Every physician has heard the horror stories.
Stories about doctors who sexually harass patients, bungle surgeries, or ignore complications in patients who then die. And what's more, they can get away with it by taking advantage of lags and gaps in the medical licensing system. By hopping state lines, or having a fistful of licenses issued by different states, they can continue to practice wherever the grass is greenest.
Now, a 番茄社区/Milwaukee Journal-Sentinel investigation reveals the scope of the problem: between 2011 and 2016, at least 500 physicians were chastised by one state medical board and yet able to hang their shingles at a new address with a "clean" license.
They slipped through the cracks even though their actions resulted in suspensions, revocation, remedial classes or a portfolio of "letters of concern" that castigate them for misconduct.
The Players
In Colorado, care of a multiple sclerosis patient by Gary Weiss, MD, prompted four medical school physicians to file a complaint with that state's medical board after the woman died.
The Colorado Board and Weiss agreed that he was "permanently inactivating" his license in 2014.
That did not stop him from practicing in Florida, where he has long held a license.
Despite malpractice lawsuits from at least seven patients all accusing him of misdiagnosing multiple sclerosis, it took Florida more than three years to publicly discuss his case.
In New York, breast reconstruction surgeon John Siebert, MD, had sex with a patient, got his license suspended for three years, and was permanently ordered to have a chaperone in the room whenever he was with a female patient. But he wasn't sanctioned by the medical board in Wisconsin, where he also has a license. Instead, he was named to an endowed chair at the University of Wisconsin-Madison.
That chair is funded by a billionaire patient who also is a major supporter and campaign contributor of the governor -- who appoints the medical board.
Check Jay Riseman, MD, on the website of the Division of Professional Registration in Missouri, and there are no red flags, no disciplinary history.
But in Illinois, where a medical board official once called Riseman an "imminent danger to the public," the families of his three dead patients remain haunted by what he did. They say they are outraged that he continues to practice medicine.
Slip, Slipping Away
The pattern that emerges is both disturbing and damning: physicians who are "caught" in one state slip through the bureaucratic net in another, where they are free to practice without any disclosure.
Yet the 500 identified in the yearlong investigation by 番茄社区 and the Milwaukee Journal Sentinel most likely underestimates the scope of the problem. It focuses only on those cases where at least one agency took some sort of public action.
Most medical issues -- including those due to negligence -- are never noticed, much less reported or acted on, said Julia Hallisy, founder of the Empowered Patient Coalition, a California-based patient advocacy group.
"The numbers you're showing are not anywhere near the real numbers," she said. "If something goes wrong in a surgery, or you get an infection, or your 80-year-old mother is given the wrong medicine, you may never know that came from this doctor, their impairment, their lack of skill.
"People who want to make the case that we have bigger fish to fry: this is bigger than we know."
A 30-year-old federal database, the was designed to keep state medical boards and hospitals apprised of physician transgressions around the country. But it's confidential and its data are often ignored or overlooked by state medical boards.
Moreover, 番茄社区/Journal Sentinel found that board officials were not always forthcoming about the reasoning behind their lack of action.
Officials in New York, for example, said Siebert showed a "moral unfitness to practice," while Wisconsin officials said the case against him was "a minor or technical violation."
Despite more than a dozen malpractice lawsuits against Riseman, officials in Kansas eventually relented and allowed him to perform surgeries -- though they made him promise not to actually do any.
Asked to explain the decision, Kathleen Lippert, executive director of the Kansas State Board of Healing Art, wrote in an email: "There is little or nothing to add ... "
To examine the issue, 番茄社区 and the Journal Sentinel enlisted the help of TruthMD's MedFax data service that compiles physician dossiers drawn from thousands of sources -- including civil and criminal courts, state medical boards and the FDA. MedFax includes data going back 15 years and about one million physicians.
The company provided an initial summary of cases of physicians who were in trouble in one state since 2011, but held clean licenses elsewhere. It also supplied dossiers on a small group of physicians who fit that profile.
From there, reporters verified the cases, investigating individual examples and obtaining thousands of pages of documents from criminal and civil courts around the country, state medical boards, the FDA, and other sources.
Physicians who held licenses in multiple states when they landed in hot water accounted for the vast majority of the cases. But in about 20%, they sought new licenses after trouble started. Then, in their new state, they faced no sanctions.
"It's a highly flawed system," said Robert Wachter, MD, chairman of medicine at the University of California San Francisco. "It has created a patchwork of accountability. It takes something pretty bad to get in trouble with your state licensing board."
Colorado to Florida
In 2014, neurologist Weiss agreed to an order that permanently barred him ever again seeking licensure in Colorado.
In 2015, Illinois reached an agreement with Weiss requiring that he permanently relinquish his license there, which had lapsed in 2002. The agreement was based on the Colorado action.
But it took until earlier this month for the Florida Board of Medicine to take public action.
The Colorado order stemmed from an accusation of failing to diagnose progressive multifocal leukoencephalopathy (PML) in a 63-year-old woman. Weiss had prescribed her natalizumab (Tysabri), an MS drug that is also known to increase risk of PML.
Over the months PML went undetected, Weiss continued the woman on the drug and her condition deteriorated, according to a complaint filed with the state's medical board by four neurologists from the University of Colorado School of Medicine.
The physicians wrote that the woman became forgetful and had trouble speaking. She soon had to use a wheelchair and eventually went to a nursing home.
"If the PML had been diagnosed in a timely fashion and treatment instituted, [her] prognosis would have been improved and [she] would have avoided much suffering," the physicians wrote in their October 2011 letter to the medical board.
It accused Weiss of acting "far below the standard of care for neurologists," a charge Weiss denied then and continues to deny.
A letter sent to the Colorado board from a physician who reviewed the case supported Weiss' argument. That physician, Ray Lopez of Miami, said the accusations "may well stem from the conflict of cultures between the purely academic and the private practitioner" and that Weiss had offered "an appropriate standard of care."
While that case led to the action in Colorado, it wasn't the end of the accusations.
Brenda Culhane is one of five people in Colorado who sued Weiss, claiming he misdiagnosed them as having multiple sclerosis and put them on potentially dangerous drugs.
Last summer, two Florida patients filed lawsuits with similar allegations.
One of the Colorado suits was dismissed this month. The others are pending, and no court has made any determination as to Weiss' fault or liability in those matters.
Culhane went to Weiss at his Vail office in 2007 because she began experiencing weakness in her upper extremities, according to her lawsuit, filed in August 2016.
Weiss put her on natalizumab. She was given more than 100 infusions through 2014, when another physician, Enrique Alvarez of the University of Colorado, determined Culhane did not have MS.
Culhane said the faulty diagnosis caused depression and anxiety.
"There is no cure for MS, so I was living with the knowledge that eventually I would be completely incapacitated," she said. "That was a very difficult thing to live with all those years."
In a sworn statement, Andrew Solomon, a neurologist and multiple sclerosis specialist at the University of Vermont who reviewed Culhane's medical records, said Culhane does not and never did have MS.
Solomon said he also reviewed the records of 10 other Colorado patients Weiss had diagnosed with MS.
"To a patient, while Dr. Weiss diagnosed them with MS, while they were put on MS medications with considerable risk for morbidity and even death, and while they received MS treatment for prolonged periods of time, it is my opinion that none of these individuals ever actually had MS," he said.
Concerns also were raised about Weiss in an affidavit sworn by John Corboy, MD, a University of Colorado MS specialist and one of the four University of Colorado neurologists who filed the complaint with the Colorado medical board.
"Based on my review of medical records, as well as numerous conversations with other neurologists throughout Colorado, Dr. Weiss has misdiagnosed many, many people with MS," Corboy said in a December 2017 affidavit.
Patient records also revealed that Weiss ordered "excessive amounts of MRIs, which were taken at the facility he owned and that he was prescribing unnecessary medications, both for financial gain," Corboy said.
In an email provided through a spokesman, Weiss said he and Corboy have a "long history. It is safe to say that he does not like me. For him to say I ever ordered a single MRI or treatment for financial gain is outrageous and flatly wrong."
He also questioned whether Culhane changed her mind about the care she got from him after talking to a lawyer or being contacted by the physician to whom Weiss sold his Colorado medical practice. That physician sued Weiss over the sale but later dropped the case.
Weiss said the physician told some of his former patients that they had been misdiagnosed.
Weiss said that making an MS diagnosis is a difficult, subjective process and that early treatment of suspected cases is important to prevent symptoms years later.
"The fact that a patient is doing well today may mean that the treatment worked or it may mean that he or she was one of the fortunate 30% who looked like they have MS, but don't," he said. "No one knows. In any case, if a patient is healthy, I'm happy."
At Weiss' Florida hearing earlier this month, his three year-old Colorado order was a point of discussion.
One Florida board member said the Colorado discipline "seems unusually harsh. Is there something that's going on?"
Another board member raised a concern about a physician barred from practicing in one state being allowed to practice in Florida: "Are we okay having someone having a license in Florida that cannot hold a license in another state, where they were banned from practicing medicine and they cannot hold a license there?"
Another board member said there was plenty of evidence that Weiss was not a danger to the public in Florida.
Another board member asked Weiss is he had any other malpractice cases.
Weiss acknowledged a case in Florida that he had settled.
Then, he added, "But I had no malpractice cases."
Brad Dalton, a spokesman for Florida's medical board, said information about Weiss' malpractice cases was not included in materials reviewed by board members, "as that was not part of the complaint against Dr. Weiss in this particular case."
Through a spokesman, Weiss said his response about "no malpractice cases" was in reference to adjudicated or settled lawsuits.
The Florida board issued a "letter of concern," a $5,000 fine, and a requirement that Weiss take continuing medical education courses. The agreement does not limit his ability to practice.
In his statement, Weiss said he only agreed to give up his Colorado license because he had developed his own health issues that made it impossible for him to live in a high-altitude setting such as Vail.
That led him to sell his Colorado business and focus on Florida, where he also lived and had been practicing for years, he said.
"Even in the unlikely event that I did not prevail in a hearing on the Colorado complaint, it was not the kind of issue that would have led to significant discipline or loss of my license," he said.
Weiss said the five Colorado malpractice lawsuits are "opportunistic" and "totally unfounded" and the Florida lawsuits are "copycats with no more hope of prevailing than those in Colorado."
" ... I refuse to settle any of the cases for even a penny," he said.
Weiss said the Florida agreement "is a very low-level 'letter of concern' triggered by my giving up my Colorado license."
The Colorado board said that if the allegations were proven at a hearing, it would amount to a "prima facie case of unprofessional conduct." Illinois said the allegations, if proven, would constitute grounds for suspending or revoking Weiss's license.
Boards, Boards, Boards
番茄社区/Journal Sentinel surveyed 62 licensing boards in separate U.S. jurisdictions. In some cases, there are two boards in a state -- one for allopathic physicians and another for doctors of osteopathy. Of those surveyed, 56 are appointed at least in part by governors, adding an element of politics to the process.
Each of those boards can have wildly different rules. A found annual rates of discipline ranged from 1.7 per 1,000 physicians in Washington, D.C., to 10.3 per 1,000 in Delaware, looking at numbers averaged over 5 years at the start of the decade.
Similarly, there is significant variation in both quantity and quality of information each board publishes.
Consider Julie Sullivan, MD, of Oceanside, Calif. That state's licensing website shows a clean record. No hospital disciplinary actions. No action taken by other states. No court orders or anything else that might raise eyebrows.
It does not mention the problems listed on the Texas Medical Board's website, stemming from her care of a patient who complained of headaches and photophobia. Despite the patient's prior similar symptoms and history of aneurysms, Sullivan did not perform a fundoscopic exam, and discharged him with a diagnosis of a severe headache.
Less than six hours later, the patient went to an emergency room where a CT exam showed a ventricle colloid cyst in the man's brain. He then suffered a fatal cardiac arrest on the way to another hospital.
Texas ordered Sullivan to take CME courses on various topics, including headache treatment. It also told her to provide a copy of the order to all institutions where she had or was applying for privileges.
Of course, that applied only within the state of Texas. California records show nothing about it.
The California site also doesn't mention that a health insurance company had trouble getting information from Sullivan about the encounter, for which it issued her a corrective action plan.
A spokesman for the Medical Board of California, Carlos Villatoro, said the site does not include Sullivan's Texas record because it preceded her licensure in that state.
Texas disciplined her on June 12, 2015. Her California license was issued on Sept. 16, 2015.
"As such, it does not meet the criteria for posting on the website," Villatoro wrote in an email.
All the Pieces
There are many sources that can provide a picture of a physician's history, including discipline by their state medical board, discipline by other states, malpractice claims and payouts, loss of hospital privileges, criminal convictions, Medicaid/Medicare exclusions and fraud charges, and actions by the Drug Enforcement Agency and the FDA.
But no state consistently reports all these pieces of the puzzle on their website. According to a 番茄社区/Journal Sentinel analysis, only five states report six of these seven categories -- Florida, Kansas, Maryland, Massachusetts, and North Carolina. Five other states regularly reported five categories: California, Georgia, Indiana, New York, and Tennessee.
The majority report only their own disciplinary actions.
"Should all state medical boards list all of these elements? Absolutely," said Sidney Wolfe, MD, of the watchdog group Public Citizen. "A background check on a doctor you have or one you're thinking of going to may have more of an effect on your health than anything else."
Even when medical boards do make this information publicly available, they frequently rely on physicians' self-reported information.
States could check up on those reports by querying the National Practitioner Data Bank, but few do, said Robert Oshel, PhD, the former director of research at the database.
A survey Oshel conducted found that 9% of the time, organizations learned something new about the physician they were looking up.
"They should never find anything new in an NPDB report," Oshel said, "because the applicant should have told them."
Insurance companies have their own protections against physicians with troubling histories. All physicians are credentialed when first added to a network, said Armando Deltoro, vice president of private market innovations for America's Health Insurance Plans, an industry group. Most plans re-credential their members again every three years, sooner if they become aware of a problem with a physician's record.
He said he could not provide the number of physicians who had been excluded after screenings.
Hiring physicians can be a "buyer beware" situation for hospitals, said William Golden, medical services director for the Arkansas Department of Medical Services.
"Medical boards tend to believe in the power of redemption and letting people make a living. They [physicians] still have to find someplace willing to hire them."
The Dusty Database
Congress created the National Practitioner Data Bank in 1986, saying it would improve healthcare quality and reduce fraud and abuse.
The database was designed as a central tool for recording malpractice payments, state disciplinary actions, restrictions from health plans or hospitals and other limits on any healthcare professional -- physicians, nurses, dentists, physical therapists and others.
"The intent was to help make sure that physicians were not able to go from state to state without any past history of activity being known," said David Loewenstein, director of the Division of Practitioner Data Bank.
It now has more than 1.3 million records of "adverse actions" going back to 1990. In 2016, the data bank logged 7.5 million searches from hospitals, insurers and state boards.
The same legislation that created the tool shrouded it in secrecy. Public versions of the database don't include physicians' names or other identifying information.
That makes it impossible to determine what happened in cases where reporters asked officials why physicians with license problems in other states were allowed to practice in their state unfettered.
In each case, officials said it was the first time they heard of the issue.
Oshel, who formerly oversaw the data bank, said it's likely the information was in the data bank. Most state boards report actions as required by law, he said.
"It was very unusual to get queries from a state board," he said. "There were states that maybe didn't submit any queries at all, or one or two."
Most states, he said, performed only 10 to 20 searches every year.
Of the 64 state medical boards, only 13 subscribe to a "Continuous Query" service, which send alerts when new updates are filed. The service costs $2-$3 per search.
Loewenstein, the data bank director, acknowledged the listings don't provide a full picture of a physician's history.
"We by no means hold ourselves out to be the all-encompassing definition of good and bad practitioners," he said. "We're a data point, to be used along with others."