Medical Malpractice: Scant Discipline for Patient Injury, Death in Wisconsin

When it comes to serious discipline against doctors in the United States, Wisconsin consistently ranks near the bottom, according to the consumer advocacy group Public Citizen. Yet the Wisconsin Medical Examining Board managed to reprimand doctors who wrote questionable “sick notes” to employers for protesters at the state Capitol in 2011 -- the same sanction the board routinely gives to physicians whose errors and/or negligence cause patients to die or undergo serious harm.

I wanted to investigate what kind of discipline the state board was meting out to Wisconsin physicians in response to complaints. At first it seemed like a straightforward records search. I planned to start by combing through a state database of disciplinary actions and analyzing the data. While doing so I would check for lawsuits in cases of interest and interview patients about their ordeals for the investigative story I had planned.

It was far more complicated than I had anticipated. In fact, one of the lessons that I’d like to pass on to reporters doing this type of investigation is to be prepared to create your own database.

To begin with, my records requests to the state netted some helpful information, but officials insisted they didn’t have a database showing doctor name, violation, discipline and other details for each case. The result: I had to create my own database. Fortunately, Wisconsin does make all of the medical board’s disciplinary orders available online, in narrative form. They range from about four to 40 pages each. I read, summarized and labeled each one, from 2010 to 2012, in a spreadsheet.

Over half of the 218 cases involved reprimands. The board’s heavy use of reprimands, which Public Citizen doesn’t consider serious discipline, is a major reason that Wisconsin ranks low in physician discipline. So I paid special attention to those cases, especially those in which patients were seriously harmed or died as a result of alleged malpractice.

In many such cases, patients had filed lawsuits -- but most ended in confidential settlements. Some attorneys said it was fine for the patients to talk about the medical board’s disciplinary actions, as long as I didn’t ask about the settlements. Other attorneys, however, said their clients couldn’t talk at all. That made it harder to personalize some of the stories and make them come alive. Similarly, when I sought comment from the two dozen doctors named in the stories, some cited HIPAA privacy regulations in claiming they couldn’t say anything.  Others spoke at length.

Besides trying to talk with as many people involved as possible, I’d also suggest looking for other state agencies that pertain to medical malpractice.  In addition to court and medical board records, two other sources proved helpful in finding details about cases, including some the board didn’t act on. Wisconsin has a Medical Mediation Panel, which attorneys must contact before they file lawsuits. The case files, of course, are public records. The state also has an Injured Patients and Families Compensation Fund, which pays malpractice payments over $1 million. Some details about the payments are public, so that helped bolster my story.

Despite help from some colleagues in my newsroom, I wasn’t able to find much useful information about Wisconsin doctors through the National Practitioner Data Bank. We did find some doctors who had been sued multiple times, but most of the activity was dated or the doctors were no longer in the state.

Ultimately, I amassed enough data to write a three-part series that examined the board’s use of reprimands, explored cases of apparent malpractice that didn’t result in discipline, and discussed whether the board needs more resources or authority. Here are some of my key findings, published in a three-part series in the Wisconsin State Journal:

• In at least 36 cases involving serious injury and 15 involving patient deaths, physicians were given only a reprimand even when they were clearly at fault. In one case, a doctor doing a routine procedure ordered an epinephrine injection to stop bleeding for Nicole Johnson, a 35-year-old mother of four, but at a dose 100 times too high. Johnson died from suffocation after the excess dose caused fluid to fill her lungs. Although the medical board reprimanded the doctor, fined him $1,200 and ordered him to take two classes, the patient’s daughter said she felt his license should have been suspended. “He destroyed my family,” she told me. “I’m baffled why he didn’t get a higher punishment that fit the crime.”

• In another case, a physician used a new medical device that he had never operated with before (and in which he had received no training) to help remove a spleen from a six-year-old girl. The “blender-like” device cut through several major blood vessels and the bowel, causing a medical emergency that left the child with permanent brain damage.  The medical board reprimanded the doctor and fined him $1,800. Although the doctor expressed deep personal remorse, an attorney whose lawsuit in the case led to a $17.3 million dollar settlement said that the board’s disciplinary action was far from sufficient.

• In various case studies, I documented a trail of minor disciplinary actions for doctors who repeatedly made medical errors involving serious injury or patient deaths. In at least one case, the physician under investigation simply moved to a neighboring state and continued to practice medicine.

• Leaders of the Wisconsin Medical Examiners Board reported that lack of money and authority prevented it from meting out more serious discipline – a problem that critics feel may attract sub-standard physicians to the state. Despite the board’s difficulties, a recent reorganization reduced its 10.5 attorneys, paralegals, and investigators to 7.7 positions, officials said.

Dozens of people joined a live chat with me on the last day of the series. I’ve received many calls and emails from patients (some of them doctors themselves) wanting to bring public attention to alleged malpractice experiences. Some patients have also contacted me to learn how to file complaints against their doctors. Perhaps most gratifying, at its first meeting after my series ran, the Wisconsin Board of Medical Examiners talked about needed changes -- including more resources and training for members and staff.

Dr. Sheldon Wasserman, chairman of the board, noted that the state medical board of Ohio had developed guidelines that suggest minimum and maximum penalties for various violations – something that I had pointed out in my series. Ohio ranks among the top states for serious discipline against doctors.

“We don’t have clear guidelines,” Wasserman said. “Why do we have this nebulous system?”

Photo Credit: M.P. King/State Journal