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In <a href="http://en.wikipedia.org/wiki/Silver_Blaze">Silver Blaze</a>, Sherlock Holmes noted the important clue of the watchdog that did not bark.  In health care, nowadays watchdogs are absent, so who is expected to bark?  So, when cases of failed leadership of health care organizations appear, in retrospect they often appear to have been foreshadowed by various events which caused no reaction..  Last week we <a href="http://hcrenewal.blogspot.com/2013/11/engaging-excellence-while-engaging.html">posted</a> about the president of the State University of New York (SUNY) - Upstate Medical University who resigned his job after revelations that he was receiving hundreds of thousands of dollars in income from outside organizations which he had not properly disclosed, and which could have constituted conflicts of interest.  Only days later, on November 20, 2013, James T Mulder, the Syracuse Post-Standard journalist who had done much of the relevant reporting, published an <a href="http://www.syracuse.com/news/index.ssf/2013/11/post_933.html">article</a> summarizing previous events that in retrospect should have suggested that there were serious ongoing problems within SUNY - Upstate leadership.  Claims that the University Fired Physician Whistle-blowers - the Case of Dr Stewart According to the summary article, <blockquote class="tr_bq">Critics of [SUNYH - Upstate Medical University President Dr David R] Smith ... [said]  he ruled with an iron first and did not tolerate opposing views. 'It became clear once he knew who dissenters were, things would happen,' said Dr. James Holsapple, a former Upstate neurosurgeon who now practices and teaches in Boston, Mass.'Dissidents would not be tolerated.' Holsapple cited the case of Dr. William Stewart, a <a href="http://www.syracuse.com/news/index.ssf/2011/04/upstate_fires_whistleblower_do.html">neurosurgeon fired by Upstate </a>in 2011. Stewart contends he was fired because he filed a complaint with the state Health Department, alleging misconduct by two other Upstate doctors. That complaint led to an investigation by the state which issued a report critical of Upstate. Upstate contends Stewart was let go because he refused to cooperate with an investigation into a breach of confidential information, including patient records. Holsapple calls the incident a ' ... clear example of Smith taking out a critic.' In a pending lawsuit in federal court, Holsapple has accused Upstate of retaliating against him for speaking out against what he calls dangerous medical practices and other unethical activities at the Syracuse teaching hospital. Upstate has denied his accusations and called them 'baseless.'</blockquote> In fact, Mr Mulder's <a href="http://www.syracuse.com/news/index.ssf/2011/04/upstate_fires_whistleblower_do.html">article</a> from April, 2011 about Dr Stewart's case noted that Dr Stewart <blockquote class="tr_bq">said his complaint ' ... made me an enemy of the regime.'</blockquote> Although Upstate accused Dr Stewart, <blockquote class="tr_bq"> ... because he refused Upstate’s request that he cooperate in an investigation into an intentional breach of confidential information, including private patient care records.</blockquote> Dr Stewart contended that he knew how to handle confidential information, <blockquote class="tr_bq">Stewart served 20 years as a member of the state Board for Professional Medical Conduct, which takes disciplinary action — including license revocation and suspension — against doctors. He chaired that board for three years in the late 1980s. Stewart said he never disclosed any private patient information. 'I took the Hippocratic oath when I graduated from medical school,' he said. Stewart said physicians are required by state law to report suspected cases of medical misconduct. Failure to do so is considered misconduct under the law. Stewart said that’s why he filed a complaint with the Health Department, alleging that a resident neurosurgeon training at Upstate was allowed to perform complex spine surgery without proper supervision because the neurosurgeon who was supposed to be doing the operation was in another operating room with a different patient.</blockquote> Furthermore, Dr Stewart alleged that Upstate sought to intimidate him, <blockquote class="tr_bq">Stewart said two private investigators hired by Upstate visited his office in December, but he refused to talk to them.</blockquote> Claims that the University Fired Physician Whistle-blowers - the Case of Dr Holsapple The case that caused Dr Holsapple to file a lawsuit against Upstate had some interesting similarities, but also some uniquely colorful aspects, as documented in an <a href="http://www.syracuse.com/news/index.ssf/2011/02/doctors_lawsuit_says_upstate_f.html">article</a> from February, 2011, by Mr Mulder.  Dr Holsapple also alleged a major quality of care problem at Upstate, <blockquote class="tr_bq"> The suit charges Holsapple’s problems began in 2007 when he objected to a plan to have a single neurosurgeon supervise two spine surgeries in separate operating rooms at the same time. Holsapple thought the plan was risky for patients. At the time death rates following spine surgery at Upstate were five times higher than normal, the suit said. The suit contends Dr. Ross Moquin, a neurosurgeon no longer at Upstate, was overseeing the two surgeries, according to the suit. While Moquin was with one patient, Dr. Walter Hall, then chair of the department of neurosurgery, and a resident doctor in training, began surgery on the second patient, the suit says. Neither Hall nor the resident were qualified to finish the operation, but Hall told the resident to complete the surgery because Moquin was busy with the other patient, according to the suit. Holsapple’s suit contends the patient suffered complications. It also accused the hospital of creating fraudulent documentation about the operation and billing fraud. </blockquote> Some of these charges appear to have been independently corroborated, at least, <blockquote class="tr_bq">That same two-room spine surgery case was cited in a recent state Health Department <a href="http://www.health.state.ny.us/"></a>investigation. In a 68-page report issued in August, the Health Department said Upstate did not provide surgical services in a way 'that assures protection of the health, safety and rights of patients ... .'</blockquote> Nonetheless, Dr Holsapple argued that the hospital punished him for his whistleblowing, <blockquote class="tr_bq">The suit says Hall stripped Holsapple of his job as residency coordinator in 2007 without any explanation, cutting his annual pay by $82,500. Hall also removed Holsapple as the department’s quality officer, according to the suit.</blockquote> Dr Holsapple also contended that the hospital attempted to harass him after he left, and did so, as Dr Stewart also argued, using private investigators, <blockquote class="tr_bq">Holsapple contends Upstate continued the retaliation after he left. He said Upstate sent two investigators to his home in South Boston in November to intimidate and harass him and his wife.</blockquote> The lawsuit suggested that Dr Holsapple was qualified to complain about quality issues, <blockquote class="tr_bq">Upstate hired Holsapple as an assistant professor of neurosurgery in 1994 after he completed his residency training there. In his suit he says he served as the quality improvement officer for the neurosurgery department, on the SUNY faculty senate and on the hospital’s medical executive committee alongside top Upstate executives, department chairs and other officials.</blockquote> It also suggested that perhaps Dr Hall, the chairman of neurosurgery whose conduct figured in Dr Holsapple's complaint, was not so qualified to sit in judgment of Dr Holsapple, <blockquote class="tr_bq">The following year nursing staff discovered images of Nazi artifacts within the computerized medical records of Hall’s patients, the suit says. Holsapple said in an interview the images were photographs of tank medals and other Nazi paraphernalia displaying the swastika. The suit says a hospital investigation confirmed the Nazi images belonged to Hall and he was forced to resign as chair of the neurosurgery department. Holsapple said in an interview Hall told hospital officials he bought and sold the Nazi memorabilia and stored the images on his computer. 'Some of the Jewish faculty were disturbed these icons were finding their way into the computer system,' Holsapple said.</blockquote> A Cheating Scandal and Probation by an Accrediting Agency Mr Mulder' November 10, 2013, summary article also reported, <blockquote class="tr_bq">The medical school was embroiled in a cheating scandal in 2011. An Upstate investigation found more than 100 fourth-year medical students cheated on quizzes in a medical literature course. Last year the medical school was placed on probation by the Liaison Committee on Medical Education, an accrediting group. That group criticized the school for having an erratic learning environment. It also said the medical school's curriculum was out of sync, student complaints were being ignored and the dean was ineffective. Upstate fixed the problems and was taken off probation earlier this year.</blockquote> Mr Mulder's article jogged by hazy memory into the recollection that I had seen several other examples of problems at SUNY - Upstate, but since the articles that illustrated them seemed to appear in isolation, I had just dumped them into the pile of  documents to be filed. A hurried search then revealed articles on the two whistle-blowers, and the cheating and probation issues above, and... A Costly Merger? I found a <a href="http://www.syracuse.com/news/index.ssf/2011/02/will_proposed_merge_between_up.html">story</a> from February 21, 2011, also authored by Mr Mulder, that suggested a merger proposed for Upstate University Hospital would lead to a big increase in health care prices, <blockquote class="tr_bq"> The cost to replace a hip, treat a heart attack and provide many other routine hospital services covered by Medicare is about 46 percent higher at Upstate University Hospital than at Community General Hospital. Some experts fear a proposal to merge Upstate and Community into one hospital with one payment rate will raise Community’s prices to Upstate’s level and increase overall health care costs in Central New York. </blockquote> So, <blockquote class="tr_bq">MVP Healthcare, a health insurer, is worried about potential price increases at Community. 'We need to know if the charges for services provided by Community General Hospital would increase as a result of the merger,' said Gary Hughes, a spokesman for the insurer. 'If the rates increase, we would be concerned how the merger would affect health care costs in the region, how that would affect the business community and individuals.' At a recent public forum on the proposed acquisition, Dr. Douglas Tucker, of MVP, said blending Upstate’s high rates with Community’s could be 'catastrophic,' especially for patients with high-deductible plans who have to pay big upfront costs before their insurance coverage kicks in. SEIU Local 1199, the union representing Community General workers, shares that concern. The union wants Community General to remain as a lower cost, private sector community hospital. The union also wants to remain at Community to preserve its members pensions and benefits. It does not want to see Community workers become state employees, who are represented by different unions.</blockquote> Note that although the merger did occur in 2011, I could not find any documentation about its effects on costs since. Summary In the last two years, SUNY - Upstate Medical University has been accused of seeking a merger mainly to drive up its prices, and of independently driving out and attempting to intimidate two separate physicians for blowing the whistle about health care quality concerns.  The department chairman whose work was criticized by one of the physicians, and who subsequently drove him to leave was himself forced out of his leadership position over allegations of Nazi photographs found within his computerized patient files.  University students were involved in a big cheating scandal, and the university was placed on probation by its accrediting agency.  These stories generated lots of concerned and sarcastic comments online.  However, I could find nothing to suggest that they lead to any official investigations by SUNY leadership, state government, accrediting agencies (other than as listed above), Medicare, medical societies, etc  I could find nothing to suggest that any actions were taken by students or faculty at the school, or by independent watchdogs or other members of civil society.  Yet in retrospect the sequence of events suggested major problems with the leadership of SUNY - Upstate Medical University.  The existence of these problems seems to have been confirmed by the revelations that the university president was accepting hundreds of thousands of dollars of outside income which he failed to properly disclose to the university, and which could have constituted major conflicts of interest.  The seriousness of the leadership problems was just underscored by the recent decision of the state Comptroller to audit the institution's contracts (look <a href="http://www.sfgate.com/news/article/NY-to-audit-hospital-where-president-is-quitting-4968340.php">here</a> for AP story), and the sudden resignation of the university senior vice president for administration and finance who apparently was receiving pay, admittedly which he had disclosed, from the same organizations who were paying the president (see story by Mr Mulder <a href="http://www.syracuse.com/news/index.ssf/2013/11/another_top_upstate_medical_administrator_steps_down_amid_pay_investigation.html">here</a>.)  One obvious conclusion is that bad leadership leads to lots of bad consequences. Another is that here in these United States we lack any effective watchdogs who can spot major leadership problems at important health care organizations before they lead to bad outcomes.    In particular, our the leadership of our academic medical organizations do not seem to get any organized scrutiny from student, faculty or alumni groups, from government agencies, from accrediting organizations, from medical societies, or from community based civil society organizations  or health care watchdog groups.  Hoping that overworked local reporters or volunteer bloggers will not only be able to spot evidence of trouble in a timely way, and then make it visible enough to generate action is whistling past the cemetery.  <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3FJQhVA_VvgKlI6r4vWn-rEAr0R_KgWXO4Z1Wcnfc7m0e1Su8SeV2CghNSraFdQ0mtzwkO4f95rm8aKkzQkQwr_SQMPTK6IVqxAcjR-6Wid-vW-3G3RK2MErMyrVNE5hfTQFGFif3NpFO/s1600/Ahnold.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3FJQhVA_VvgKlI6r4vWn-rEAr0R_KgWXO4Z1Wcnfc7m0e1Su8SeV2CghNSraFdQ0mtzwkO4f95rm8aKkzQkQwr_SQMPTK6IVqxAcjR-6Wid-vW-3G3RK2MErMyrVNE5hfTQFGFif3NpFO/s1600/Ahnold.jpg" /></a></div>    IMHO, concerned citizens, hopefully including those in and in training for the health professions, need to set up organized civil society watchdog groups to hold health care leadership accountable, and to push for involvement by government, accrediting organizations, medical societies, etc.

No Dogs to Bark - Failure to Connect the Events Foreshadowing the Fall of the Upstate President

In Silver Blaze , Sherlock Holmes noted the important clue of the watchdog that did not bark. In health care, nowadays watchdogs are absent...

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