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A Deadly Farce: The Medical Board of California

MEDICAL NIGHTMARES IN CALIFORNIA-How many who are reading this know that California has a Medical Board whose sole purpose is to regulate doctors in order to keep patients safe? Did you know that you can report a complaint about a doctor to the Medical Board? 

Our organization comes across people all the time who had no idea they could file a complaint against a doctor. Far too many people, unfortunately, put doctors on pedestals and think they can do no wrong, and even more believe that medical errors will never happen to them or a loved one. Think again, it’s happened to both of us, three times for Eric Andrist. More on that later. 

Now, how many believe that if you did​ report a bad doctor to the Medical Board, they would effectively handle the complaint, and protect consumers from further harm? It is estimated that over 40,000 patients die in California alone every year, from preventable medical errors, making it the third leading cause of death behind cancer and heart disease. We’re not talking about accidents; we’re talking about errors that absolutely could have been avoided. 

Here’s another stat for you: The Medical Board of California takes in nearly 11,000 complaints every year, but only about 4%* of them end up with any discipline. (*From the 2017-2018 Annual Report of the Medical Board of California.  If you add up the “Administrative Outcomes” in the far-right column, it comes to 406, which is about 3.7% of the 10,888 complaints they took in.) 

So, what’s going on with the other 96%? That’s what we’d like to know, too, but the Board is protected by laws that allow them to hide their actions from the public. The Board will post disciplines against doctors--but not complaints. Every four years, through the Sunset Review, the legislature pretends to care about making the Board better and fixing any problems, but there is little real accountability going on. We sent the legislature a 200+ page report detailing problems with the Medical Board, and not one legislator contacted us and thanked us or bothered to ask any questions; they just extended the Board for another four years despite what we told them. 

IF THE MEDICAL BOARD MOVED ANY SLOWER, THEY’D GO IN REVERSE 

What is even more surprising is that the Medical Board takes on average, two and a half to three years to complete a full investigation of a doctor and levy a discipline. We’ve even unearthed investigations that took between four and six years. 20-year-old Alex Smick of Downey was overdosed to death after he checked himself into a hospital after taking too many pain meds for a sports injury. Dr. Daniel Headrick gave him a lethal cocktail of medications and then instructed the staff to NOT check on him while he was sleeping. The next morning, he was found face down in his bed in a pile of vomit, dead. It had been so long since anyone had checked on him that he was already in rigor mortis. 

Alex died on February 23, 2012. His family filed a Medical Board complaint against Dr. Headrick on November 6, 2013. The Board couldn’t be bothered interviewing the doctor until October of 2015--almost two full years after the complaint was filed. It took another eight months for it to be referred to the Attorney General’s office and then another four months until an Accusation was filed against the doctor. 

Right before Christmas of 2017, five and half years after Alex’s death, the family received the Medical Board’s decision in the death of their son. Dr. Daniel Headrick was given a “Public Reprimand,” a disciplinary action that is only intended for the most minor of violations, certainly not a death. In total, it took four years and 16 days (or 1477 days) for the Medical Board to process the Smick’s complaint. 

Dr. Headrick later went on a public television show, bragging about his lenient discipline from the Board and putting the blame on everyone but himself. Some of the complaints that are under review at this moment are from 2013; the Medical Board does not move quickly to resolve complaints even when they involve the death of a patient. 

A 96% DISCIPLINARY FAIL RATE 

Ponder this: The Medical Board derives the bulk of its working capital from the license fees of the very doctors that they also must discipline. How is that not an automatic conflict of interest? If they revoke too many licenses, they’d lose those license fees. The Board complains all the time about not having enough money to pay staff and investigators (even with a budget over $60 million) and that’s with closing 96% of the consumer complaints. If even 50% of those closed complaints are legitimate, how could they possibly investigate them, when they apparently don’t even have enough money to investigate the 4% they do end up disciplining? 

On January 22, 1993, the Los Angeles Times published an article detailing how rank and file employees of the Medical Board blew the whistle on their superiors who had been literally throwing consumer complaints in the trash in order to clear their desks of them. “Among the investigation's findings, was the disclosure that hundreds of Medical Board cases had been improperly dismissed--and in many instances destroyed--in an apparent attempt to reduce a backlog that had prompted criticism from the Legislature. 

[Whistleblowers] said a three-person management team marched into several key offices in 1990 and began going through files. They said certain files were tagged, indicating that they should be closed and, in some cases, destroyed. Those that were targeted, they said, seemed to be the cases involving doctors free from previous complaints or patients who had not followed up to see if the board had pursued their complaints. "You would see a stack of files two feet high on a supervisor's desk one day and by the next hardly any would be left," recalled one investigator. (Los Angeles Times, January 22, 1993.) 

It’s hard to not wonder whether this is still happening today. Annette Ramirez of South Bay was harmed by Dr. James Scharffenberger who sliced her bowel after a routine surgery. For more than 36 hours, nurses failed to report her abnormal vital signs and her doctor failed to adequately follow up to check her condition after surgery. An infection rapidly spread through her system causing her to go into septic shock. Gangrene spread to her arms and legs, which led to the amputation of her arms and legs, as well as the excision of flesh from multiple areas of her body. 

Annette (photo left) filed a complaint with the Medical Board only to have them close it down within months without any discipline for the doctor that left her in this condition. And lest you think Annette’s story is an exception, we have gathered a number of egregious stories of patients being harmed and the Medical Board closing their complaints, including two others with patients who had their arms and legs amputated: Robert Downey, Mario Guzman, Daniela Zelig, Morgan Westhoff, Cali Andrist, Eric Andrist. 

DEALS, DEALS AND MORE DEALS! 

In April of 2016, the son of TV Judge Glenda Hatchett, Charles Johnson and his wife Kyira, checked into Cedars Sinai to have a baby by repeat elective cesarean delivery in the early afternoon. The procedure was performed by Dr. Arjang Naim. Not long after their son Langston was born, blood-tinged urine was seen in Kyira’s catheter. Six hours later, Dr. Naim was notified about a concern for internal bleeding. A massive transfusion was initiated, and she was taken to the operating room shortly before midnight. During that surgery, Kyira was found to have three liters (or about ⅘ of a gallon) of blood in her abdomen. Kyira’s heart stopped on the operating table at 1:15 a.m.; she was declared dead at 2:20 a.m., not being able to survive the massive blood loss. 

Charles Johnson filed a complaint with the Medical Board and in October of 2018, the Board gave Dr. Naim just four years of probation, an amount less than their own minimum guidelines recommend. At our request, Charles flew to San Diego for the Medical Board’s quarterly meeting shortly after the decision was announced and confronted them about it. 

PERVERTED DOCTORS IN THE NEWS 

We’ve been working with several news outlets on reports about local area doctors. This past November, 10News in San Diego ran a story on more than 150 area doctors who were disciplined for sexual abuse and other serious violations. In December, NBC-LA chronicled the story of Sarah Al-Habib and how she had been sexually assaulted by her doctor, Dr. Zaher Azzawi of Rancho Cucamonga. In February, NBC told the story of three LA-area doctors, all of whom are on the Sex Offender Registry, but are still practicing medicine, and how the Medical Board of California makes no effort whatsoever to warn patients about them. 

Here’s a list of 32 doctors in the state of California who appear on the Sex Offender Registry (most of them are no longer practicing.)  

Recently, we discovered the case of a Dr. Robert Stephens, an anesthesiologist in San Diego. Several nurses reported witnessing him sexually assaulting several unconscious patients. The case was reported to the California Department of Public Health who in turn should have reported it to the Medical Board of California. We have been unable to find any evidence that they did. The Medical Board verified that he is under investigation, but they refuse to warn the people of this state about him, insisting that the law does not require them to. Oddly, though, their sister agency, the Contractors State License Board does warn consumers when one of their contractors has had a complaint filed against them. Apparently, our legislators think consumers should know about a bad bathroom contractor, but not about a doctor that could sexually assault them the next time they’re in the hospital, unconscious.

To show how bad the laws are that govern the Medical Board, look at the case of Dr. Ryszard Chetkowski, (photo left) who runs a fertility clinic in Berkeley. Chetkowski was accused by at least six women of sexual misconduct. Even after the Medical Board detailed the horrific sexual assaults in seven causes for discipline in an accusation, the Board still only gave him a Public Reprimand. By law, Public Reprimand’s disappear from the Board’s website after 10 years, unlike other documents which remain visible indefinitely. So, if you look up Chetkowski on the GH now, he has a completely clean record; there’s not one mention of the sexual assaults anywhere. It begs the question, were favors done for this doctor so that he was purposely given a discipline that would eventually disappear, even with the severity of the charges? Is no act heinous enough that it can’t be bartered away? 

 By not acting quickly enough (or at all), the Medical Board puts consumers in danger. A great example of this is the case of Dr. Michael Popkin of Granada Hills. According to reports, the Medical Board knew about sexual assault complaints against Popkin as far back as 2001. An accusation was filed against him in November of 2003 but contained no charges of sexual misconduct. (See LAPD mugshot, left) It became clear that he had continued to sexually assault patients when he was arrested in 2016. The court issued a court order preventing him from treating female patients in October of 2017 and the Medical Board finally revoked his license in April of 2018, some SEVENTEEN YEARS after first receiving sexual assault complaints about him. Because of the Board’s inaction, more people were harmed. 

ABSOLUTE POWER CORRUPTS ABSOLUTELY 

When we first started doing our in-depth investigation of the Medical Board, one of the first cases we investigated was that of Dr. Hari Reddy, a doctor who had his license revoked over the sexual assault of four patients, one of whom was a 15-year-old girl. He tried once to petition the Board to get his license back and they denied the request. He applied one more time in 2010. This was shortly before Governor Jerry Brown appointed Reddy’s friend, classmate and co-worker, Dr. Dev GnanaDev to the Medical Board. Long story short (and you can read more about it HERE), on GnanaDev’s very first disciplinary panel case, they voted to give Reddy his license back. Not long after this occurred, Reddy’s brother-in-law, another Reddy by the name of Prem Reddy (CEO of the always-in-trouble Prime Healthcare), donated over $40 million to GnanaDev’s new medical school in the Inland Empire, and now serves as the school’s chairman of the board. 

Recently, the Medical Board and the Attorney General’s Office had to fess up to one of their own medical “experts” (Dr. Aaron Stone) behaving in such a way that the accusation against Beverly Hills plastic surgeon, Dr. Kenneth Hughes, had to be dismissed. Hughes’ attorney basically called the expert a liar and corrupt. So, while the accusation very well could have had legitimate concerns in it, the Board was forced to dismiss the action and now, Hughes’ profile on their website provides no information whatsoever to the public in regard to anything a patient might need to be concerned about. You can watch key portions of the hearing exposing the “corrupt expert” HERE.

Hughes has at least two pending court cases in the Los Angeles Superior Court, but you won’t find that information on the Medical Board’s website, either. In 2014, Eric Andrist, the co-author of this article, was diagnosed with four hernias. He went to see a surgeon, (Dr. Kulmeet Sandhu) in 2015 and laparoscopic surgery was performed that fall. A few months later, all his symptoms returned, and he went back to her in 2016. She ran more tests and blamed the reoccurrence on his “bad genes.” He went back in for a re-do surgery in the fall of 2016. 

A few months later, all his symptoms returned once again, and he again went back to see the surgeon. She ran more tests and found that the hernia was even worse than when he had started out. She was prepared to take him in for a third surgery, but now, not trusting that she knew what she was doing, he went to get a second opinion. The new surgeon ran a battery of tests and told him he was in terrible condition and they needed to do surgery right away, which took place in the fall of 2017. During the surgery, the new surgeon found that Dr. Sandhu had sewn his stomach to itself (in a procedure called a Full Nissen Fundoplication), instead of to the esophagus, rendering it useless. 

To top it all off, the hospital sent him home after the surgery without checking the surgery site. When he got home, he discovered that his eight-inch incision had popped open and he could see into his abdomen. He filed complaints with both the Medical Board (on Sandhu) and the Department of Public Health (on Glendale Adventist Hospital). Both complaints were closed without investigation. There appears to be a price to pay when someone tries to hold the government accountable. 

We started our little nonprofit, The Patient Safety League, so that we can officially try to help victims of medical errors, warn the public about doctors with all degrees of disciplinary actions, and monitor state agencies like the Medical Board of California and the Department of Public Health, both of which are not properly protecting us. We started our website due to the lack of information on the Medical Board’s website. Consumers can check our website HERE.  

Right now, we’re existing hand-to-mouth, and it often costs us a lot of money from our own pockets to do our job. Ironically, a doctor recently reached out and helped us come up with the money we needed to get us to the upcoming Medical Board meeting in northern California next month. Tax-deductible donations can be made to the Patient Safety League on its website.

 

(Eric Andrist and Marian Hollingsworth are Co-Executive Directors of The Patient Safety League.) Edited for CityWatch by Linda Abrams.