by David Cundiff, MD
After the LA County + USC Medical Center closed my “Pain and Palliative Care Service” because of budget cuts in 1995, I spoke out publicly about the dysfunctional financial reimbursement system funding charity care in LA County.
For example, when my consultation service controlled the pain and distressing symptoms of over 400 terminally ill cancer and AIDS patients per year and discharged them to home hospice programs, the hospital lost about $9 million per year of potential Medicaid inpatient revenue. My op-ed piece in the Los Angeles Times in November 1997 exposed the unnecessary but lucrative acute care inpatient days at the hospital.
In a letter to the federal Healthcare Financing Agency, I threatened a qui tam whistleblower suit citing over $200 million a year of overcharges for Medicaid patients in my hospital.
To stop my whistleblowing activities, the hospital administration charged me with malpractice in a case in which I discontinued the anticoagulant warfarin (Coumadin) in an alcoholic man with liver failure, advanced tuberculosis, and a clot in his leg. I reasoned then and now that, because of his alcoholism and liver failure, the risk of bleeding to death was greater than the risk of him having fatal clotting. Unfortunately, he died a week later of clots in his lungs.
This incident prompted me to study the evidence-basis of anticoagulation for venous thromboembolism. Surprisingly, I found that the only three published placebo or NSAID controlled trials of standard anticoagulants for deep venous thrombosis were all negative (deaths: anticoagulants: 6/66 versus placebo or phenylbutazone: 1/60). The publication in MedGenMed of my review challenging the efficacy of anticoagulants for VTE elicited no rebuttals. A Cochrane review that I co-authored on the same topic had a corrupted conclusion written by peer-reviewers favoring continuing the use of heparins and warfarin.
After finding biases and undisclosed financial conflicts of interest in peer-reviewers involved with my Cochrane review, I critiqued all Cochrane anticoagulation reviews. My article, “A Systematic Review of Cochrane Anticoagulation Reviews,” in the Medscape Journal of Medicine detailed the methodological errors and biases in 59 Cochrane systematic anticoagulation reviews and challenged the conclusions that favored anticoagulation treatment for 30 medical indications. About 100,000 people bleed to death each year due to anticoagulant treatment for those indications. No one has rebutted this review.
Since alcoholism is an absolute contraindication to prescribing warfarin, the Deputy Attorney General brought in my patient’s daughter at the Medical Board hearing to testify that her father was not alcoholic and never drank beer by the can but only Colt-45 Malt Liquor by the quart. She contradicted the admitting medical resident’s recorded history of alcoholism. The judge believed the patient’s daughter over the admitting medical resident and revoked my medical license. In a subsequent sworn deposition in her civil damages suit, the daughter recanted her Medical Board testimony. She said he drank unknown amounts of cans of beer and 40-ounce magnums of Colt-45.
In my medical license reinstatement hearing, I would like to introduce as evidence my review of anticoagulation for venous thromboembolism and the sworn deposition of the daughter recanting her Medical Board hearing testimony denying her father’s alcoholism. However, the new Deputy Attorney General that will attend the hearing promises to object to my attempts to relitigate the original case. I asked him to brief California Attorney General Jerry Brown on my case and let Brown decide whether to allow me to challenge my original conviction based on new evidence. The Deputy AG, who is supervised by the Deputy AG that convicted me, refused to consult with Brown.
Whether I get my license back and the original revocation rescinded is important to me but relatively minor compared to whether my challenges to guidelines for anticoagulation treatment for 30 medical indications are transparently addressed by the medical community.
The relatively poor quality of hospice and palliative care practice and teaching in many academic medical centers may also be improved by the complete airing of my case.
David Cundiff is an internal medicine physician.
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