Dr. Death: What Lessons Can We Learn from the Tragic Events that Occurred in Texas

This post is based on a webinar that features Dr. Todd Sagin, President and Medical Director of Sagin Healthcare Consulting, and Vicki Searcy, Vice President of Consulting with VerityStream.

With a Ph.D. in molecular biology, his M.D., membership in the Alpha Omega Alpha Medical Honor Society, and a completed internship and residency, Christopher Duntsch looked like many of the well-qualified doctors we encounter while credentialing physicians every year. However, Dr. Duntsch, now commonly referred to as Dr. Death, went on to practice as a neurosurgeon and has since been responsible for multiple deaths and the maiming of patients.

Looking for Red Flags in a Physician’s Background

Dr. Duntsch performed surgeries at multiple hospitals that left his patients permanently injured or dead, yet it took years for his license to be revoked. Looking back, there were red flags that foreshadowed his deterioration into a physician serial killer. Now there is evidence-based literature that shows many physicians who are later deemed disruptive or unprofessional in their conduct manifest that behavior early in their training. The following events exemplify the tendencies that could have indicated Dr. Duntsch’s dangerous decline:

• Dr. Duntsch only did around 100 surgeries during his six years of surgical training—which is only about one tenth of what you would expect a typical neurosurgeon to do during his or her training.
• He was reported to have been sent to an impaired physician program during his residency program. Along with this report are assertions that he used LSD and painkillers during this time. In his last year of training he was observed closely and was not allowed to operate alone.
• His contract at The Minimally Invasive Spine Institute was terminated. One motivator for this termination is that he left town while on call and abandoned patients in the hospital.
• While on staff at Baylor Plano, several physicians who were in surgery with Dr. Duntsch were “horrified” about his performance, and he was reported to the Texas Medical Board for practicing at the level of a surgeon in training without awareness of how bad his technique was.
• He emailed a colleague saying, “I am ready to leave the love and kindness and goodness and patience that I mix with everything else that I am and become a cold-blooded killer.”

As Dr. Duntsch went on to practice, his malfeasance caused the deaths of two individuals and left many others with permanent injuries. He moved from one hospital to another, leaving a trail of maimed patients. As those who are looking into the backgrounds of physicians during the credentialing process, it has become increasingly important to ask ourselves—is the verification of completion of education programs enough? When should I ask for more information about a physician’s performance or if there were any problems in his or her history?

Were NPDB Reporting Requirements Followed?

Under the guidance of National Practitioner Data Bank (NPDB), it remains murky whether or not Dr. Duntsch’s actions were properly reported by the institutions where he was employed. He was never suspended for more than 30 days, formally or informally, and the requirement was that a suspension based on clinical incompetence or unprofessional conduct that lasts more than 30 days must be reported. There is also a requirement to report if someone resigns under investigation­; however, it is not clear to the public whether Duntsch’s leave of absence and resignation from Baylor took place during a formal investigation.

Last year, the National Practitioner Data Bank updated their guidebook, providing updates and additional agreements regarding reporting guidance, on the following listed items. Hospitals now must report more than previously, as when Dr. Duntsch was practicing.

• Certain agreements not to exercise privileges
• Leave of absence while a physician is under investigation
• Physician resignation while under reappointment review
• Investigations underway, but not concluded by the time appointment expires
• Resignation while a performance improvement plan is in effect
• A wider range of proctoring conditions

What We Can Learn from this Tragedy

There are lessons we can learn from the tragedy that occurred in Texas that should influence credentialing processes going forward. Consider how the following takeaways could change your organization’s approach to credentialing, preventing a Dr. Duntsch scenario from occurring in your hospital:

1. Put patients first. Whenever significant concerns arise, an immediate plan should be put into effect to assure patient safety.
2. Honesty, transparency, and professionalism should govern communication between hospitals, doctors, and healthcare entities.
3. Don’t rely on state medical boards, but always report concerns promptly.
4. Report appropriately to the NPDB.
5. Don’t be reckless with temporary privileges.
6. Always follow-up on hearsay. Hospitals need to have a culture where their staff feels safe to report their concerns about practitioners in order for interventions to occur.
7. Go with your gut feeling.