Enemy of the People

June 22, 2005 -- Recent press articles across the globe have focused on the case of Jayant Patel, the surgeon whose work at a hospital in Bundaberg, Queensland (Australia), including reported links to the deaths of 87 patients, earned him the nickname "Dr. Death." These pieces include a lengthy story in the June 19 New York Times by Raymond Bonner, "Deaths and a Doctor's Past Transfix Australians," which focuses on the testimony of ICU head nurse Toni Ellen Hoffman about her relentless efforts to protect patients from Patel. Other notable stories--whose headlines alone paint quite a picture--include "Patel 'laughed' at nurses' complaints" in today's The Age (Melbourne), "Dr. Death told nurses he was germ-free" in yesterday's New Zealand Herald, and Meraiah Foley's AP piece "Nurse: Surgeon Had 100 Pct. Complication Rate" in yesterday's Guardian. The pieces show that nurses have clinical expertise, and that at least some are willing to use it to protect their patients from powerful physicians. Sadly, this is not the only recent case in which it has been reported that a physician was recruited to a hospital that was desperate to have him, nurses soon began to issue dire warnings about the physician's incompetence, those in power closed ranks and the nurses were scapegoated, mocked or ignored, while patients continued to develop serious complications and even die in large numbers. Does this mean nursing's focus on "patient advocacy" is pretty much an illusion, as some have suggested?

The New York Times piece explains that soon after Dr. Patel was recruited from the U.S. to the municipal hospital in the "farm town" of Bundaberg in 2003, "nurses were hiding patients from him." Even physicians at the hospital were concerned; an anesthesiologist reportedly dubbed him "Dr. Death." Much of the story concerns the current investigation by a Queensland government commission into Patel's potential responsibility for the patient deaths, and how the hospital could have hired him without discovering that he had been disciplined in New York and Oregon. A central issue for the story and the panel seems to be how problem physicians can begin again in a new locale even after serious disciplinary action.

Prior to the resumption of the commission's work this week, the principal testimony had reportedly come from head ICU nurse Toni Ellen Hoffman. Hoffman, "in testimony bolstered by the hospital's director of medicine," stated that Patel had performed many esophagectomies for which the hospital did not have follow-up facilities, and that he had refused to transfer the patients to a better equipped hospital in nearby Brisbane. Hoffman also testified that the surgical wounds of Patel's patients often came apart, and that he refused to perform CT scans on cancer patients, leading to operations when other treatments would have been preferable. Patel apparently responded to her concerns by stating that he was bringing in half a million dollars a year in revenue to the hospital. Witnessing "troubling episodes" "[w]eek after week," Hoffman registered her concerns orally, by e-mail and in letters to her supervisor, the nurses' union, and hospital administrators. She was told it was a "personality problem." Reportedly, she could not go to the press because the Queensland state health department bars employees from talking to the press.

In July 2004, a man reportedly came into the hospital after having been crushed by a camper van. Reportedly, after wildly shifting assessments from Dr. Patel, the man died. Hoffman then "laid out her concerns and asked for an independent audit." The next month, the hospital chose Dr. Patel as its "employee of the month." (Perhaps they were emulating TIME magazine's "Man of the Year" award, which is based on impact, rather than merit.) Then, "[m]ore patients died." Finally, at the point when the hospital was about to give Patel a new long term contract, Hoffman contacted a state legislator, who went public. "Ms. Hoffman was vilified, as doctors and politicians rallied to Dr. Patel's defense." The president of the Queensland branch of the Australian Medical Association reportedly opined that it was a "disgrace" that Patel had to leave his job. Apparently most local residents did not believe the allegations either, until a "veteran investigative reporter" in Brisbane did a Google search on Patel, which brought up the U.S. disciplinary actions, some of which related to severely botched operations. It must have been gratifying to Hoffman that her concerns gained traction only after a reporter found indications on the Web of other problems dating from years earlier in another nation.

The Guardian piece focuses on the experience of renal nurse Lindsay Druce, who reportedly testified that she "became alarmed when she noticed a 100 percent complication rate" in the kidney patients on whom Patel operated. Druce found that "all six kidney patients Patel operated on during 2003 had developed complications allegedly caused by his failure to properly insert a type of drainage catheter." In response to Druce's concerns, Patel was "very dismissive," walking away as he noted, "I am the surgeon." After a patient died in December 2003 following surgery to repair a catheter that Patel had allegedly inserted incorrectly, Druce went to the hospital's "renal specialist and Director of Medicine" Peter Miach, who "banned Patel from operating on any other kidney patients." Dr. Miach testified that he also sometimes "instructed the nurses" to watch over "his patients" to ensure that Patel did not operate on them. (The article does not explain what the hospital's Director of Medicine did for patients who were not "his patients.") The piece also describes Toni Hoffman's efforts to "hide patients from Patel, who would sometimes stalk the intensive care unit looking for patients to operate on."

The story in The Age has further details on Patel's "demeaning remarks" toward the Bundaberg nursing staff. Jennifer White, former nurse manager of the hospital's operating theatre, reportedly testified that during monthly meetings involving physicians and nurses, Di Jenkins, the nurse unit manager of the surgical ward, had "warned of an increasing number of patients suffering from wound dehiscence." White reportedly assured the Bundaberg commission that after 30 years in nursing, both she and Jenkins "know what wound dehiscence is," though she had only rarely seen the condition in recent years, "caused by faulty suture materials or incorrect surgical technique." However, White testified that Patel "laughed at their concerns, telling them they didn't know what wound dehiscence was and they should research it." She noted that the then-director of medical services, Dr. Darren Keating, had also laughed at the "joke."

Unfortunately, this type of scenario is not unprecedented. In her recent book "Nursing Against the Odds," Suzanne Gordon describes several recent cases in different nations in which nurses' warnings about physician competence were ignored to the detriment of patients' health, including a notorious Winnipeg case in which (as here) a small hospital hired an apparently well-regarded surgeon from the United States and failed to heed nurses' warnings despite a mounting death toll. Gordon concludes, essentially, that nurses' "subordination" to physicians discredits the profession's "claim" to be all about patient advocacy. The Truth believes that nurses are not subordinate to physicians, and despite the practical obstacles to nurses' advocacy in cases like these, including physicians' considerable social and economic power, nurses are ethically obligated to do what they can to protect patients, and many, like Ms. Hoffman, do just that at considerable personal risk. Of course, it's obvious that many nurses have a long way to go in advocating for their patients and themselves, and that physicians and society have a lot to learn about the value of nurses' substantive health care expertise. But this is why we are here.

The Truth salutes Ms. Hoffman for what was, based on the Times account, remarkably determined patient advocacy in the face of great adversity.

See the June 19, 2005 New York Times article "Deaths and a Doctor's Past Transfix Australians" by Raymond Bonner, the June 21 New Zealand Herald article "Dr. Death told nurses he was germ-free", Meraiah Foley's AP piece "Nurse: Surgeon Had 100 Pct. Complication Rate" that ran in the June 21 Guardian, and "Patel 'laughed' at nurses' complaints" from The Age on June 22.