Attorney Barbara McQuade explicitly said, ""Our first priority is patient care. The agents and attorneys acted with a great attention to detail to stop these allegedly dangerous practices as quickly as possible."

Why couldn't the Michigan Board of Medicine have done the same? Why couldn't the other relevant state medical boards do the same about the other doctors? Unfortunately, our current system doesn’t do a very good job of protecting the public from physicians who practice obvious quackery or who commit fraud, for many reasons. Most medical boards are overburdened and underfunded. Consequently, until patients or fellow practitioners complaints are made and there is actual evidence of patient harm, there is all too often literally nothing they can do. Also, in my experience, state medical boards tend to prefer to go after physicians who misbehave in undeniably bad ways: alcoholic physicians or physicians suffering from other forms of substance abuse; physicians who sexually abuse patients; or physicians who are “prescription mills” for narcotics. These sorts of cases are easier to adjudicate. They are much more clear-cut and detrimental to patients, but most importantly they don’t force boards to make value judgments on the competence and practice of physicians, such as determining whether Dr. Fata's use of chemotherapy or Dr. Durrani's surgical practice are outside the standard of care. Unless a patient is hurt and complains, state medical boards often can't even investigate.

That doesn't leave physicians off the hook. Having spoken to oncologists I know last week, I know that some of them who saw patients of Dr. Fata's as second opinions had serious misgivings about some of the courses of treatment they encountered. I know that some physicians in the area of Dr. Fata's home base (Crittenton Hospital Medical Center) did not think very highly of him. Although I've never had any personal interaction with him and don't recall seeing any of his patients for surgery what I can tell, there were many indications and red flags, but for some reason Dr. Fata practiced for eight years untroubled by the state medical board or the law except for the occasional malpractice suit. Did any of these doctors seeing Dr. Fata's patients for second opinions think to report him to the medical board? What about those doctors who saw some of Dr. Durrani's patients and told them they had had unnecessary surgery. While it's true that sometimes doctors have differences of opinion, if what the feds say is true these go far beyond reasonable medical differences of opinion between health care professionals. Of course, it doesn't help that in some states health care professionals can suffer serious consequences for filing reports, as two nurses in Winkler, TX discovered when they tried to report a bad doctor. Also making it difficult to discipline physicians is the problem that in many states physicians who are on these medical boards are unpaid and reluctant (as they see it) to strip a fellow doctor of the means of his or her livelihood. There’s also a cultural tendency among physicians to stick together. We understand the difficulty of making decisions that can have profound consequences in our patients’ lives, and we tend to want to bend over backwards to give fellow doctors the benefit of the doubt.

Advocates for science-based medicine cannot help but be appalled at how easily physicians can get away with practicing so far outside the standard of care, even to the point that patients are harmed, with little or no interference by state medical boards. It's bad enough when it's done through a belief in quackery, but it's even worse when it's done in order to turn patients into cash cows. Boards are outgunned and underfunded to the point where they can barely deal with the sorts of cases Dr. Atwood described. Also, truth be told, part of the problem is that the attitude among doctors seems to be that a medical license is a right, not an incredible privilege bestowed upon us by society that takes an equally incredible commitment and skill to be allowed to keep. That being said, I will take this opportunity to emphasize again that doctors who consistently do not practice science- and evidence-based medicine to the minimal standard of care, be it because they are incompetent, dishonest, impaired by substance abuse, or because they have come to believe in quackery, do not deserve to be physicians. If we as a profession do not find a way to do better, legislators will do it for us, but that shouldn't be our primary motivation. Our primary motivation should be that quality patient care should rule supreme because our patients deserve no less.