By Douglas Gillison
For the sick and dying veterans in Jackson, Miss., the entries to the list are short but unmistakably indignant.
- May 3, 2007: “obvious colon [cancer] missed — [patient] is inoperable.”
- March 2004: “2 -3 cm [right upper lobe of lung] mass missed by Khan.”
- February 2007: “Presented inoperable with brain [metastasis].”
- July 28, 2005: Chest X-Ray, “New [right] perihilar nodule missed.”
- Feb. 11, 2007: “Mass is now 5.5 cm.”
- March 2007: “[Patient] died.”
Ultimately stretching to nearly sixty patients with apparently undiagnosed ailments — allegedly including at least five who developed inoperable lung cancer — the list was kept by radiologists at the G.V. (Sonny) Montgomery Veterans Affairs Medical Center in Jackson, who later used it in a successful lawsuit for workplace discrimination.
More than six years after top VA officials were first warned that misread radiological exams could have led to an untold number of missed diagnoses at the Jackson VA hospital — above and beyond the roughly five dozen identified by the radiologists — the agency has yet to identify the full scope of the problem. The VA has contacted almost of none of the potential victims. And a state medical board looking into the matter says the VA has “not been responsive” to its questions.
The claims of missed diagnoses at the VA medical center in Jackson surfaced in a letter to the White House from the federal government’s whistleblower agency, the Office of Special Counsel, earlier last year. Five hospital employees blew the whistle on what appeared to be a broken system at the Jackson VA hospital. Nurses, they said, were illegally writing prescriptions for painkillers while staff failed to sterilize scalpels and bone cutters between uses.
These and other allegations of wrongdoing and misconduct have fueled a wave of Congressional criticism and media scrutiny of the government-run hospitals, charged with caring for more than eight million former service personnel every year.
Relatives of patients, lawmakers and whistleblowers accuse agency hospitals of allowing the suicides of psychiatric patients in Atlanta, a deadly outbreak of legionnaires’ disease in Pittsburgh and botched surgeries in Dallas, among other problems resulting in preventable deaths and delayed care.
Bob Slater, an Army veteran of three combat tours in Vietnam and a patient at the Jackson center for 40 years, said that doctors at the hospital had failed to treat his chronic kidney disease for years, even though it was plainly apparent from his blood work.
“You’re talking about nine years of damage,” he said, adding that he felt “disgusted” with the hospital.
In a letter to the White House in September, Carolyn N. Lerner of the Office of Special Counsel, the federal agency charged with reviewing whistleblower complaints, said that the VA’s response to the question of the missed diagnoses had been “insufficient and unreasonable.”
The agency had done limited reviews of a small sample of the accused radiologist’s reports. But, she added, “[T]he agency admits […] that it has not determined what number of cases constitutes a sufficient review to achieve a statistically viable error rate,” Lerner’s letter said.
While promising reforms, VA officials have downplayed irregularities that have come to light. Last year, Dr. Robert A. Petzel, the department’s former top health official, dismissed specific allegations of wrongdoing at the Jackson center as “kerfuffles.”
“Various allegations have been thoroughly investigated,” Rica Lewis-Payton, director of the VA’s South Central network, which includes Jackson, said in Congressional testimony in November 2013. “We are working aggressively to identify and correct errors and we are adopting a series of reforms to improve.”
“When appropriate to do so, we hold people accountable,” she said.
According to her official biography, Lewis-Payton served as deputy regional director from 2004 to 2008, making her responsible for day-to-day operations when the hospital was carrying out the purportedly faulty radiological work.
Senior VA officials have been aware of the matter for at least six years.
In 2007, Dr. Margaret T. Hatten, a radiologist at the Jackson center, emailed the VA Undersecretary for Health, Dr. Michael J. Kussman, laying the blame for missed diagnoses squarely at the feet of a fellow Jackson radiologist.
To increase his compensation on a per-image basis, she wrote, Dr. Majid A. Khan, who served at the Jackson VA from 2003 to 2007, had allegedly taken for himself an unfairly large share of radiological images that were designated as more lucrative to review.
Hatten accused Khan of speed-reading through so many that he failed to notice glaring anomalies.
“There are many veterans who have been hurt and it is no coincidence that Khan’s name is attached to an unacceptable number of misses which have [led] to patients’ later returning inoperable and/or experiencing greater morbidity than they should have,” Hatten wrote in one 2008 message copied to James B. Peake, then the secretary of Veterans Affairs.
Khan, currently working as a radiologist at the nearby University of Mississippi Medical Center, did not respond to a request for comment left at his office. Tom Fortner, a medical center spokesman, said the center was reviewing the allegations.
According to Hatten’s April 2008 email, Khan admitted in front of several witnesses that he did not in fact examine every image he reviewed, saying: “I don’t have time to. If I looked at all the images, we would have to hire more radiologists.”
Over a seven-month period between 2006 and 2007, Khan also spent up to half of his workday interpreting MRI imagery for the University of Mississippi Medical Center, his current employer, all while “looking at images like a rapid movie reel,” Hatten claimed.
Her log of Khan’s alleged diagnostic misses helped form the basis of a lawsuit brought by her and two other Jackson radiologists alleging that Khan and his immediate superior, Dr. Vipin S. Patel, who at the time was chief of radiology, had put themselves ahead of other Jackson radiology staff and created a hostile work environment. (The lawsuit had already been filed at the time of Hatten’s 2008 email to Kussman.)
Khan and Patel are both of South Asian ethnic origin. And, in language that was at times irate, Hatten accused Patel in her email of “actively trying to promote his own kind” by favoring Khan.
However in her email she denied that she and her fellow staff harbored any prejudice “because there are 3 others with his or similar national origin for whom we do not have these concerns.”
At trial in 2010, Khan testified that the occasional diagnostic failure was part of radiology.
“Your clients sitting over there, although they read far less than me, I have cases that they missed,” he said, according to a trial transcript. “Margaret missed a lung mass in a lumbar spine MRI, which I picked up on the CT. Linda has missed a sacral tumor, which I told her and she added an addendum. Brighid has missed acute infarcts.”
“In radiology it’s just like that. There’s no radiologist in the world that has not missed a finding.”
However, Hatten testified at length, describing a productivity rate by Khan that sometimes involved reviewing hundreds of pages in just minutes.
In March of 2007, she told the court, Khan in one instance signed off on four MRIs and a CT scan in fewer than 20 minutes. The next month, Khan completed four exams, including a CT of the head and two MRIs of the spine, in just two minutes.
“You cannot look at an MRI of the lumbar spine and the cervical spine and a head CT in two minutes and do it properly,” she testified, estimating that that this would involve a total of 200 to 300 images.
Hatten and Drs. Brighid McIntire and Linda L. Finnegan were together awarded $185,000 in back pay from the VA after a jury found that the three women had suffered gender discrimination, a hostile work environment and retaliation for their complaints about the department.
While the jury found that there was bias in Khan’s favor at the hospital, it did not determine whether the complaints about his work were true.
After a whistleblower complaint was lodged last year with the Office of Special Council in Washington, the VA said an internal investigation had not substantiated the speed-reading claims against Khan, who had spent 26 hours more per month than his colleagues had in reading images, according to the Office of Special Counsel.
Two separate prior reviews of Khan’s cases, including one with a sample size of 321, resulted in an error rate of 3.7 percent, which was not abnormally high. The VA said it could take further action if its chief radiology consultant, Dr. Charles Anderson, identified a proper sample size for review.
The VA said its investigation also found that Khan’s remarks about not reviewing every image in fact referred to his decision not to re-read a particular image in a case in which he had already identified an abnormality.
However the VA did commission an outside study by a company called Lumetra, which found that of the 58 cases identified by the plaintiffs, 31 gave reason for a high level of concern and a total of eight were deemed to have had moderate to high impact on patients.
Lumetra nevertheless said the 58 cases were not a random sample and might not reflect Khan’s performance overall.
In commentary on the VA response, a whistleblower, Dr. Charles G. Sherwood, a former ophthalmologist at the Jackson VA and a witness in the plaintiffs’ trial, told the Special Counsel’s office that that the VA’s response was mere “smoke and mirrors.”
Multiple witnesses had testified that they understood that Khan was speaking generally about his work, not about a single case.
He also said the VA had ignored Khan’s double duty for the university medical center and that it was unclear whether Lumetra had received anything other than Khan’s image studies even though additional documents would be necessary for a proper peer review.
In 2007, a VA administrative board recommended that a review of 2,000 to 3,000 of Khan’s cases be undertaken. However a separate panel that the hospital convened, called a Professional Standards Board, said this was unnecessary.
In responding to the Special Counsel this year, the VA acknowledged that there was an appearance of bias in favor of Khan by the leader of the Professional Standards Board.
Officials at the Jackson VA believed a review of 3,000 cases would cost $300,000, or $100 per case, which Sherwood said offered “an indirect measure of the value put on the life of a veteran.”
Trial testimony indicated that four patients had filed grievances internally at the VA in cases where Khan was accused of errors, including missing a case of colon cancer. VA officials have said that only two of Khan’s patients received “institutional disclosures,” or formal notices of medical error.
There was no sign, however, that any of the remainder had been contacted.
In congressional testimony on Nov. 13, Dr. Gregg Parker, chief medical officer for the South Central VA network, which includes the Jackson center, told lawmakers that the 58 cases from Hatten’s lawsuit had been referred earlier this month to the VA’s Office of the Medical Inspector.
This was being done “so that they can finally bring closure to any concerns” about those cases, said Parker.
According to Sherwood, the whistleblower, the Mississippi State Board of Medical Licensure, a regulatory body for doctors in the state, has subpoenaed files concerning the 58 patients whose conditions were allegedly overlooked by Khan.
Dr. H. Vann Craig, the board’s executive director, told 100Reporters that he could not confirm the existence of any investigation.
“I will tell you this. The VA has been less than cooperative,” he said. “We have asked questions of the Jackson VA and they have not been responsive.”
In her letter to President Barack Obama in September, Lerner, the Special Counsel in Washington, said it was “increasingly difficult to believe that the agency’s past reviews of Khan’s work were objective or sufficient.”
“[I]t is not reasonable to conclude that the agency’s prior reviews of Khan’s work ensure that no additional patients have been harmed or that management’s responses have been sufficient.”
The Department of Veterans Affairs did not return telephone calls seeking comment.
Slater, the kidney patient, said he believed that his care at the hospital had improved as a result of a recent appearance on national television.
“Suddenly, because I was on TV, I’m going to be referred to a renal specialist,” said Slater, 64.
Slater said blood analysis as far back as 2004 had indicated that he had chronic kidney disease but that this had gone untreated until he discovered it himself after accessing his own medical records on the Internet in 2009.
“At least with all the attention they’re getting, they’re talking about it,” he said. “I’m pretty disgusted with ‘em. I’m givin’ ‘em a second chance but I’ve also got me an outside doctor.”
“Let me put it this way. They ain’t gonna do no surgery on me.”
Slater said his disease had greatly diminished his quality of life, requiring him to stay near a toilet and preventing him from playing with his grandchildren as much as he would like to.
“Other people have diseases that cause the same thing but mine could have been prevented,” he said.
Slater said he served as an infantryman in places including the Mekong Delta and that he was present for the Tet Offensive of early 1968.
“You realize we weren’t welcome coming home. The fear of speaking out is as real as the sun coming up, because you don’t know what they’ll do,” he said. Other veterans, he added, were scared to complain publicly for fear of losing their medication or being denied care.
“I was just fed up,” he said.
Retired Air Force Major General Erik Hearon, who has been active in criticizing patient care at the Jackson medical center, said Slater was not alone.
“That’s a very common belief among the veterans, that they’ll cut off their prescriptions and appointments,” said Hearon, who has been outspoken in calling attention to problems at the Jackson VA hospital.
Another medical center patient, who said he was an Army veteran of three conflicts extending back to World War II, asked not to be named for precisely this reason. But he said the level of care at the he had received at the Jackson center was poor.
“You go in there and there’s something wrong with you, they’ll diagnose it and give you some pills but there’ll be no follow-up,” he said.
In an interview, Sherwood, the whistleblower, spoke of “enormous personal disappointment” in the way the VA, where he had spent more than 30 years of his own career, had conducted itself in Khan’s case.
Sherwood pointed in particular to trial testimony about a memorandum purportedly composed at VA headquarters in Washington which directed Hatten to channel future complaints “through your chain of supervision,” something she viewed as a “gag order.”
“There was no curiosity displayed by anybody in the administrative chain of command about these patients and whether this was real,” he said.