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Why Choosing the Right Surgeon Matters

surgeryThree years before LaVerne Stiles chose Dr. Constantine Toumbis to do her ill-fated spinal fusion surgery, a remarkably similar series of events played out at Citrus Memorial Hospital.

George Bogner, a 43-year-old truck driver, came to Toumbis after worsening neck pain made it impossible to work.

Hours after Toumbis performed Bogner’s spinal fusion in June 2009, Bogner began to thrash in his hospital bed, gasping for air. Inside his neck, more than a quart of blood had pooled, squeezing off his windpipe. He was pronounced dead that night.

A private autopsy arranged by Bogner’s family concluded he had died of surgical complications, but Bogner’s death certificate — signed by Toumbis himself — listed the cause as “natural” and mentioned nothing about internal bleeding.

It was the kind of case that should have triggered action from multiple systems designed to monitor doctors’ practices, both inside the hospital and beyond its doors.

That’s not what happened.

Like all hospitals, Citrus Memorial has a peer review panel made up of doctors tasked with examining cases where the care came under question or drew complaints or lawsuits.

Bogner’s case was referred to the committee, a standard practice when a patient died, according to a former hospital employee. The committee never investigated, even though Bogner’s estranged wife later sued Citrus Memorial and was paid a settlement. Toumbis was not named in the lawsuit.

The gaps in Citrus Memorial’s safety net are common at hospitals across the country, experts say. Facilities routinely fail to identify the kind of outliers spotlighted by ProPublica’s analysis or to intervene when such doctors are flagged.

Peer review panels, long the chief mechanism for physician accountability in hospitals, are a prime example. Such committees have an array of tools to help doctors improve, from sending them for more training to compelling that they be coached by colleagues.

In egregious cases, peer review committees can recommend that hospitals suspend or withdraw a doctor’s privileges. Yet there’s evidence that hospitals are doing so less and less.

Hospitals are required to report such sanctions to the National Practitioner Data Bank, a federal clearinghouse of doctor discipline used by health care employers. Reports dropped by more than 20 percent between 2004 and 2013. A quarter of American hospitals — 890 facilities — have not reported a single disciplinary action in the past 25 years.

“Physicians haven’t gotten that much better!” Robert Oshel, who spent 15 years handling research and disputes at the data bank until he retired in 2008, wrote in an email. Oshel volunteers as a data analyst for Public Citizen, a consumer advocacy group. “Peer review is not effectively protecting patients from incompetent and miscreant physicians.”

Toumbis, 49, had privileges at another Florida hospital, Seven Rivers Regional Medical Center, as well as at Citrus Memorial.

Toumbis performed 316 spinal procedures on Medicare patients at Seven Rivers between 2009 and 2013 and another 247 at Citrus, records show. ProPublica found 23 cases in which Toumbis patients suffered postoperative infections or injuries after operations at Seven Rivers and 21 who were readmitted after procedures at Citrus. That doesn’t include Bogner, not a Medicare patient, or Stiles, who died before she could be readmitted.

Asked about Toumbis, officials at Seven Rivers said the hospital had a “steadfast commitment to quality care and improvement” and that many of the readmissions flagged by ProPublica involved patients who had prior back surgeries or complex medical histories. Officials said the hospital regularly reviews readmissions, but they declined to further discuss Toumbis’ cases.

Colleagues at Citrus were aware that Toumbis had issues. ProPublica interviewed more than a dozen doctors, nurses, physical therapists and other hospital employees familiar with Toumbis’ work. All said it was known that his patients experienced a high rate of complications.

There was also a troubling incident in his past. When Toumbis was in medical school, he stabbed a classmate in the neck after an altercation at a bar. He was convicted of assault, a felony, but was still able to get a medical license.

Three people who sat on Citrus Memorial’s peer review committee for years said they couldn’t recall a single instance in which it did anything tougher than send doctors letters of inquiry.

The panel is called the Performance Improvement Committee — PIC for short. The dark joke among some hospital insiders was that “PIC” actually stood for “Protect, Ignore and Cover Up.”

Ryan Beaty, Citrus Memorial’s chief executive for 10 years until he retired in 2014, said the leaders of the medical staff seemed uncomfortable with policing fellow doctors. “They’re reviewing themselves,” Beaty said. With such leadership, “the process is not going to be as effective as it should be.”

It’s not clear if the PIC looked closely at any of the cases identified by ProPublica in which patients that Toumbis operated on at Citrus Memorial suffered complications.

In about 2010, a hospital official (not a doctor) presented the PIC with information showing that a number of Toumbis’ patients had suffered tears to the dura, the membrane that envelops the spinal cord, during fusion surgeries. Such tears can be serious and should not be common complications.

The committee declined to analyze the cases further, deeming them unfortunate but acceptable side effects of the surgery, a former hospital official said.

The PIC also didn’t substantively investigate Stiles’ death from postsurgical bleeding in 2012, two former hospital officials said.

Peer review is often undermined by the personal and financial ties that bind doctors together, according to experts and a 2008 study.

Toumbis was among the most powerful physicians at Citrus Memorial. He served last year as the chief of staff and, in November, was named to the hospital’s board of trustees. He also rings the cash register: Between 2009 and 2013, Medicare paid the hospital $9 million for cases in which he is listed as the operating physician.

Even when hospitals identify problems with doctors’ competency or practices, they can face formidable hurdles in imposing discipline. Doctors have extensive due process rights that can mire even clear-cut cases in layers of mandatory notifications, hearings and appeals.

In early 2013, it looked as if Toumbis’ pattern of problems might finally draw serious scrutiny. Prompted by reports that his patients were suffering high complication rates, Citrus administrators initiated a review of cases handled by Toumbis and two colleagues who also did spinal fusions.

According to a former hospital official, they found that Toumbis had a higher complication rate than his peers but concluded that his results were acceptable when compared with what little national data was available. No action was taken. The hospital declined to respond to questions about the review or its outcome.

Today, Toumbis remains a busy member of Citrus Memorial’s staff — in fact, he’s now the hospital’s only spinal surgeon.

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