Respectful Insolence

About a week and a half ago, I wrote about a local oncologist who was arrested by the FBI for massive Medicare fraud in which physician involved diagnosed cancers that weren’t there, gave chemotherapy to patients who either didn’t have cancer or were in remission and thus didn’t need it, and had developed a self-referral system to his own imaging facility. The story of this oncologist, Dr. Farid Fata, founder of a very large multi-location oncology practice (Michigan Hematology Oncology), made international news, which is exactly not the sort of coverage Detroit needs right now, given all the other badness happening at the moment, such as the city going into bankruptcy. It doesn’t matter that Dr. Fata didn’t practice in Detroit proper, but rather in the tony northern suburbs; his actions reflect on the region.

The scope of the misdeeds of which Dr. Fata is accused is truly staggering: Over $150 million in Medicare billing and collecting $62 million over the last three years, the percentage of which was fraudulent currently unknown. Over the last two years he billed $24 million for chemotherapy, by far the most of any oncologist in the state of Michigan (Dr. Fata did treat patients who actually did have cancer and who did need chemotherapy; so it’s hard to tell how much of his billing was appropriate and how much was fraudulent):

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The last time around, I touched on how cases like this one represent a profound failure of state medical boards. There is little doubt that, as the story evolves, the state medical board here in Michigan screwed up big time. Whether it tried to do the right thing and failed due to lack of resources or the way the law is written or whether there were other reasons, we don’t know. What we do know is that the medical board failed—and failed massively—in this case. The indications were there. The complaints were there, as we will see. The suspicions were there. But nothing happened until the feds noticed his fraudulent Medicare billing. Indeed, I wonder how he got away with his Medicare billing for so long, given that he saw 70-80 patients a day and billed the maximum level for most of them. That’s usually an enormous red flag. Indeed, at a recent meeting for families of patients of Dr. Fata, one patient’s son reported:

When Matt Fiems of Canton began taking his mother, Susan, of White Lake, to Dr. Farid Fata’s former Michigan Hematology Oncology office in downtown Rochester in 2007 for treatments for ovarian cancer, he was taken aback by the size of Fata’s operation.

“I called it Fata Incorporated,” he said. “Once you were referred, you got his diagnosis, his prescription of chemotherapy at his infusion centers.”

The operation was so large, in fact, Fiems said he and his mother had a difficult time finding a seat in the waiting room, which he said would overflow with patients on a regular basis.

“His offices were always very crowded,” he said.

There had been several complaints as well:

One person who says she spotted—and reported—warning signs is oncology nurse Angela Swantek of Shelby Township, who visited Fata’s former downtown Rochester office in 2010 while looking to work closer to home.

“Within 15 minutes of being in his office, I knew there was no way I’d be accepting a position in his office,” Swantek said, noting she observed improper mixing and administering of chemotherapy. Swantek said she notified the Michigan Department of Licensing and Regulatory Affairs about her concerns, but was told 13 months later by the department that no violations could be found.

“When I reported him to the state, my complaint was strictly about patients being mistreated,” she said. “It had nothing to do with overbilling or misdiagnoses.”

This is pretty blatant, if a job candidate being given a tour of a facility as part of her job interview can so readily spot the improper handling of chemotherapy. As noted in the previous story I cited, much of this mixing was done without a pharmacist supervising the process.

It also turns out that the medical community was also suspicious. Because of where Dr. Fata practiced, I don’t recall ever having personally dealing with any of his patients, but speaking with some of my colleagues over the last couple of weeks has been—shall we say?—illuminating. Apparently Dr. Farid was incredibly aggressive about protecting what he viewed as his prerogatives and not exactly shy about throwing his weight around on the basis of the revenue that he generated for his home base of Crittenton Hospital. If what I’ve been told is to be believed, he would chew out referring physicians if they sent patients to other hospitals or cancer centers in the area, telling them that they “owed” him a certain number of patients referred to him to make up for it and would go ballistic at his staff if one of his patients sought a second opinion. This behavior strikes me as consistent with reports in the legal complaint against him that he would berate his staff if they scheduled PET scans or other tests at facilities that he didn’t own or have an interest in. I also learned from my colleagues that apparently Dr. Fata would routinely use the threat of taking all his patients elsewhere to get whatever he wanted from Crittenton Hospital. It was an effective threat, because he brought a lot of revenue to the hospital.

Unfortunately, as a story from last year from a local magazine demonstrates, Dr. Fata is not the only doctor apparently got away with bad behavior for a long time, with the state medical board doing, in essence, little or nothing about it:

But enforcement is getting less, not more, strict.

Wolfe notes that the rate of serious discipline — revocations, surrenders, suspensions, and probation/restrictions — was 20 percent lower in 2010 (2.97 actions per 1,000 physicians) than the peak rate in 2004 (3.72 serious actions per 1,000 physicians), with considerable evidence of under-disciplining physicians.

“At this point, with all that’s been written, I would think they’d [state medical boards] be hyper-aware of protecting patients,” says Bill Heisel, contributing editor/blogger for Reporting on Health. “They will usually plead poverty and say they don’t have the money and people to go after doctors.”

Wolfe agrees. “Most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner,” he wrote in 2011 at the posting of Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2008-2010, on Public Citizen’s website.

Michigan ranked 38th in the study, and has ranked from 37th to 40th since 2003 (with the higher the number, the worse the showing).

I’ve written about this before in the context of various “complementary and alternative medicine” (CAM) quacks who practice with seeming impunity, whom state medical boards have been unwilling or unable to shut down. Examples include Dr. Rashid Buttar in North Carolina and Dr. Rolando Arafiles in Texas. (And don’t even get me started on the Texas Medical Board and Stanislaw Burzynski.) Then there’s Dr. Mark Geier in Maryland and multiple other states. The only good thing about the Geier case is that, once Maryland finally after decades pulled his medical license, the other states where he was licensed to practice medicine followed suit reasonably quickly because losing your license in one state can be a grounds for pulling it in other states. Sadly, Michigan is far from alone, as this recent story in USA Today, Dangerous Doctors Allowed To Continue Practicing, shows:

Despite years of criticism, the nation’s state medical boards continue to allow thousands of physicians to keep practicing medicine after findings of serious misconduct that puts patients at risk, a USA TODAY investigation shows. Many of the doctors have been barred by hospitals or other medical facilities; hundreds have paid millions of dollars to resolve malpractice claims. Yet their medical licenses — and their ability to inflict harm — remain intact.

The problem isn’t universal. Some state boards have responded to complaints and become more transparent and aggressive in policing bad doctors.

But state and federal records still paint a grim picture of a physician oversight system that often is slow to act, quick to excuse problems, and struggling to manage workloads in an era of tight state budgets.

When I write that I believe that there should be one standard, a science-based medical standard, for determining what treatments fall within the standard of care, I mean it for all doctors. While it is true that I write about this issue mostly in the context of protecting the public from CAM practitioners, it goes far, far beyond that. I also mean it with respect to all doctors. To me, it is the same issue if a CAM doctor is prescribing drugs that can’t possibly help but can definitely harm or a cancer doctor in Michigan is prescribing chemotherapy drugs to patients with advanced cancer who can’t possibly be helped by them but whose quality of life in their remaining months or weeks can definitely be destroyed by them. The issue is to protect patients from the bad behavior of doctors.

There are three main points where bad doctors can be shut down. (At least, that’s the way it’s supposed to be.) The first, of course, is licensure by state medical boards, but, as we have seen, the oversight by these boards is frequently quite lax. True, it’s not lax in all states, but at the very best it can be described as highly variable. The second is credentialing by hospitals. In general, however, it’s hard not to be credentialed by a hospital where you want to practice, particularly if, like Dr. Fata, you did your oncology training at Memorial Sloan-Kettering. Often, if a physician is denied credentialing at a hospital, it is not uncommonly for reasons other than medical training and skill, such as rival physicians not wanting to let a competitor in on their home turf. Yet, apparently a local hospital did deny Dr. Fata privileges, as reported above. The problem is, if you’re a physician with an active practice, hospitals are highly unlikely to deny you credentials unless the evidence that you practice substandard medicine or engage in unethical or illegal activity is impossible to ignore. Take the example of Crittenton Hospital, which basically appears to have let Dr. Fata do whatever he wanted, as long as he kept that sweet, sweet money flowing. The final point of impact is being credentialed as a provider in insurance plans. However, insurance plans are unlikely to deny a physician membership in its health plans unless there have been multiple malpractice suits or other indications of problems.

Finally, there is a developing fourth point of impact, and that’s the way Dr. Fata was taken down: Being busted by the feds for Medicare fraud. However, that can only happen if there is actual evidence that a doctor is committing Medicare fraud, something that might or might not be related to substandard patient care. Often the two go together, but not necessarily. It is possible to provide adequate care and still defraud the government.

So what to do? Clearly, at the very least, state medical boards, particularly those that are substandard, need to be empowered and funded to do their jobs. That, at least, is a start. There also needs to be a shift in the culture of medicine in which physicians and other health care professionals who observe behavior like Dr. Fata’s report such doctors to the state medical board. Surely, lots of oncologists saw Dr. Fata’s patients as second opinions and were disturbed by what they saw him doing. Did any of them report their concerns to the state medical board? To me, it doesn’t matter if it’s an alternative medicine quack, a fraudster treating patients inappropriately with chemotherapy in order to bilk Medicare and Medicaid, or a doctor administering unapproved drugs or potentially toxic unvalidated cocktails of chemotherapy and targeted agents to patients. We as a medical profession need to protect patients from them all.

Comments

  1. #1 Michael Finfer, MD
    August 23, 2013

    We do need more effective policing. Every bad doctor tarnishes all of us.

    Here in NJ, I have not heard of any disastrous enforcement failures such as this, but the state medical board clearly needs more money, if not a lot more money. At current funding levels, they do not have enough people to answer the telephone. I have to assume that this problem is not an isolated one.

    I also think that many doctors are reluctant to report all but the most egregious violations, and perhaps some are reluctant to do even that. They see it as ratting or collaborating with the enemy. That’s an attitude that needs to change, but I am not certain of the correct path forward.

    I have to say, though, that I have yet to see anything that I was even tempted to report. I am happy about that.

  2. #2 Bobio
    August 23, 2013

    Perhaps ISM could author draft legislation for skeptics in the states and for federal lawmakers. That would be a start.

  3. #3 Bob
    August 23, 2013

    Actually, to what degree would doctors have to be retrained to meet those standards. A lot of quack-do-diddly-do has been incorporated into practices, AND a sizable percentage of best procedures/practices have not been studied yet anyway. Or am I wrong about that?

  4. #4 palindrom
    August 23, 2013

    This is a very interesting, and of course rather disturbing, post.

    As I understand it, and as I’ve observed it in friends, medical training involves quite a bit of acculturation in addition to the technical learning — people have to learn to “play doctor”, so that they can work effectively with patients, and they gain self-confidence — hopefully well-founded! — so that they can intervene without being paralyzed by indecision and fear, and so that when things go wrong (as they inevitably will sometimes) they don’t end up in an endless cycle of self-recrimination.

    Medical school is famously difficult, and at least in the old days constituted something of a 4-year hazing. I’m wondering whether this leads to an “us-versus-them” mentality — other physicians tend to grant wide, wide latitude, because you’re one of them. Police forces are notorious for this dynamic — brutal or corrupt cops are shielded by the thin blue line of silence. Is there also a “thin white line” in the medical profession — a tendency to defer to the fact that the person exhibiting susicious behavior is, after all, another doc who went through the same rigorous training you did? And if so, how can this be ameliorated without eroding professional identity and collegiality?

  5. #5 prn
    August 23, 2013

    Fata sounds awful, especially with the falsified cancer diagnoses. No doubt MSK should review its selection processes too.

    However, I could not disagree with Orac more about the “one way” highway for cancer treatment. It is a highway to ruin in the US, both for inflated costs, an order of magnitude higher, and horrid, unnecessary side effects, an order of magnitude higher. I know we will argue about the outcomes and slow evolution of treatment part.

    Because of medicines and techniques not available in the US, it has become *possible* to do much better in a 3rd world country than even the prestige parts of the US. I’ve actually turned down UPenn and MDA trained surgeons for their foreign trained counterpart’s recognized skill set.

  6. #6 JGC
    August 23, 2013

    Because of medicines and techniques not available in the US, it has become *possible* to do much better in a 3rd world country than even the prestige parts of the US.

    Which third world countries, exactly, are reporting better outcomes than the US due to medicines and techniques not available in the US?

  7. #7 Lawrence
    August 23, 2013

    @prn – yes, we would love to take a look at those reports.

  8. #8 Shay
    wallowing in bucolic nostalgia
    August 23, 2013

    Completely OT, but I grew up in Rochester before it got tony. I can remember when Crittenden Hospital was still a cow pasture.

  9. #9 Eric Lund
    August 23, 2013

    Indeed, I wonder how he got away with his Medicare billing for so long, given that he saw 70-80 patients a day and billed the maximum level for most of them.

    At 80 patients a day, that’s 18 minutes per patient, assuming Dr. Fata doesn’t eat, sleep, or use the restroom. It also assumes Dr. Fata was seeing patients in one location that day (we know he had multiple offices). How long did it take for an auditor to do the math and realize that Dr. Fata was routinely billing for more than 24 hours in a day?

    Swantek said she notified the Michigan Department of Licensing and Regulatory Affairs about her concerns, but was told 13 months later by the department that no violations could be found.

    Does the department warn doctors in advance that there will be an inspection? If so, it’s quite easy to tell your staff, “The inspectors are coming, so do everything strictly by the book today.” And even if they are not, the inspectors are probably easy to spot. Not to mention that the boss can easily blame (and fire) an underling for “screwing up” in front of an inspector.

  10. #10 Gary
    Maryland, USA
    August 23, 2013

    Chiropractors in Maryland and December offer free “gourmet” meals in ads placed in the Washington Post offering to tell diabetes 2 sufferers how it can be “reversed”, offering help to women with thyroid problems, those with sleep apnea. In other words, branching out as per Brandon Credeur D.C.’s videos, which were exposed by a Denver TV channel.
    Sadly, the Maryland Chiropractic Board has its head in the sand (“it’s not illegal to talk about this”), although Viriginia Health Department is more proactive (suspending one chiroquack’s license for six months)

  11. #11 Daisy
    August 23, 2013

    @Eric, In some states when someone files a formal complaint against a physician, the medical board writes the physician a letter requesting the patients records. At least one medical board apparently puts more weight in the records that the physician produces as opposed to the records provided by the patient. Some physicians might be inclined to creatively edit or even dispose of certain records when they are essentially forewarned of an investigation.

    Some physicians may have a history of being suspended or fined, but after a few years, depending on the state, that information is no longer openly listed on the state medical board website. One would have to write to the state and ask specifically if there are any sanctions that are public record but no longer listed on the medical board website. Who would ever guess that they would have to go to this extreme to find out about a bad doctor?

    Aside from that, in some states, a physician may have been suspended or reprimanded in the past, but such information is not a matter of public record. The public and their patients are not informed. I think this is a great injustice to the patients.

  12. #12 William M. London
    Los Angeles, CA
    August 23, 2013

    The type of egregious behavior you are describing here is NOT appropriately labeled quackery (which refers to the PROMOTION of products and services with non-validated or invalidated claims for safety and/efficacy for financial gain). Practitioners do not have to engage in quackery to rip off, abuse, and endanger patients. You perform a public service by exposing any serious threat to patients, not just quackery.

  13. #13 prn
    3rd world vs USSA @6, 7
    August 23, 2013

    Guys, it is not a matter of *average* or standard, it is what is doable and reasonably available off the shelf there. Totally different situations, many people in the 3rd world die decades younger with very limited options.

    As for technique, an example in the Japanese literature and editorials, there are procedures for rectal resections, that call for great precision and speed, where their surgeons are clearly looking down at the US practices historically.

  14. #14 Krebiozen
    August 23, 2013

    prn,
    Evidence for any of your unlikely-sounding assertions? Please put up or shut up.

  15. #15 Mephistopheles O'Brien
    August 23, 2013

    If there’s no (or limited) regulation, then certainly one might get effective treatments before they’re proven just like one might get ineffective (or downright harmful) treatments well after they’re discredited or before the evidence of safety and effectiveness is in.

  16. #16 Daisy
    August 23, 2013

    As I see it, one major problem is that a physician can be under investigation for outrageous offenses against patients and yet the medical board may take up to ten years to complete their investigation.

    During an investigation, none of the doctors patients may be warned about the dangers as their physician is deemed innocent until proven guilty. This is even despite the fact that the physician may already be known to have contributed to or caused the death of multiple patients.

    After a physicians license is revoked, patients are still not properly and fully informed. There is no responsibility upon the state medical boards to inform the patients, the victims. The offending physician may simply send a note to their patients stating the practice is closing, and give no reason for the closure. People might think it was due to retirement, instead of multiple patient deaths.

  17. #17 Krebiozen
    August 23, 2013

    Japan is a “3rd world country”? I don’t think so.

  18. #18 Lucario
    SoFla, where night has fallen
    August 23, 2013

    This sort of negligence in medical care worries me. How does one know beyond a resonable doubt that one’s doctor is not a scam artist, and what other steps can one take to protect oneself from quackery like this?

    This scares me.

  19. #19 Denice Walter
    August 23, 2013

    re “third world countries” for better outcomes:

    is that better FINANCIAL outcomes?
    by shopping around as a medical tourist for cut rate surgery?

    ” Get your new knee in Goa
    Save money and try our exotic cuisine.
    And we have lovely beaches, too”

  20. #20 prn
    August 24, 2013

    Re prn@13. Perhaps I should have said what I thought was implicit, “…what is doable and reasonably available off the shelf with the best 1-2% of facilities and doctors” there [3rd world], vs the median care, typically delivered in the US to the HMO and indigent zones.

    Kerbiozen@14 (yrs old?) prn, Evidence for any of your unlikely-sounding assertions? Please put up or shut up.

    K, I know that there is a lot of disconnect between our experience, reading and point of view, but that sounds more like “just STFU”.

    It is hard to exactly re-source any given article that I’ve stumbled upon and read over the last several years, publications sometimes relatively obscure in the West. The following article doesn’t quite have as strong a “flavor” as the Japanese editorial that I read, but hopefully you can still discern some of the Japan/East vs West points of contention, and view:
    TME + extended lymphadenectomy vs RT

    The editorial from a Japanese journal, was shocking because it was so unusually candid and direct about Japanese surgeons’ attitudes, in English, along the lines: In the West, their medicine zaps rectal patients with [inferior] RT, because their surgeons are too likely to fat finger a delicate operation, like TME + extended lymphedecomy, that requires superior precision and speed to succeed without excess morbidity.

    Krebiozen@17:Japan is a “3rd world country”? I don’t think so.
    Another disconnect. Some 3rd world doctors train in some of the better medical institutions in Japan or the US.

  21. #21 Krebiozen
    August 24, 2013

    There are far less strict regulations in many developing countries, as compared to the US and Europe, in many areas, from vehicle exhaust emissions to which drugs are available without a prescription.

    Personally I don’t think this is a good thing. Most of the regulations about what drugs and other treatments are permitted do exist for good reasons. One man’s quack clinic set up in Tijuana to avoid rules designed to protect patients is another man’s life-saving clinic that is bravely escaping FDA oppression.

    I was at university with a young man who ran a business importing local crafts from South East Asian to sell on a London market. He would also bring back a range of lethal medications that he bought at pharmacies over the counter, from amphetamines to valium to heavy duty opiates, which he would use as party drugs, or share with friends.

    On the rare occasions he was stopped and searched coming back to the UK he would explain that he had bought them at a pharmacy for a headache/diarrhea or whatever, and they would simply confiscate them and send him on his way. A quick search reveals that little has changed.

    If prn has any evidence that these lax regulations can or do lead to better outcomes, I would be interested to see it.

  22. #22 Krebiozen
    August 24, 2013

    prn,

    K, I know that there is a lot of disconnect between our experience, reading and point of view, but that sounds more like “just STFU”.

    Not at all. I’m often interested in what you have to say, as your areas of interest overlap mine, but I do get frustrated when you make an assertion such as, “Because of medicines and techniques not available in the US, it has become *possible* to do much better in a 3rd world country than even the prestige parts of the US”, without any examples or evidence to support it.

    I would have been nice if you had given an example of a treatment that is available in a developing country along with evidence it leads to better outcomes than standard of care in a “prestige part” of the US. I don’t think you can do that because I don’t think it is true.

    This is highly reminiscent of a number of claims I have seen on CAM sites that say in essence: “X is safe and highly effective, but suppressed by Big Pharma in Y, though it is used extensively in Z”. where X is a CAM treatment, Y is the country the writer is in, and Z is a part of the world a long way from Y where it is hard to check the facts. Burzynski and Budwig come to mind in this regard.

    It is hard to exactly re-source any given article that I’ve stumbled upon and read over the last several years, publications sometimes relatively obscure in the West.

    I suggest you keep better records, a lesson it took me a while to learn. I keep all comments related to medicine and skepticism I make, here and on other blogs, in a series of RTF files that I save in a folder on my PC, along with any related URLs that I didn’t necessarily include in my comment. I often add comments that I don’t post anywhere, and include links that were relevant (I intend this as raw material for a book).

    When the RTF gets a bit long and ungainly I start a new one. I’m typing this in number 28. A simple search of that folder for key words brings up whatever I have written on those subjects before. I also save PDFs in a separate folder. A PDF reader like Foxit allows you to search all PDFs in a folder, which can be very useful indeed.

    I don’t really understand the relevance of the Japanese paper you linked to, though I did find it interesting. There are a number of variations in medical practice between different countries. I was hoping for an example of a safe and effective treatment that is suppressed by the FDA (or whoever) in the US but allowed in a developing country.

  23. #23 Lawrence
    August 24, 2013

    @prn – saying some medical treatments may be better in 3rd World countries and then giving Japan as an example is not a good way to support your argument.

  24. #24 Chris Hickie
    August 24, 2013

    An absolutely horrible example (that happened here in Tucson) of a weak state medical board can be found here:

    http://en.wikipedia.org/wiki/Murder_of_Brian_Stidham

    Some of you may remember this from 9 years ago. What I don’t understand about the AZ medical board is that they gave Schwartz back his license (after a suspension) even though he had written thousands of illegal prescriptions for stimulants and narcotics (for his own use) using some of his patients’ parents to help him. He’d also even been sued for surgical malpractice (and the board was aware of that when the news of his prescription drug abuse broke). That level of legal, ethical and moral abuse of the privileges accorded a physician should have resulted in an immediate revocation of his medical license, but it did not.

    It was shameful. I wish there was mandatory jail time for physicians convicted of illegal prescribing of controlled substances (along with permanent loss of one’s medical license).

  25. #25 TBruce
    August 24, 2013

    Another tragic example from my province:

    http://www.trutv.com/library/crime/serial_killers/weird/doctors/8.html

    There was plenty of warning that the doctor in question was a bad actor. When he was a med student, his behavior was so sketchy that his classmates went to the Dean to suggest that he be kicked out. He lost his license temporarily for shacking up with a 13 year old girl whom he later married (she was 16 then). After the murder, the college underwent a review, and penalties were toughened, at least in BC and Ontario. Disciplinary actions have gone down since then (in BC, at least). I hope it’s because the penalties are working.
    Still, a couple of doctors I’m acquainted with have been struck off temporarily for unethical prescribing behavior.

  26. #26 Shay
    encore un biscuit, s'il te plait
    August 24, 2013

    And when you’ve got the local law on your side you can (almost) get away with it.

    http://www.medscape.com/viewarticle/753029

  27. #27 Alain
    mom
    August 24, 2013

    A cookie for mom’s ‘puter please.

    Alain

  28. #28 Sastra
    August 24, 2013

    To me, it is the same issue if a CAM doctor is prescribing drugs that can’t possibly help but can definitely harm or a cancer doctor in Michigan is prescribing chemotherapy drugs to patients with advanced cancer who can’t possibly be helped by them but whose quality of life in their remaining months or weeks can definitely be destroyed by them. The issue is to protect patients from the bad behavior of doctors.

    Although we know that alties generally use a double standard when it comes to regulating and condemning alternative medicine vs mainstream “allopathic” medicine, I’m curious as to how easily a condemned doctor can slide from one side to the other. Where is the boundary?

    The image of the Brave Maverick Doctor bucking the System out to get him is so popular among the alties that I can’t help but wonder if even Fata could slip from being part of the wicked Establishment to one of the persecuted … if he just slants his rhetoric ever so slightly to the ‘woo’ side. Lean on testimonials; talk about being patient-focused; invoke some sort of healing psy power; refer to having one’s own unique insights into what needs to be done. Would the villain become a hero?

    I don’t know. It does look like Fata would be particularly difficult to reframe into the BraveMaverickDoctor role, but I may be underestimatingCAM proponents.

  29. #29 Liz
    WA
    August 24, 2013

    Great. I hope this guy isn’t an investigator on any of the clinical trials my company is running.

  30. #30 LW
    August 24, 2013

    @Krebiozen: “(I intend this as raw material for a book).”

    Can one put in an advance order?

  31. #31 prn
    August 24, 2013

    Lawrence
    @prn – saying some medical treatments may be better in 3rd World countries and then giving Japan as an example is not a good way to support your argument.

    Lawrence, you’re not following the discussion closely. Japan and the West are separate sources of technology, technique and training for 3rd world MDs. Some of the Japanese advances are also available in the 3rd world, but not the US.

    My experience is that one can often eclectically combine different components for a higher performance. This makes the 3rd world an interesting option for the technically saavy.

  32. #32 Daisy
    August 24, 2013

    @22 Krebiozen

    Please include a chapter with helpful hints and suggestions like those you mentioned in #22. I’ll reserve a copy too.

  33. #33 earl
    August 24, 2013

    I wanted to send ORAC a scoop not post a public comment or join a conversation. I can’t find his email address.

  34. #34 Lawrence
    August 24, 2013

    @earl – check his other, not-so-secret blog.

  35. #35 Chris,
    August 24, 2013

    earl, click on Orac’s name under the title of this article, and all will be revealed.

  36. #36 Dangerous Bacon
    August 24, 2013

    “Some of the Japanese advances are also available in the 3rd world, but not the US. ”

    And what might those be?

  37. #37 Kathryn
    August 24, 2013

    I even have an anecdote related to quackery and Medicare.

    i was referred to a doctor for primary care, who immediately tried to diagnose me with Lyme disease because it is the One True Cause of all ailments. He wrote up a long list of tests I was to get (with Quest Diagnostics, which is a bonafide lab) and I didn’t get them, because it seemed like a waste.

    I contacted Medicare and tried to let them know a doctor on their roster was one of those Lyme quacks, and after many rounds of phone tag I talked to an investigator who understood what I was talking about. A month or two later, I received an OVERNIGHT FedEx package containing a letter saying that he had not billed Medicare yet and therefore there was nothing to investigate. Do you know how much overnight FedEx costs? Why were they wasting taxpayer dollars on FedExing me a letter they could’ve sent certified USPS for a fraction of the cost?

    Medicare doesn’t care if its patients are getting appropriate treatment, just whether or not the doctor uses the right procedure codes. They denied payment for my annual gyn exam a few years ago because “this is supposed to be a well-woman visit, and if they diagnosed you with [age/hormone thingy] this was obviously not a WELL woman visit.” Apparently i was supposed to have the annual check and a separate visit at extra cost to tell me I needed to have a blood test for [female stuff].

  38. #38 Narad
    August 25, 2013

    And we have lovely beaches, too

    Among other things. I haven’t read Cleo Odzer on Goa in the ’70s yet, but I did make vindaloo from scratch last week.

  39. #39 herr doktor bimler
    August 25, 2013

    ” Get your new knee in Goa
    Save money and try our exotic cuisine.
    And we have lovely beaches, too”

    Too many syllables in your haiku.

  40. #40 Krebiozen
    August 25, 2013

    LW and Daisy,
    Thanks for the votes of confidence – you just significantly moved this project up my priority list! Consider your advance orders booked.

  41. #41 Krebiozen
    August 25, 2013

    Narad,

    I haven’t read Cleo Odzer on Goa in the ’70s yet,.

    What we do to those poor locals with our weird alien cultures…

    but I did make vindaloo from scratch last week.

    Brave man. I have done the same, but find a ready bought paste (not a sauce) – Patak’s is excellent – almost as good and a serious time saver. Personally I prefer the similar but sweeter Persina pathia to a vindaloo.
    I think I’ve mentioned it here before, but I do highly recommend Rick Stein’s ‘India’ (for the food, not Stein himself so much). He was shown two recipes that included vinegar*, one in Kolkata and one in Goa.
    * For the uninitiated, vindaloo literally means “meat with wine and garlic” (the ‘aloo’ is not from the Hindi word for potatoes, as I used to assume) and is a legacy of the Portugese colonization of Goa.

  42. #42 Krebiozen
    August 25, 2013

    ‘Persian’, not ‘Persina’ and sorry about the botched link – typing while being dragged out of the house by my …..

  43. #43 Denice Walter
    August 25, 2013

    bimler, it’s not haiku, it’s a voiceover for a television advert.

    -btw- there’s this old, disheveled river town north of here that is slowly becoming a hipster magnet ( mimicking the more successful gallery hipsterville not as far north), last night I wound up at a “Saturday North and South Indian Buffet”:
    they usually have a dozen or more vegetarian entrees, one lamb and several chicken. There are a slew of condiments and sometimes 4 desserts ( last night, sadly only two). Coffee and chai masala included.

    Hipster posh is usually Thai now. So you have to SPECIFY when you talk about someone’s fabulous curry.

    .

  44. #44 Antaeus Feldspar
    August 25, 2013

    It almost makes one wish there was a version of Kickstarter for funding sting investigations. State medical boards are too hampered; they are almost required to come late to the party because if they show up at any other stage the lawyers say “you were clearly biased against my client!” News organizations can get the really damning evidence with hidden recordings, but they won’t do so unless they’re sure to get a really juicy story from it. What if crowdsourcing could fund the digging that needs to be done?

  45. #45 Krebiozen
    Dragging myself reluctantly away from (mmm) curry
    August 25, 2013

    Antaeus,

    What if crowdsourcing could fund the digging that needs to be done?

    Hallelujah! We, the people, don’t realize what power we would have if we would only get together and use it. We might even regain some control over those in positions of power who seem to think they can cr@p all over the rest of us with impunity. In most cases they only have an early retirement and an enormous golden handshake to fear if they get caught, unless the true extent of their malfeasance is publicly exposed*.

    Effective surveillance equipment is extremely cheap these days. A few cooperative patients with digital voice recorders recording devices (“Do you mind if I record this doctor? I get very confused”) would be enough to expose creeps like Fata.

    * Of course, if only journalism hadn’t mostly turned into a press- release-regurgitating-machine we wouldn’t have to.

  46. #46 Daisy
    August 25, 2013

    What if crowdsourcing could fund the digging that needs to be done?

    The person would need a lawyer to represent them in case they were sued by the doctor they were investigating.

    We might even regain some control over those in positions of power who seem to think they can cr@p all over the rest of us with impunity.

    Wouldn’t most people consider it vindictive and taking the law into your own hands? Then again, such a plan might work if you find a volunteer who has cr@p dripping all over them after suffering from years of quackery. There’s something to be said about people with little left to lose. They might embrace such an idea.

  47. #47 Narad
    August 25, 2013

    re, but I do highly recommend Rick Stein’s ‘India’ (for the food, not Stein himself so much). He was shown two recipes that included vinegar*, one in Kolkata and one in Goa.

    I imagine that wild fermentation of coconut water would have been discovered fairly early on in the south.

  48. #48 Krebiozen
    Digesting a chick pea pathia
    August 25, 2013

    Daisy,

    The person would need a lawyer to represent them in case they were sued by the doctor they were investigating.

    That’s where crowdsourcing comes into its own, whether it’s finding an ethical lawyer who would do the work pro bono – the publicity mighy make it worth their while – or large numbers of people putting a small amount of money into a legal fund.

    Wouldn’t most people consider it vindictive and taking the law into your own hands?

    Would they? If a doctor is acting in a way that is putting patients’ well-being at risk, and the authorities are unwilling or unable to deal with it, it doesn’t seem vindictive to me at all. I don’t think gathering evidence and presenting it either to a medical board or a DA is vigilantism either. I think these fears are played on by those in positions of power to keep the rest of us in our place.

  49. #49 Lawrence
    August 25, 2013

    @Krebiozen – it would be worth an email over to Popehat, I believe….

  50. #50 Daisy
    August 25, 2013

    @48 Krebiozen, I’m glad you feel that way. I’m in complete agreement. Although, I know nothing about crowdsourcing, it would seem a faster course of action that might perhaps speed up a possible ten year long medical board investigation.

  51. #51 flip
    August 26, 2013

    But state and federal records still paint a grim picture of a physician oversight system that often is slow to act, quick to excuse problems, and struggling to manage workloads in an era of tight state budgets.

    It’s almost as if governments, and the people who elect them, put health policies and issues below other concerns.

    I also wonder if policing, reporting or consequences of bad behaviour has to do with how the public views things. If the public wants CAM, and if it is ‘supported’ by government oversight or study, and if it is ‘integrated’ into practices and taught at colleges… then does this convey to those who police doctors that it’s not bad behaviour to be looked into?

    But also I think part of it is that we forget how hard it must be to find evidence of wrongdoing. I’d be willing to bet that catching a bad doctor is much like catching a white collar criminal, as compared to someone stealing a TV. Much harder to find evidence when the person is more likely able/aware of ways to cover up the crime.

    The issue is to protect patients from the bad behavior of SOME doctors.

    FTFY.

    … Oh my, this reminds me. Chiropracter opened up a few blocks away from me recently. Walked past the door last week and saw the sign saying “suffering from headaches, sleeplessness, diabetes, etc” – the usual round-up of random symptoms that they think they can cure. Sigh… I was highly tempted to go in and start heckling them to see what they say about vaccines so I could then report them. – Actually, maybe I can take a photo of the door and send it to my local skeptics’ group and get some action that way.

    @Krebiozen

    Your book sounds like it would be very interesting. I’d love to read it.

    @Antaeus

    What if crowdsourcing could fund the digging that needs to be done?

    I’d say that the screams of Big Pharma shills would get louder.

    Wouldn’t it be far better to try to raise interest in better funding for government agencies or tighter regulations? Or raising funds to help pay for lawyers’ costs for those who were hurt but can’t afford to sue?

  52. #52 Antaeus Feldspar
    August 26, 2013
    What if crowdsourcing could fund the digging that needs to be done?

    I’d say that the screams of Big Pharma shills would get louder.

    Wouldn’t it be far better to try to raise interest in better funding for government agencies or tighter regulations? Or raising funds to help pay for lawyers’ costs for those who were hurt but can’t afford to sue?

    I wasn’t proposing it as a perfect ready-to-go solution; I was more just trying to think outside the box, to think how we could get around what seems a major stumbling block: namely, that the professional boards which CAN come down with the power of the state behind them have to move very slowly, lest they be accused* of abusing the power of the state. And the problem is, it IS a valid concern. Suppose Rolando Arafiles had managed to get to the state medical board first and accuse the two nurses who reported him of misdeeds of their own; then among all the other harassment they endured for doing the right thing by reporting him, they’d also be fighting a wrong-headed state investigation.

    * I’m more concerned about defense lawyers using it as a strategy; less so about people just tossing accusations, since they’ll do that no matter WHAT the facts are.

    The thing that gets me with a lot of these investigations – not just Fata, but stuff like Madoff – is that whenever it FINALLY gets into the headlines, the collected evidence is so egregious that everyone’s shaking their heads and saying “WHY in Hell didn’t the regulators move on this before??” At that point, of course, the regulators DO move, because everyone can see that they should, that this is them moving against a really bad actor.

    I’m just wondering if we the people have a way of accelerating that process, of moving things faster to that point where everyone can see that the bad actor needs to be reined in and the regulators don’t have to hesitate about stepping in.

  53. #53 Anj
    Off topic!
    August 26, 2013

    http://www.forbes.com/sites/emilywillingham/2013/08/24/measles-outbreak-traces-to-vaccine-refusing-megachurch/

    This story has been making the rounds, but this particular article features an author (Emily Willingham) who is active replying to comments. It’s refreshing. Stop by and show her some love and support.

  54. #54 Orac
    August 26, 2013

    And this has nothing to do with this post. Not even close.

  55. #55 Daisy
    August 26, 2013

    #52 I’m just wondering if we the people have a way of accelerating that process, of moving things faster to that point where everyone can see that the bad actor needs to be reined in and the regulators don’t have to hesitate about stepping in.

    Are we talking about quackery or doctors like Dr. Fata who are accused of being negligent and greedy?

    In regards to quackery, and IANAD, I wish I’d kept a tally of how many doctors I’ve heard say something similar to “I know their treatments aren’t evidence or science-based, but I don’t think they’re doing any harm”. Peoples views need to change. It will take more than enlightening the regulators and exposing them for failing to do their job. Society, patients and doctors need to understand what IS the harm, and more specifically WHY it so harmful. If one doesn’t know they’re being harmed, conned or otherwise taken advantage of, they will likely not object to it. In fact, they might welcome it quite like a fool.

    Many doctors appear either afraid or unwilling to even inform their own patients that they are being taken advantage of by another practitioner, SCAM or otherwise. Perhaps they are afraid that their patient will repeat what was said and it will cause the doctor problems in the future. In any case, those attitudes must change and patients must be warned and educated.

    What about the doctors reading this blog, what would you tell one of your patients who comes to you and says how much an energy realignment with a chiropractor or L.Ac. helped them? Would you label them the fool and dismiss all of their medical complaints as being purely psychological due to this strong placebo effect? Patients are seeking care and grasping for it wherever they can get it. If that chiropractor or L.Ac. appears to be giving them the non-dismissive medical attention that they feel they need, then that will help drive the patients towards those SCAM practices. Much change needs to take place on many levels. I do agree whole-heartedly that exposing some of the more egregious medical con artists would be a good start.

    Another excellent starting point being addressed on Science-based Medicine is that SCAM providers should not be licensed. Licensing them gives the appearance of being a legitimate provider selling legitimate services. Establishing laws to license them and allow them to practice, while trying to expose them for quackery or dangerous practices might lead to a never-ending battle. The approach to fight against true quackery would in many ways need to be different as compared to fighting against negligent and greedy doctors.

  56. #56 flip
    August 27, 2013

    @Antaeus

    I think the issue is multi-pronged and it should actually be attacked from a number of fronts. So yeah, I can see your point and how it could be useful to have more funds available via different avenues.

    The thing that gets me with a lot of these investigations – not just Fata, but stuff like Madoff – is that whenever it FINALLY gets into the headlines, the collected evidence is so egregious that everyone’s shaking their heads and saying “WHY in Hell didn’t the regulators move on this before??” At that point, of course, the regulators DO move, because everyone can see that they should, that this is them moving against a really bad actor.

    I guess it could partly be down to investigations: look at Deer. He got most of the info and documents through a long, hard process. (Obviously it takes time to hunt down info, corroborate it, etc) But he also had the free reign to do it and the focus was not spent on attempting to make it as speedy as possible or as fair as possible for all parties. Also, he can say “I’m a journalist, I have no opinion on this, I will report accurately”, whereas the regulators are tarred much like the police, whom people are less inclined to talk to.

    I’m just wondering if we the people have a way of accelerating that process, of moving things faster to that point where everyone can see that the bad actor needs to be reined in and the regulators don’t have to hesitate about stepping in.

    I think actually this comes down to more education. A person may not realise there’s something wrong with a treatment or doctor; a person may know but shut up due to fear/lack of time/lack of interest and of course, thinking they were the only one to be affected; a person may know but not know what to do about it; etc.

    Like Daisy points out, part of the problem is something I mentioned earlier. There are people who simply let it go, because they don’t know enough or are convinced from a glancing overview of a subject.

    The other thing is: a lot of us have friends or family members that are into woo and a lot of us steer clear of discussing it for fear of upsetting them. I don’t know what the answer to that is except to try and nudge them in the right direction.

    Going back to the bit about being multi-pronged, I can see that improvements could be made by fighting for better funding for regulators, as well as funds for those willing to fight back in lawsuits, *and* more and more and more of us need to get information out about these people.

    The reason why people go “why didn’t regulators move on this before?” is because by this point enough people have created a tipping point. One person starts the ball rolling, a victim comes out of the woodwork, a lawsuit gets settled. The more publicity all of this gets, the more other victims turn up and the information gets disseminated.

  57. #57 prn
    Baco bits, Denice and K
    August 28, 2013

    Dangerous Bacon@36: Some Japanese drugs not approved by the US FDA include DPD inhibited tegafurs, polysaccharide Krestin, and serrapeptase.
    —————–
    Denice@19: is that better FINANCIAL outcomes? by shopping around as a medical tourist for cut rate surgery?

    Yes, cost savings too can be quite substantial, most of all for chemistry substitution costs – I don’t see typical US billings of $30,000-40,000-$50,000 per month. Rather they are seriously under $1000. More importantly, “experiment” duration past 99% die off for 5FU-LV based tx for multisite mets with bad markers and lack of common, multiple Grade 1-2-3-4 side effects for modern US “standard” or “approved tx” are nice bonuses.
    NB – advanced tx as a *package* is not commercially available, just some of the components. It is common for well off, less educated patients to pay $25,000-30,000 per month for the current Western pharma care. More, if they insist on brand names, like UCSF, Stanford etc. We’ve been to a number of memorials, after they paid, and paid, and suffered a lot.

    ” Get your new knee in Goa Save money and try our exotic cuisine…lovely beaches, too”

    Delays to get multiple diagnostics and opinions can be much shorter than what I typically see from US pts. e.g. If I want to arrange additional scans, perhaps 16-42 hrs for less than your US copay with a capricious, long dallying insurer, and perhaps a waiting list at the US scan center. Vs often same day for some consults. Oh, not only are the facilities newer, cleaner and less crowded, the staff is not so hard of hearing and nice suites are less than many US co-pays for crummy, shared rooms.

    Slight downside: *average* education and skill/experience levels may not be as high but sure beats doing without, due to cost, external utilization controls, or time critical delays. One can still consult globally, with the US, too.
    —————-
    K, I am going to let it ride.

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