Badness in Baltimore: Can Peer Review Catch Rogue Doctors?

A couple of months ago, a Baltimore reporter called to get my take on a scandal at St. Joseph’s Hospital in Towson, an upscale suburb. A rainmaker cardiologist there, Dr. Mark Midei, had been accused of placing more than 500 stents in patients who didn’t need them, justifying the procedures by purposely misreading cath films. In several of the cases, Midei allegedly read a 90 percent coronary stenosis when the actual blockage was trivial – more like 10 percent.

Disgusting, I thought… if the reports are true, they should lock this guy in jail and throw away the key. After all, the victims now have permanent foreign bodies in their vascular beds, and both the stent and the accompanying blood thinners confer a substantial lifetime risk of morbidity and mortality. As I felt my own blood beginning to boil, the reporter asked a question that threw me back on my heels.

“Why didn’t peer review catch this?” he asked.Cypher stent

Hospital peer review is getting better, partly driven by more aggressive accreditation standards for medical staff privileging. In my role as chief of the medical service at UCSF Medical Center, I’m now expected to monitor a series of signals looking for problem doctors: low procedural volumes, unusual numbers of complications, and frequent patient complaints, unexpected deaths, and malpractice suits. When a flashing red light goes off, my next step is to commission a focused review of the physician’s practice. The process remains far from perfect, but it is an improvement over the traditional system, in which docs tapped a couple of their golfing buddies to vouch for their competence.

But cases like Dr. Midei’s don’t trip any alarms. Most of his patients were probably quite content – many had chest pain and a stent undoubtedly seemed like an appropriately aggressive, high-tech cure. “He put two stents in almost immediately,” said one grateful patient. “I felt relief.”

Although this patient, 66-year-old Peggy Lambdin, later received a letter indicating that her coronary artery was less than 50 percent blocked (clinically meaningless and not an indication for stenting), she was unfazed. “No one can ever tell me that I didn’t need that stent,” she told the Baltimore Sun. “I feel like [Dr. Midei] saved my life.”

Moreover, I’m guessing that Dr. Midei’s complication rate was quite low, as it usually is when one does procedures on healthy people. He probably followed all the protocols mandated by accreditors and the relevant specialty societies. (Oh yeah, except for the ones regarding professionalism.)

The problem is this: as long as the cardiologist reading the cath is the one who pulls the trigger on the intervention, we have a potential Fox/Henhouse problem. Every time a respected professional commits egregious fraud (think Jayson Blair or Bernie Madoff), the same question arises: is there any way to pick the few bad apples out of some very large barrels?

Obviously, the Mideis of the world could be caught by requiring that every cath undergo an independent second reading. Some insurers in New Jersey now require such readings before they authorize a stent, and at least one SoCal Kaiser hospital mandates that each cath be presented at a conference before a treatment decision is rendered, analogous to what many tumor boards do for cancers. 

Such required peer review might have benefits beyond simply preventing the rare case of fraud. If done well, it might also ensure that other conflicts of interest and non-evidence-based decisions are avoided to the degree possible. For example, a meta-analysis in last month’s Annals of Internal Medicine illustrates the limited value of percutaneous coronary interventions – whereas older studies found that PCI was more effective than medical therapy in treating angina, more recent studies show that these differences have narrowed or even vanished. I’d guess that, when recommending a treatment for a patient with mild angina and a 60% LAD lesion, a peer review group is more likely to pay attention to this kind of evidence than the average cath jock  – who may not only be staring at his kid’s private school tuition bill but also at a patient whose bias is to see a stent as a more intuitively satisfying solution than “just medications.”

Some will argue that mandating second opinions for every cath is the equivalent of hitting a nail with a sledgehammer, and they might well be right. However, I do favor at least random over-reads of a sample of catheterization studies. Something like this already happens in a few specialties. In many teaching hospitals, a random sample of pathology studies is reviewed by a second provider. In a few forward-thinking practices, radiologists re-read a sample of x-rays, looking for discrepancies. In response to this case, in fact, St. Joseph’s now requires that 5% of its cath cases undergo a random and blinded re-review. Random audits won’t catch every case of fraud, any more than IRS audits catch every tax scofflaw. But they do help keep people honest, particularly if the audits are coupled with a culture in which the docs welcome feedback and strive for continuous improvement.

Speaking of which, the Midei case made me wonder about the institutional culture at St. Joseph’s. Was Midei a rogue interventionalist working in isolation? Perhaps so – it’s common for no other doc to be looking over the shoulder of a cardiologist and his cath readings. But cardiologists don’t perform caths on desert islands – they are assisted by cath techs and nurses. In my experience, these folks become as adept at reading cath films as any physician. If the allegations against Midei are true, it strains credibility to think that no one in the lab knew that inconsequential lesions were being read as tight stenoses and treated with stents.

And what about the hospital administrators? Stents are big business. When Johnson & Johnson first launched their
drug coated Cypher stent in 2003, Dr. Midei told the Baltimore Sun,
“This is the hottest thing in cardiology in years.” And it was:
Maryland hospitals chalked up nearly $250 million in stent business in
2009, and St. Joseph’s stent revenues were $38 million, up more than 50%
in 5 years. Before the case broke, St. Joseph’s advertised itself as
the busiest cath hospital in Maryland, averaging nearly 20
interventional cases daily. While it is possible that no St. Joe’s leader knew precisely what was happening, I’m guessing that some did but chose to look the other way: the pressure to steer clear of the golden-egg-laying goose must have been intense. Perhaps the fact that the hospital’s CEO and two other senior executives resigned after the case broke provides a clue as to who knew what when.

Cases like this one are terribly troubling, not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship. Part of the solution must be more robust oversight procedures, such as mandatory second readings of randomly selected cath films.

But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.

15 Responses to “Badness in Baltimore: Can Peer Review Catch Rogue Doctors?”

  1. ad May 12, 2010 at 1:44 am #

    This is just the tip of the iceberg. Factor in the unneeded procedures that precede the intervention and then we are really talking money. The Center for Medicare Services financially penalizes all cardiologists for the transgressions of a few.

    Yet we must all accept responsibility we know the transgressors but are afraid to expose them.

    Does the medical profession use the Mafia as a model of corporate responsibiliy and has the Hippocratic Oath been replaced by Omerta??

  2. Dr.Nick May 12, 2010 at 2:42 am #

    Take away fee for service and this problem goes away.

  3. bev M.D. May 12, 2010 at 12:05 pm #

    Thanks for mentioning us pathologists since i was about to. Reviewing each other’s slides (and each other’s frozen section accuracy rate, correlation with 2nd opinion rate,and many other quality indicators) is second nature in most pathology groups,and in more radiology groups than you suggest. Why has this attitude not penetrated more deeply into clinical specialties?
    I think clinicians need to look in the mirror and ask these questions. it is not just to catch fraud, but to catch actual mistakes,analyze them,and improve patient care.

  4. ldm May 12, 2010 at 5:08 pm #

    I’m guessing the hospitalists all knew that if you called this guy, your patient is probably getting a procedure…but at least he responds promptly to consults!

  5. Richard Rohr May 14, 2010 at 6:52 pm #

    I have a friend who dealt with a “death angel” case some years ago in New Jersey. His takeaway lesson from that experience is that there is no peer review system or quality improvement system that can detect deliberate criminal activity.

  6. exodus May 15, 2010 at 4:24 am #

    Great post, Bob.

    This highlights a perpetual problem in cardiac care – lots of patients with chronic stable angina getting angioplasties and stents that may be no better than aggressive medical therapy.

    Peer review might catch some of these folks. However, it is time to begin supplementing this with a population health approach. How about reviewing the Dartmouth atlas data on an ongoing basis to identify overutilizers?

    Specialty societies shoulder at least part of the blame. Once a new procedure or drug comes out, it is often just a matter of time before off-label uses skyrocket. Shouldn’t they be the ones speaking against such uses?

    Thirdly, technologies and new drugs are often adopted with haste; before long term outcomes data are available. By the time long term data becomes available, a ton of patients have received these new procedures at high cost.

    Lastly, this sort of fraud and abuse reflects a key structural problem in the healthcare system – a predominance of specialists causing the phenomenon of supplier induced demand.

  7. bev M.D. May 21, 2010 at 12:48 pm #

    This post was picked up by The Health Care Blog (May 14), and there are very disturbing comments there from M.D.’s, suggesting that this fraud is widespread with the collusion if not the coercion of hospital administrations; and that those who speak up are threatened. Is there a scandal here that needs correction? Short of some sort of group effort at exposure, strengthening the peer review process and separating it from the administration’s influence seems to be the line of last defense – which may have already been breached.

  8. ABC May 21, 2010 at 6:05 pm #

    Amazingly, this article hits just about every issue that has been a discussion thread on the listserv of the National Patient Safety Foundation.

    About a year or two ago, I read an entry on the Hospital Impact blog (by and for hospital administrators) where the advice they share with each other is to “push the high-end procedures”, especially in bad economic times. This advice contravenes most of the paragraphs in the Code of Ethics of their professional organization, ACHE, not to mention the principle of evidence-based medical care in general. This article reminded me of that, especially your suspicion about the administration’s collusion in this case. Of course, they probably wouldn’t call it “collusion,” which sounds so dirty, but rather “good business practice.”

  9. Savatore Gatti, MD May 22, 2010 at 3:24 pm #

    The linked report which follows from the Pittsburgh Tribune Review begins to drill through the wall of protection at UPMC which backs the comments made by observers on this blog and those at THCB. http://www.pittsburghlive.com/x/pittsburghtrib/news/pittsburgh/s_682244.html

  10. Mario Scuillio, MD May 22, 2010 at 8:30 pm #

    Can peer review or the Joint Commission catch the rogue administrators in Pittsburgh if the BOD is participating in ringing the cash register?

  11. Haris Aleem MD May 26, 2010 at 4:38 pm #

    Great post, Bob. I actually was at St. Joe ( as an internist ) for many years, but this news came as a complete surprise to all of us. From all accounts, DR Midei is a nice and thoroughly profesional guy, but who knows ?. I am convinced that the hospital was in complete collusion with him and probably coerced him to do many of these procedures. Now that this has become national news, the’yve thrown Midei under the bus. Sad and shameful .

  12. BaltimoreResident May 28, 2010 at 3:38 pm #

    The real story behind the Dr. Midei controversy had much more to do with him leaving Mid-Atlantic Cardiology for St. Josephs just prior to Mid-Atlantic being sold to a competing system. Had the sale gone through, each doctor in the practice would have made millions overnight, however once Dr. Midei left the group, the competitor lost interest and thus the other doctors didn’t make a dollar. It’s been widely quoted that one of the other associates in the pratice told Dr. Midei that he would make it his mission to ‘destroy you personally and professionally’.

    The only thing Dr. Midei is guilty of is being a great human being who has saved thousands of Baltimore residents.

  13. Another Baltimore Resident May 28, 2010 at 8:49 pm #

    As Baltimore Resident above mentioned, those that know that backstory behind Dr. Midei’s embattled departure from Mid-Atlantic Cardiology know that he has categorically been targeted for retribution by one of the senior partners, as well as stabbed in the back by St. Joe’s administrators.

  14. bev M.D. May 30, 2010 at 4:59 pm #

    Baltimore residents;

    It would seem the allegations on both sides could be easily resolved by having an independent expert review the cath images from the stented patients? There is no need for this to be a ‘he said, she said’ controversy. Or what am I missing?

  15. StJoesRN June 7, 2010 at 1:28 am #

    Well said, bev M.D. The films don’t lie.

Leave a Reply