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Anatomy of a Tragedy

Dr. Christopher Duntsch’s patients ended up maimed and dead, but the real tragedy is that the Texas Medical Board couldn’t stop him.
by Published on
Justin Clemons
Mary Efurd

In late 2010, Dr. Christopher Duntsch came to Dallas to start a neurosurgery practice. By the time the Texas Medical Board revoked his license in June 2013, Duntsch had left two patients dead and four paralyzed in a series of botched surgeries.

Physicians who complained about Duntsch to the Texas Medical Board and to the hospitals he worked at described his practice in superlative terms. They used phrases like “the worst surgeon I’ve ever seen.” One doctor I spoke with, brought in to repair one of Duntsch’s spinal fusion cases, remarked that it seemed Duntsch had learned everything perfectly just so he could do the opposite. Another doctor compared Duntsch to Hannibal Lecter three times in eight minutes.

When the Medical Board suspended Duntsch’s license, the agency’s spokespeople too seemed shocked.

Dr. Christopher Duntsch
Dr. Christopher Duntsch

“It’s a completely egregious case,’’ Leigh Hopper, then head of communications for the Texas Medical Board, told The Dallas Morning News in June. “We’ve seen neurosurgeons get in trouble but not one such as this, in terms of the number of medical errors in such a short time.”

But the real tragedy of the Christopher Duntsch story is how preventable it was. Over the course of 2012 and 2013, even as the Texas Medical Board and the hospitals he worked with received repeated complaints from a half-dozen doctors and lawyers begging them to take action, Duntsch continued to practice medicine. Doctors brought in to clean up his surgeries decried his “surgical misadventures,” according to hospital records. His mistakes were obvious and well-documented. And still it took the Texas Medical Board more than a year to stop Duntsch—a year in which he kept bringing into the operating room patients who ended up seriously injured or dead.

In Duntsch’s case, we see the weakness of Texas’ unregulated system of health care, a system built to protect doctors and hospitals. And a system in which there’s no way to know for sure if your doctor is dangerous.


Up until 2003, medical care in Texas was regulated by a system of checks. Hospital management, the court system and the Texas Medical Board formed a web of regulation that penalized and prevented bad care.

But in the past 10 years, a series of conservative reforms have severely limited patients’ options for holding doctors and hospitals accountable for bad care. In 2003, the Republican-dominated Texas Legislature capped pain-and-suffering damages in medical malpractice lawsuits at $250,000. Even if a plaintiff wins the maximum award, after you pay your lawyer and your experts and go through, potentially, years of trial, not much is left.

The Legislature has also made suing hospitals difficult. Texas law states­ that hospitals are liable for damages caused by doctors in their facilities only if the plaintiff can prove that the hospital acted with “malice”—that is, the hospital knew of extreme risk and ignored it—in credentialing a doctor. But the Legislature hindered plaintiffs’ cases even more by allowing hospitals to, in most cases, keep credentialing information confidential. In effect, plaintiffs have to prove a very tough case without access to the necessary hospital records. This is an almost impossible standard to meet, and it has left hospitals immune to the actions of whatever doctors they bring on. Hospitals can get all of the benefit of an expensive surgeon practicing in their facility and little of the exposure. This has freed hospitals from the fear of litigation, but it’s also removed the financial motivation for policing their own physicians.

The medical malpractice cap and the near-immunity for hospitals snapped two threads from the regulatory web. What remained was the Texas Medical Board.

But the Medical Board wasn’t designed to be an aggressive enforcer. It was mostly designed to monitor doctors’ licenses and make sure the state’s medical practitioners are keeping up with professional standards. The board’s mandate, spelled out in the Medical Practice Act, recognizes a doctor’s license as a hard-won, valuable credential. Doctors’ rights are to be protected at every step of the process. The board can’t revoke a license without overwhelming evidence, and investigations can take months, with months or years of costly hearings dragging on afterward. The protections make some sense. The Legislature doesn’t want the Medical Board taking a doctor’s license—and livelihood—unnecessarily or based on flimsy or frivolous claims. But the result is that unless a doctor is caught dealing drugs or sexually assaulting patients—or is convicted of a felony—it is difficult to get his or her license revoked.

What all this means is that the Texas Legislature has committed the state to a policy of medical deregulation—a free-market system in which doctors can practice as they please with limited government interference. Only their consciences, and those of their fellow doctors, limit them.

Into this milieu rolled Christopher Duntsch, M.D., like a 100-year storm.

When he moved to Dallas in late 2010, Duntsch was 41 years old, fresh out of a residency program at the University of Tennessee Health Science Center’s Department of Neurosurgery in Memphis. In 2011, he founded a neurosurgery practice, Texas Neurosurgical Institute. He hired a marketing team and nurses. In November 2011 he was granted surgical privileges at Baylor Regional Medical Center of Plano. He put together a website and began bringing in patients.

Dr. Randall Kirby was another surgeon at Baylor Plano. In January 2012, he assisted on one of Duntsch’s surgeries. Kirby had spent 16 years performing general surgery in the Dallas area, in which time he’d assisted on more than 2,000 spine operations. Duntsch, he said, was the worst.

As they dressed for surgery, Duntsch boasted to Kirby that he was the best neurosurgeon in Dallas. “He felt,” Kirby wrote to the Texas Medical Board a year later, that “most of the spine surgery being done in Dallas was malpractice, and he was going to have to clean things up.”

The operation was a spinal fusion in which two vertebrae are joined; surgeons use a metal plate to help hold the vertebrae together. The procedure can improve stability in the back, according to the Mayo Clinic, and relieve pain. Among neurosurgeons, the procedure isn’t considered terribly difficult. Kirby said Duntsch had problems at nearly every step of the operation. He seemed to have a hard time moving organs and blood vessels out of the way, according to Kirby. He nicked the patient’s vertebral artery, causing the space he was working in to fill with blood. He then had trouble moving the plate into place.

“His performance,” Kirby wrote, “was pathetic . . . He was functioning at a first- or second-year neurosurgical resident level but had no apparent insight into how bad his technique was.”

After surgery, the patient, Barry Morguloff, woke up in more back pain than he’d started with and had no feeling in his left leg. For the next several months, he was in constant pain, according to Mike Lyons, his attorney. Scans later revealed bone fragments from Morguloff’s vertebrae lodged in the nerves of his back, according to Lyons.

Three weeks later, Duntsch performed a spinal fusion on Jerry Summers, a childhood friend. During the surgery, Duntsch sliced into one of the arteries running down Summers’ spine, causing massive bleeding, which he tried to staunch by packing coagulants around the wound. When Summers woke up he couldn’t move his arms or legs. Rather than immediately ordering scans to find out what was wrong, Duntsch moved on to other patients, according to Kirby’s letter to the Medical Board.

Baylor brought in a senior surgeon to fix the damage to Summers’ spine. His report was damning. He blamed Summers’ paralysis on Duntsch’s “surgical misadventures,” which had led to the artery being cut; the final straw, he wrote in his report, had been the packing of coagulants around the cut, which had seriously damaged Summers’ spinal cord. Topping it all off had been Duntsch’s failure to order tests and re-operate on Summers in a timely manner—a delay that likely cost his childhood friend the use of his arms and legs, according to the senior surgeon’s report. Summers remains paralyzed.

Following Summers’ surgery, Baylor Plano suspended Duntsch for 30 days—after that, he was supposed to be supervised on every surgery he performed, according to Kirby.

But Baylor didn’t hold him to that. Soon after Summers woke up paralyzed, a woman named Kellie Martin came to see Duntsch at Texas Neurosurgical Institute. She was 55 and had been experiencing persistent back pain after a fall at home. When physical therapy didn’t relieve the pain, her family doctor suggested she see a certain neurosurgeon—but the doctor couldn’t find that surgeon’s card, so she suggested Duntsch instead. She said Duntsch came highly recommended.

Kellie Martin and her husband, Don, went to see Duntsch, who suggested a procedure called a microlaminectomy, in which part of the spine is removed to relieve pressure on the nerves.

“He sounded impressive,” Don said. “He talked impressive. He was very eloquent in stating the causes and the need for the procedure. He felt confident. We felt confident too.”

Kellie Martin went into surgery on March 12, 2012. It was supposed to be a simple procedure, which is, perhaps, why Baylor didn’t put anyone in the operating room to supervise Duntsch. Don Martin, who was waiting outside, was told the operation wouldn’t take more than 45 minutes. Forty-five minutes passed, then an hour, two hours, with no word.

Don was a lieutenant with the Garland Police Department, and had spent enough time in hospitals to know this delay wasn’t a good sign. He went to the operating room and asked to speak to the doctor. When Duntsch came out, he told Don there had been “some complications,” and that Kellie would have to stay the night, but that the operation had gone fine.

Duntsch went back into the operating room and left Don waiting. He waited until they told him his wife had been sent to the intensive care unit. Then he waited for several more hours until the nurses came out to tell him and his daughters that Kellie Martin was dead.

Kellie Martin
Photo courtesy of the Martin Family.
Kellie Martin in Cape Cod, 2010 (left). Don and Kellie on their wedding day, June 6, 1979.

The Collin County medical examiner who performed the autopsy was so astounded by what had happened to Kellie Martin’s body that he brought her back in for another examination. He listed the cause of death as “therapeutic misadventure,” according to his report. During surgery, Duntsch had sliced through one of the arteries alongside Martin’s spine, as he had with Summers. Unlike with Summers, though, he hadn’t noticed in time, and Martin bled to death, according to Texas Medical Board records.

Martin’s surgery was Duntsch’s last at Baylor. He resigned soon after, with full clinical privileges. By all appearances, he had simply decided to leave.


After his wife died, Don Martin found himself at a loss. “My whole world crashed,” he said. “I thought, this couldn’t have happened. It was supposed to be such a simple procedure. It was horrible. When I think about it, it’s just devastating.”

When I spoke to him, a year after his wife’s death, he told me that they had trusted Duntsch, and that there had been no sign suggesting they do otherwise. “Maybe,” he sighed, “we should have gotten a second opinion.”

But a second opinion wouldn’t have helped. Kellie Martin was in good health; a laminectomy is considered a minor procedure. There’s no reason to assume another doctor would have advised her differently. But no one bothered to tell the Martins—and there was no way for them to know—that their doctor had left a man paralyzed a month before in a case in which the hospital’s own surgeons found him at fault.

One might think that if a doctor had paralyzed one patient and had another die in the course of a month, it would be someone’s job to figure out why. But as in many other areas in Texas—benzene pollution from hydraulic fracturing sites; ammonium nitrate pileups at fertilizer plants—Martin’s death and Summers’ paralysis fell into a regulatory no man’s land. Once Duntsch left Baylor, he was no longer the hospital’s problem. The only entity that could stop Duntsch from seeing more patients was the Texas Medical Board.

But the board is limited in its ability to investigate malpractice. For one thing, it can open a case only if it receives a written complaint—akin to a police department that forbids its officers from investigating criminal activity they witness. With the exception of pain management clinics and anesthesiologists, the board doesn’t have the authority to inspect a doctor, or to start an investigation on its own.

During the summer of 2012, as Duntsch was searching for a new hospital, another doctor who had witnessed Duntsch’s errors at Baylor sent a complaint about Duntsch to the Medical Board, according to Kirby.

That complaint was filed—along with the 6,000 to 8,000 other complaints the Medical Board receives each year, in addition to the thousands of licensure applications the agency’s 156 employees must review. The process for resolving complaints is slow and painstaking, set up in statute to guarantee doctors the maximum legal protection. First, the Medical Board staff has to screen every complaint and has 45 days to decide whether the agency will act on it. If the board decides to act on a complaint—and only one in four complaints makes it that far—investigators begin subpoenaing hospital records, which the board will eventually send to a pair of volunteer doctors in the same specialty who will review the case (if they disagree, a third doctor has to be found to break the tie). These doctors are busy—they have practices of their own that pay a lot better than volunteering for the Medical Board—and there aren’t many of them. In a specialized field like neurosurgery, that means further months of delay.

Once the case has been put together, the investigators will make a recommendation to the board itself, a group of 12 physicians and seven laypeople appointed by the governor. They know if they try to discipline a doctor, the burden of proof will be on them. A poorly put-together case can mean months or years of expensive litigation. So the board members tend to act conservatively. They move slowly and only take action they’re reasonably sure will be effective. It takes the Texas Medical Board an average of nine months to resolve complaints. Some drag on for years.

And all the while, until their cases are resolved, doctors—even those accused of the most heinous malpractice—can continue to practice. Even the fact that the board is conducting an investigation remains confidential until the investigation is over. It’s left to hospitals to police their doctors.

In July 2012, four months after Kellie Martin’s death, Duntsch applied for surgical privileges at Dallas Medical Center. The hospital conducted an initial background check on Duntsch, and he came up clean. So while hospital administrators did a deeper background examination, they granted Duntsch temporary privileges.

It’s not clear how much Dallas Medical Center officials knew about Duntsch’s past or how much Baylor told them. Neither hospital would talk about Duntsch for this story. The answer, in both cases, seems to be very little. According to Baylor, Duntsch had clinical privileges when he resigned. As for what Baylor told Dallas Medical Center, a Baylor spokesperson said in a statement to the Observer that, “It has been the longstanding policy of Baylor to respond with comprehensive information when it receives a proper inquiry from another hospital. Because the credentialing process is deemed confidential under Texas Law, we are not permitted to discuss specific physicians or specific requests other than to say all policies were followed.”

Dallas Medical Center also declined to comment, citing privacy concerns. But according to Dr. Robert Henderson, another neurosurgeon at Dallas Medical Center, the “comprehensive information” Baylor sent over when Duntsch applied consisted of an email saying that there were no issues with Duntsch’s performance, that he’d been on staff and had voluntarily resigned.

Henderson says that Duntsch told the Dallas Medical Center administration about the Martin and Summers cases, but explained that the outcomes hadn’t been his fault: Summers, he said, had been paralyzed by a bad drug interaction, and Martin had died because of complications from anesthesia. He didn’t tell them about Baylor’s internal reports that faulted him in both cases, according to Henderson. Duntsch’s explanation, along with the email from Baylor, was enough to get him a trial run of five surgeries at Dallas Medical Center.

“I think their rationale was, he’s a trained neurosurgeon, a combined M.D.-Ph.D.,” Henderson said. “How much risk can there be?”

The first three surgeries of Duntsch’s trial took place on three consecutive days in July 2012, a month after the first complaint against him with the Texas Medical Board. The first surgery went fine. In the second, while doing a cervical fusion on a woman named Floella Brown, Duntsch “removed a bone from an area that was not required by any clinical or anatomical standards, resulting in injury to the vertebral artery,” according to Texas Medical Board records. Brown was later found unresponsive in her hospital room and staff couldn’t contact Duntsch for 90 minutes, according to those records. Brown had suffered excessive blood loss and a stroke, according to the agency. By the time she was transferred to UT Southwestern Medical Center later that day, she was brain dead. As she lay dying, Duntsch performed his third surgery, on a woman named Mary Efurd. Another spinal fusion; another routine procedure. Efurd woke up after surgery in horrible pain, barely able to move her legs.

Two days later, once Efurd was stable, Henderson was assigned to do the repair surgery. A CT scan found that the metal spinal fusion hardware, meant to be placed on the patient’s spine to keep the vertebrae from moving, was sunk into the muscles of her lower back, inches from her spine.

Henderson went in to remove it. He had been a neurosurgeon for 40 years and what he saw inside Efurd’s back shocked him.

“He had amputated a nerve root,” Henderson said. “It was just gone. And in its place is where he had placed the fusion. He’d made multiple screw holes on the left everywhere but where he had needed to be. On the right side, there was a screw through a portion of the S1 nerve root.”

At first, Henderson thought Duntsch might be an impostor. He faxed over a picture of Duntsch to the residency program at the University of Tennessee Health Science Center to see if Duntsch had graduated.

“I couldn’t believe a trained surgeon could do this,” Henderson told me. “He just had no recognition of the proper anatomy. He had no idea what he was doing. At every step of the way, you would have to know the right thing to do so you could do the wrong thing, because he did all the wrong things.”

But the school told Henderson that Duntsch had completed the residency program. He was horrified to realize that Duntsch was going to keep practicing. After a few calls to various Dallas-area medical societies, someone suggested he call the Medical Board.

“So I called them up, and they said, ‘Will you fill out a complaint, and we’ll probably read the complaint in about 30 days, and we’ll start an investigation after that.’

“I said, ‘You don’t seem to understand. This guy already killed somebody, made another a quad, made a partial paraplegic out of my patient.’ I said, ‘He needs to be stopped. Not only shouldn’t he be operating, he shouldn’t be making any decisions about treatment or pathology.’ It had no effect whatsoever.”


After the Brown and Efurd debacles in July 2012, the CEO of Dallas Medical Center, Dr. Corazon Hernandez, fired Duntsch and reported him to the Medical Board, according to Henderson.

Over the next year, the Medical Board would receive at least six more complaints from doctors who had seen Duntsch’s work up close. Doctors, and then, later, lawyers would call the board’s investigators and sometimes even the board members themselves, begging them to do something. They all received the same response Henderson had: Send us what you have, and we’ll get back to you.

We now know that the Texas Medical Board was working behind the scenes in summer 2012, trying to find grounds to temporarily suspend Duntsch’s license. The temporary suspension was a power the Legislature gave the board in 2003. For the first time, the board could suspend without a hearing doctors who “constituted a continuing threat to the public welfare,” i.e., cases where the public couldn’t afford to wait for the full board proceedings. For a temporary suspension, the standard is even higher than the board’s other enforcement actions. It isn’t enough to prove that a doctor did something awful. To suspend a license, as one Medical Board staffer explained, there has to be enough evidence to prove a pattern.

And while the Medical Board investigated, the pattern continued. If you were a patient in the Dallas area around this time looking for a spine surgeon, there would have been nothing to suggest that Duntsch was a risky choice. Because investigations are confidential, Duntsch’s public record with the Texas Medical Board remained clean. On the online doctor-rating site, he had 4.5 stars out of five. He had a slick marketing team in Best Docs Network, a physician PR company that pumps out infomercials to local TV stations. In one, Duntsch tells the story, over stock footage of an operation, of a taxing back surgery he performed on an older woman. The surgery, he said, beaming into the camera, was a resounding success. “And the only thing she complained about was she couldn’t find what she wanted to watch on TV.”

Meanwhile, he was continuing to get patients, continuing to operate. In December 2012, he performed a cervical fusion at Legacy Surgery Center of Frisco that left his patient with paralyzed vocal cords—an unheard-of complication. In January, one of his patients at University General Hospital Dallas woke up paralyzed from the waist down, according to the patient’s lawyer.

None of this hurt his career. At the end of May 2013, Kirby and Henderson received invitations to a celebratory dinner, courtesy of University General Hospital, to meet their new neurosurgeon, Dr. Christopher Duntsch, at an expensive uptown restaurant.

Kirby called the owner of University General. “I called them and said, ‘He’s bad news, multiple members have reported him to the Med Board.’”

According to Kirby, the hospital owner told him that Duntsch had privileges to do only minimally invasive surgeries.

It was a minimally invasive surgery, Kirby said, that killed Kellie Martin.

Jeffrey Glidewell
Jeffrey Glidewell

Two weeks later, on June 14, 2013, Kirby got a call to come to University General to do a recovery surgery on one of Duntsch’s patients. The surgery had gone so badly, Kirby later wrote to the Medical Board, that the rest of the OR team had to physically restrain Duntsch from continuing. For two days the patient, Jeffrey Glidewell, lay unattended in the ICU while Duntsch made excuses to the family. Finally the family fired him. When Kirby saw Glidewell, he later wrote the Medical Board, he was “horrified.” The incision, he wrote, was cut into Glidewell’s throat “two or three inches lower and an inch midline from where it should have been oriented … saliva and pus were coming out of the wound.”

Duntsch, it turned out, had, as with other patients, cut into Glidewell’s vertebral artery; an MRI found that he had also left a sponge festering in the soft tissue of Glidewell’s throat.

Later in June 2013 Kirby sent a sworn statement to the Medical Board in which he laid out all of Duntsch’s patients he knew about and included reports from many of the surgeons who had worked on them. Near the end of his report, Kirby wrote, “The [Medical Board] must stop this sociopath Duntsch immediately or he will continue [to] maim and kill innocent patients.” Perhaps it was the completeness and forcefulness of his presentation, perhaps it was the fact that another neurosurgeon had just joined the board, and he understood as none of the rest did the severity of what Duntsch had done. Whatever the reason, this time the board acted. On June 26, the board held an emergency meeting and suspended Duntsch’s license.

More than a year had passed since Kellie Martin’s death and the complaint that started it all. In the time between the first complaint to the board, and when Duntsch was finally stopped on June 26, five of his patients were seriously injured and one died.

Until the day of the suspension, if you had looked Duntsch up on the Texas Medical Board website, you would have found him a physician in good standing.


After his license was suspended, Duntsch disappeared. At his home and office, my calls rang and rang before going to voicemail boxes that were full. It’s not clear how such a well-trained surgeon could have performed so disastrously, but the June 26 Medical Board report offers a hint: “Respondent is unable to practice medicine with reasonable skill and safety due to impairment from drugs or alcohol.”

Duntsch’s license is currently on temporary suspension pending further action by the board. In the aftermath of the debacle, the doctors who saw Duntsch’s handiwork were left to make sense of what happened.

Kirby, the surgeon from Baylor, was philosophical. “This is a once-in-a-generation occurrence, that we have someone off the rails this bad—this is why no one saw this coming.”

Most of the doctors on the Medical Board, he pointed out, aren’t surgeons. “They just can’t comprehend that an M.D.-Ph.D. neurosurgeon could do what Christopher Duntsch was doing. Like pilot training—you don’t expect a trained pilot to get drunk and fly his plane into the ground.”

But it’s more complicated than that. Duntsch was an anomaly, one of the worst malpractice cases Texas has seen in decades. (So far only Mary Efurd and the family of Floella Brown have filed suit against Duntsch, though the other patients or their families have all retained counsel as well.)

But Duntsch was an anomaly for another reason: the barrage of complaints to the board. This was a very rare phenomenon—most of the doctors who reported Duntsch had never filed a report before. Duntsch’s case raises the question: If it took a year to stop a doctor accused of this much, what else is getting through?

In 2012, the public interest research group Public Citizen commissioned a research project to cross-reference doctors sanctioned by the Texas Medical Board with those listed in the National Practitioner Databank, managed by the federal Department of Health and Human Services. Every time a doctor loses clinical privileges at a hospital, or has them suspended, hospitals are required by law to notify the National Practitioner Databank. Public Citizen found that 793 Texas doctors had lost clinical privileges between 1990 and 2011.

Many of them had committed serious practice violations. Their fellow physicians had found them committing such offenses as malpractice, sexual assault and drug use.

But Public Citizen found that of those 793 doctors, the Texas Medical Board had taken serious action in less than half the cases.

Among these doctors who escaped Medical Board action was one who racked up 22 malpractice suits over 12 years, totaling $2.4 million in judgments, for such things as performing unnecessary or harmful procedures or, in one case, removing the wrong body part, according to the federal database. Though the Texas Medical Board is required by statute to investigate any doctor with more than three malpractice suits, no action was ever taken against the doctor by the state. (And the National Practitioner Databank doesn’t make doctors’ names public, so we don’t know who they are.) Though a hospital peer review took this doctor’s privileges in 2006, he continued to practice for three more years until he retired, according to federal records.

Another had 13 civil judgments against him, including for wrongful death, permanent injury and two cases of removing the wrong body part. In this case, as well, the Texas Medical Board took no action, according to Public Citizen.

Even when the board does sanction a doctor, those sanctions are often light—even in cases in which the doctor is badly impaired. In 1998, the board found Dr. Greggory Phillips to be addicted to painkillers, and that he was prescribing painkillers to himself and family members. The board suspended his license but then immediately stayed the suspension and gave him probation. In 2007, he was found to be leaving presigned prescription pads with his nurse so she could prescribe controlled substances while he was away, according to Public Citizen. In 2008 one of his patients died of a prescription drug overdose after he had prescribed her a lethal dose of the painkiller Tramadol. The patient’s mother complained to the Medical Board. While that complaint worked its way through the system, another of his patients died of a hydrocodone overdose. The board, when it finally handed down an order in 2011, faulted him for both deaths. The board fined him $3,000, assigned him a monitor, and required him to take classes in medical recordkeeping. In February 2013, for unclear reasons, the board took his license.

And then there was the 2011 case of Dr. Rolando Arafiles, the West Texas doctor who sicced the county sheriff on two nurses who dared report him to the Texas Medical Board (see “Intent to Harm,” March 2011). Before moving to West Texas, Arafiles had run a small alternative clinic in Victoria, peddling chelation therapy, a fringe cure that is supposed to rid the body of heavy metals. One patient had a stroke following a chelation therapy. A Medical Board investigation later found that Arafiles’ assistant was inappropriately prescribing stimulants and diuretics to patients. The board forbade Arafiles to supervise nurses or physician assistants anymore. But a few years later, he popped up in Kermit doing just that—as well as selling drugs out of the operating room and performing bizarre surgeries he hadn’t been trained for. In June 2010, following the media circus around the prosecution of the Kermit nurses, they filed a complaint against him. Yet Arafiles didn’t surrender his license until November 2011, after he had been convicted of a felony.

These doctors are anomalies too. The point isn’t that all doctors are dangerous, or even that any more than a tiny minority are. But in Texas, when you go to see a doctor, there is a small but real chance that the doctor has been found by his or her peers to be a danger to the public, and that no one has bothered to do anything about it yet. That as you walk into the waiting room of a Christopher Duntsch or Greggory Phillips or Rolando Arafiles, somewhere, in some office in Austin, the parties the state has deemed responsible are sitting at desks quietly investigating.


At one point Dr. Henderson sent me a tape of a conversation he had with the main Medical Board investigator assigned to Duntsch’s case. The conversation took place in January 2013, after it had become clear that Duntsch would practice until someone stopped him, six months before anyone actually did. On the tape, Henderson demands to know why Duntsch is still practicing.

The investigator, Maria Lopez, lets him yell. When she responds, she’s quiet.

“Sometimes we know that someone’s bad, but when it comes to taking them to a hearing and proving it to where we can actually do some disciplinary action, it takes time of gathering evidence. … Unfortunately, sometimes it takes longer than we want.”

What Henderson took from this, he told me, is that “we’re dealing with people who don’t do the job they are hired to do.”

But it’s more complicated than that. Before we ask if the board does its job, we have to ask what is the job the Legislature assigned to the board, and what resources the board gets to do that job.

Texas’ number of license applications has grown every year since 2003, when medical malpractice damage caps passed. Every year the board is both overseeing many more doctors and bringing in more money. But it doesn’t get to keep much of it: In fiscal year 2013, the board sent almost $40 million to the state’s General Revenue fund, of which it got about $11 million back. (Like other state licensing agencies—the Pharmacy Board, the Nurse Practitioner Board—the Medical Board operates at a surplus for the state.)

Public Citizen concluded that the board moves slowly because it’s understaffed and underfunded. But when I talked to Medical Board spokesperson Megan Goode about this, she said Public Citizen had it wrong—that the board isn’t underfunded at all. Things were rough during the state budget crisis in 2011, but now hiring is back up to normal.

The problem, she said, isn’t staff. In an official statement, she wrote, “The way the law is currently written, with a high bar of evidence for the board to meet, the process can take time so that the board can build a solid case. It would clearly be a policy decision for the Legislature to consider whether the process or the standards for evidence required for a temporary suspension need to change.”

Leigh Hopper, formerly the Medical Board spokesperson, put it more bluntly. “You could have a Medical Board that’s the size of the [Texas Department of Public Safety],” she said, “but the state doesn’t want that. It’s more or less satisfied with the way that things work.”

We have to consider the uncomfortable possibility that Christopher Duntsch is to the medical system what the recent West explosion was to the fertilizer industry—a regrettable tragedy, but the price of living in a free-market system. And that with Duntsch, as with other bad doctors, the system worked exactly as it was designed to.

  • NWB

    There is no regulation in Texas of ANY kind. Regulation in Texas only exists to protect the businesses and individuals from the consequences of their actions, just like this so called physician was protected. This is why Angie’s List is the best place to screen your physician. (No, I am not a cyber shill.)

    • Jessica Darko

      Just keep telling yourself that… as if the Medical Board doesn’t exist, or the AMA, etc.

      If it weren’t for the regulatory framework you types have put in place, people would be able to look up the success rate of their doctors.

      Regulations CAUSED this!

      • jrs505050

        texas has GOOD laws. We’re trying to prevent Tesla from selling cars here. Think about the jobs we could lose without these good laws. Texas provides JOBS for people and we have a great governor.

        • NWB

          You are delusional. Most jobs in Texas are minimum wage with no benefits, and many people have to work two or three jobs to survive. If you prevent a company from doing business in the state, that does not create jobs.

          • Cyndee Malowitz

            I believe jrs505050 is being facetious.

        • Chris

          Lol you trolling right?

        • Carygold

          Are you trolling? Preventing Tesla from selling the best rated car in the country in Texas is protectionist. it doesn’t create jobs it prevents them. Also, it protects car companies from competition… You were kidding… Right?

        • jimbo701

          This is a snark, right?

      • JF

        Really? Where would we be able to look up their success rates? That would require the Texas government to create a public database of success rates and require that all medical centers submit information in a timely manner, plus some kind of fine if they don’t comply. These things don’t just organically appear.

        • RickRussellTX

          Those who were wronged would be able to get court orders to review the hospital records, bringing the situation into the open and putting Duntsch where he belonged — at the business end of multiple civil lawsuits.

          Damage caps (remember the damage cap in place for BP?), confidentiality restrictions, state-run medical boards: these are the tools of regulatory capture. This is not a free market, where legal disputes are handled in court and without arbitrary limitations.

          • Thomas Redman

            That would require some kind of regulation to require a hospital to release records to the appropriate persons and a regulatory body to oversee that those regulations are enforced.

          • RickRussellTX

            That “regulation” already exists in the form of civil tort, and the regulatory body is the courtroom. This tragedy happened because those institutions were subverted by protectionist regulatory capture.

          • ImaginaryD

            Quite, but tort reform defanged civil tort claims, and then there was no free market incentives for hospitals to care. If the hospital faced liability it would have made more comprehensive inquiries but in this case they only did what was necessary to show that they did not have “malice”.

          • vippy

            And do not vote for Greg Abbot here in Texas because unlike him, who profited highly from his unfortunate accident, he does not want you to do the same! Hypocrite of the highest order.

      • jimbo701

        There are good regulations and bad regulations. Seems as if the Texas legislature has instituted a bunch of bad regulations with regard to doctors.

    • Final_Word

      Your ignorance is showing.

  • flora68

    After working in the medical field in (Austin) Texas for decades, I thought I’d pretty much heard it all….boy, was I WRONG! I have just finished this excellent article and am sitting here absolutely STUNNED…. I can’t remember the last time anything I read left me literally BREATHLESS, but this did. This should be a freaking movie! Kudos to Saul Elbein.

    As a lifelong Texan, I am very aware that things are dangerously permissive here, in terms of regulations on businesses, doctors, etc., but still, I had NO IDEA that such outrageous malpractice could possibly continue like it did. I know the physicians I worked for would never have believed this possible, not in a million years. I don’t consider myself naive (who does?), but like most Americans, I’d counted on at least a MINIMAL degree of reasonable government protection from the most egregiously dangerous practitioners, like Christopher Duntsch. It’s troubling to realize that in reality, we’re out there with NO protection….

    So my question is, is the problem REALLY “the way the law is currently written”? What is the name/number of that law, and specifically what does it say that hogties the TMA Board so totally? Is there no room for interpretation? Seriously, it’s one thing to have “a high bar of evidence for the board to meet”, but surely this case more than passed that bar long before he was stopped.

    Could the investigators possibly do more, and/or act quicker? Are they partly stymied by fear of litigation? To me their actions made them SEEM insufficiently motivated, utterly lacking the appropriate sense of urgency that those complaints should have generated. But that’s just my take; I could be totally wrong. Maybe they’re very capable and dedicated, and doing all that anyone could possibly do under the circumstances. I’d like to know more about all this.

    I hope they find Christopher Duntsch soon and keep tabs on him; he’s one dangerous dude, hopefully NOT out there, still back-alley-butchering without a license.

    • Jessica Darko

      Yes, freedom is dangerous, and short of totalitarianism, you guys will never be happy. Those people died because of people like you, as much as this surgeon. YOU prevented his patients from being warned, the blood is on your hands. But rather than take responsibility for your evil, you run around screaming that mommy government shold protect you from all the ills of the world— refusing to admit to your self that it was mommy government that created this ill.

      • texasaggie

        The fact that there is a long way between totalitarianism and absolute freedom never seems to make an impression on these Manicheans. That’s part of the problem with being a wingnutter is that there are only two choices to everything, right or wrong.

        Should I buy a steak or not buy a steak? The option of buying a half a chicken doesn’t occur.

    • Final_Word

      “I have just finished this excellent article and am sitting here absolutely STUNNED…. I can’t remember the last time anything I read left me literally BREATHLESS, but this did.”
      LOL. Are you sleeping with the author?

  • Drew

    We don’t have a free market system, so to blame the free market makes no sense. A seventh amendment free from tort reform suppression is a critical part of any free market. We don’t need greater dependence on an obviously inadequate govt bureaucracy. More regulation won’t protect us from tragedies like West or Duntsch. The only thing that will protect us is the seventh amendment. It is the only regulation worth a damn. Great article otherwise, just disappointing to see the misguided attack on the free market.

    • Jessica Darko

      Leftists can’t handle reality, so they must deny it at every turn and blame, naturally, their chosen enemy.

      No matter how much government screws things up, they will always claim the problem is lack of government.

  • George Schwarz

    This is a well-done article. However, as others have
    implied, the “free market” part of the analysis is off-kilter.

    A free market can exist only under certain conditions. One is
    that the buyers and sellers have equal knowledge about the price and the
    quality of the product. There should also be price elasticity, meaning in basic
    terms that the greater the supply the lower the price, everything else being
    equal. We know, based on this article, and on other knowledge this paradigm
    doesn’t work in the health/medical industry.

    In other words, it the most egregious of errors to discuss
    medical care in terms of a free market.

    First, no truly accurate performance information that
    underpins a free market consumer decision exists. Even if the Texas Medical
    Board could act accurately and instantaneously, the fact that it and the NPDB
    are so secretive would vitiate against the free market model. Further, all hospital
    peer review activity is privileged, by law, adding another barrier to the free market
    decision-making. And, everything else being equal and knowing a doctor has a “clean”
    record, how does a consumer judge a provider’s quality. Are there legitimate
    metrics? If so, what are they?

    Second, with intervention of third-party payers, the entire
    pricing paradigm undergirding a free market simply doesn’t exist. (Please, don’t
    rant about the government here. Blue Cross was founded in Waco in 1929 and is only one of many private interveners
    in our medical care.) In fact, if one looks at the history of medicine in the United States,
    doctors didn’t post prices and consumers didn’t generally know prices for the
    services before health insurance.

    Third, we know the number of providers of any medical care
    service no longer impacts the pricing (see above).

    There is so much more to this issue than the free market
    model, of course. There are pressures from BigPharma, medical equipment suppliers
    and other political forces, including how ethically bankrupt many in the industry

    Still, it is important, when looking at health care issues,
    to understand the context when the words “free market” are thrown around.

    George Schwarz, retired health care reporter and former hospital

    Publisher and editor, The Amarillo Independent

    • Randy Yansen

      you forgot no transaction costs, no switching costs…both are high in healthcare once your sick

      • George Schwarz

        You post makes no sense. Please explain. And, tell me why I should take you seriously if you don’t know the difference between your and you’re.

        • Bojorco

          Form vs. content. You’d do well to learn the difference.

        • mmr

          I know the difference between “your” and “you’re” but sometimes I accidentally mix homonyms up when I’m typing quickly. I am neither agreeing nor disagreeing with the original post but it is silly to suggest that a simple typo invalidates somebody’s argument.

    • dudewithlogic

      the news is always a lie never gathering the factys before slandering an individual. dr Duntsch will continue practicing in 6 months via TMB. Aqusations are just that the investigation is closed.

  • gwayne

    This appears to be a great example of criminal unregulated capitalism as it was meant to be. The free market,free from regulations is possible because of the money connection that supplies the texas body politic. Welcome to a republican controlled state. In Europe where the society is far more advanced than the us, they practice the”precautionary principle” of regulated capitalism where such things like what happen in the us do not happen often and then action prevents anyone from murdering as is common in the us.

    • Jessica Darko

      Yeah, just keep telling yourself that. REgulations caused this problem, so rather than admit that, blame “unregulated capitalism”. It’s a shame you fascists live in such denial.

      • John

        …this is a joke, right?

        You gotta know when to hold em and know when to fold em, lady.

      • texasaggie

        You do realize that it’s fascists that oppose regulations, don’t you? From your post I thought at first that you were making fun of the idea that regulations caused this problem and the fascists who are trying to remove them and prevent others from being imposed.

    • Taylor Wilson

      Ok, compare Dallas average medical care, employment, and income, to say a liberal city such as Detroit.

      • texasaggie

        Or San Francisco or Boston or New Haven or any of a vast number of cities that have a much better standard of living than Dallas.

        And everyone does remember that a couple years ago a survey found that McAllen had the highest Medicare costs per capita in the nation. It was found that the whole system there ran on kickbacks and bill padding, but that is SOP in TX.

    • PeterisP

      In this case, free market *requires* regulation – free market requires fully informed buyers/sellers that can make their choices. As patients were unable to know the reputation/history of the doctor, it was a scam market, not a free market – but some regulation that mandates full disclosure could actually make free market economics work there.

    • Old Rich Basturd

      “Advanced” Europe?

      The continent that gave us National Socialism, Fascism, Communism, the international slave trade, imperialism, the Holocaust, ethnic cleansing, eugenics…

      Lay off the liquor, it’s making you sound stupid gwayne.

      • gwayne

        Thank you for contributing a lack of historical perspective, but it’ll take more than that from a rich bastard to change americas warmongering history and citizens united that’s destroyed a once decent place to live thanks to the GOP.

        • Old Rich Basturd

          Take your ignorant whining to North Korea.

          They still believe that nonsense you’re peddling.

  • Jessica Darko

    Standard position of the left— regulation prevents the market from expelling bad actors, so the solution is– wait for it– more regulation! LOL! IF there were no “Texas Medical Board” that could “revoke his license”, and no AMA preventing statistics about surgical success of doctors from being revealed, then patients could find out about these bad doctors before being cut open by them.

    It is your regulations that caused this problem!

    • JF

      Again, how would patients find out about these bad doctors? Magic? No hospital is going to release any kind of success rates or information about outcomes unless they are required to do so! Do you really believe that hospitals would be putting up billboards about “medical misadventures” if only they were legally allowed to do so? I really don’t understand your position.

    • PeterisP

      If there was no Texas Medical Board that could revoke his licence, he would still be practicing today – as evidenced by the number of medical institutions described in the article that were perfectly happy to send patients to be butchered despite knowing his history.

      “Preventing statistics about surgical success from being revealed” is a bad thing, sure – but in this case, noone involved would disclose the statistics anyway unless some regulation would force them.

    • gwayne

      That’s correct except in Texas the regulations are established and controlled with a GOP agenda and it is in that legislative control that insures improper monitoring of butchers somewhat like the EPA is controlled by higher controls that are fulfilling the agendas of corporate criminals who are able to make huge shoe box filling campaign donations from the ill gotten gains that were earned from a total lacking of conscience for anyone suffering any of the consequences.

  • dannoinIT

    The issue is transparency. If hospitals were required to provide details on the number of surgeries each surgeon in practicing at the hospital for a given treatment, the success rate, and the number of follow-up treatments after the initial surgery, patients would be able to make a more informed decision. It is also prudent for a patient to get more than one opinion, preferably from another unaffiliated medical institution. Laws are needed to force transparency.
    Patients tend to trust the doctor and aren’t skeptical about a doctor’s abilities. It is a “free market”, we need to be better consumers of medical services. We also need our state governments to support transparency.

    • gwayne

      I agree totally, but in that lies the problem. The GOP controlled legislature is not willing to strangle the “golden cow”, so anyone under the knife could very well discover another waiting to be uncovered butcher. Welcome to Texass, find another better regulated medal profession as ours is criminally lacking in proper oversight.

    • Cyndee Malowitz

      This could work as long as the physicians weren’t able to “cherry pick” their patients. All of them should be required to perform surgeries on a certain percentage of Medicare/Medicaid patients, elderly patients, etc, so the playing field is level.

  • Toby AndJihad

    The failure of regulatory agencies in Ohio mirrors this story from Texas. The Medical Board of Ohio has had multiple complaints of injury filed against Urologist Jihad Kaouk of the Cleveland Clinic. Foreign training and lacking board certification, he was appointed department head. The Cleveland Clinic was cited two consecutive years for having no credentialing requirements or certification in the Urology department. CMS cited the Cleveland Clinic for six (6) unreported operating room fires in one year, unreported burn injuries to patients, patient burns not charted in patient record, violation of patient’s rights, lack of informed consent, lack of a governing board, etc. CMS cited Jihad Kaouk for performing multiple simultaneous complex major surgeries begining at the same twice per day using residents (without patient knowledge or consent.) Jihad Kaouk, like Duntsch, represented volume experience and surgical outcomes, as well as professional credentials which were false, including a medical license from Iowa to CMS. Complaints to CMS led to six CMS investigations citing to Tobey Cosgrove, Cleveland Clinic CEO, in every one, CMS ““deficiencies cited are significant and limit your hospital’s capacity to render adequate care and to ensure the health and safety of your patients.” There have been no consequences imposed by CMS or by The Joint Commission, on the egregious failures of the The Cleveland Clinic. Instead, they politely suggest the victims file complaints with State Medical Board. As in the /Duntsch case, Jihad Kaouk has had complaints filed by his victims with the State Medical Board since 2009, perhaps earlier. The State Medical Board responds to all inquiries with, “The investigation is open and ongoing,” while Kaouk, like Duntsch, continues to harm patients while the Medical Board of Ohio shows no sanctions or complaints against this doctor. Like Texas, the Ohio Medical Board will sanction physicians convicted of drug violations, sexual assault (provided there are many victims) and violations of illegal use of handicapped parking passes. sic. However, crimes of fraud, alteration of medical records, falsification of medical records, spoliation of medical records and other material evidence, battery, malpractice, and permanent injury due to incompetence require years of investigation and are rarely sanctioned. Ohio, like Texas, has capped damage awards and imposed legal obstacles, making civil complaints by injured patients nearly impossible. Ohio, like Texas, has become a magnet for incompetent and criminal doctors who know they will be protected from prosecution. Confidentiality and legislative imposed laws protect incompetent and criminal doctors. Patients have no rights!

    Please read below the links to six CMS investigations of Cleveland Clinic caused by complaints against Jihad Kaouk and the Cleveland Clinic for which no sanctions have been imposed by CMS, Joint Commission, State Medical Board, or any other oversight agency.

    20100121 CMS Survey

    20100430 CMS Survey

    20120803 CMS Survey

    20120920 CMS Survey

    20120223 CMS Survey

    20130517 CMS Survey:

  • Inand Outagain

    There’s only two explanations why people live in Texas. One is because they’re an asshole, and the second is because they’re too poor to leave.

  • stringer_bell

    Seems this guy is a poet:

  • gwayne

    It appears that a state legislated “golden cow”system that pays the bulk of its monies into the general fund cannot be trusted to insure the safety of patients who deserve better. It’s much the same with other agencies controlled by our republican majority in this state. If the GOP ever served those constituents who only voted them in office over the corporate criminals whose graft file the shoe boxes, I’ll shit little green apples. I’ve absolutely no confidence in the GOP and never will. I think a dog crossing a freeway during rush hour has a better chance of survival in Texas than any genuine assistance from Austin.

  • Steve Joffe

    As a physician, I am also struck by a fact not mentioned in the article. The University of Tennessee Health Science Center’s Department of Neurosurgery graduated him from its training program. Surely his supervisors knew

    • Kathy

      Many people look the other way..if you speak up you will be ostracized.

      • Cyndee Malowitz

        It’s illegal for physicians and nurses to NOT report this type of problem. How dare anyone, much less a healthcare professional, go to work every day knowing their patients could potentially be harmed by a dangerous physician. Anyone that would do that needs to get out of healthcare – that is PATHETIC!

        • Kathy

          You are absolutely correct. It is worse than pathetic. The Fort Hood event could have been averted if people would have spoken up and actually done something. Nidal was promoted and advanced from the beginning…and with taxpaper dollars.

          • vippy

            Same again, no one wants to rattle the cage! Whistleblowers get punished these days, remember!

        • rugbylover

          Cyndee, you obviously are not a healthcare professional, with that being said let me enlighten you to the dark side of medicine that no one wants to talk about. As a healthcare professional, you are correct in that it is illegal for healthcare professionals not to report this type of problem; again, with that being said, you have no idea of the consequences for reporting such action. Prime example, the two nurses in South Texas who took a stand against a dangerous MD. Ask them how their lives have forever been altered for doing what was right? Of course their are Whistleblower laws in place, not just nationally, but at the State level as well, these are essentially a bunch of bullshit. The organization won’t fire you for reporting, but they will make your life a living hell, make up trumped up performance issues, or subject you to the most rigorous of scrutiny that most people end up quitting because their professional life has become intolerable. There are many ways to retaliate against whistleblower.

          You also forgot to mention the ethical and moral issues surrounding the hospital itself. Baylor Plano Regional Medical Center, had an ethical and moral obligation to immediately rescind Dr. Duntch’s medical privelages, but they did not. They also failed to follow their own action plan of supervision for medical and surgical procedures pertaining to this physician; thus giving him carte blanche to continue to maim, and kill innocent lives. The senior administrators, and medical board of this facility should also be held equally accountable for the tragedies that occurred there. Instead they chose to look the other way. One could ask why would they do that? Follow the money, there was an intensive and costly marketing strategy in bringing Dr. Duntch to this facility, advertising him to the community as an “expert.” If I were any of these patients I would also bring on a “class-action” suit against the facility for negligence.

          The healthcare professionals who do speak up, are either terminated, or are essentially blackballed by Group One, you can google that for yourself. Yet, there are those of us out there who are not willing to be silenced, who do speak out, who do advocate for their patients’, who refuse to carry out dangerous orders, who are your last line of defense in keeping you whole, safe and alive.

          • Patricia Garvin Fox

            Very well said. Reporting an impaired physician is not for the faint hearted no matter what level of health practitioner you may be. I was personally involved in two such cases but was fortunate to have support from my supervisors in seeing that the matter was pursued and rectified. It helps to work for a hospital that puts patient safety ahead of everything else.

            In one case, patients reported bizarre behavior by a physician at odd hours to me and this turned out to be due to substance abuse. The physician was sent to treatment and allowed to return with a limited ability to prescribe controlled substances and special monitoring for several years. No patient harm occurred in that case.

            In the other, I witnessed a senior physician with stellar credentials and no previous concerns do something totally inexplicable and life- threatening. I reported immediately to my superior and she confirmed the action with the patient who fortunately survived. The physician was immediately suspended from patient care and determined to have a previously undiagnosed brain tumor which was successfully treated. The patient’s infection was treated successfully even though the impaired physician’s actions had made identifying the cause difficult.

            It bewilders me that any hospital could so callous that they permitted a repeat offender like Duntsch to continue his mayhem. I know it need not be so even when reporting comes from an allied health practitioner

        • vippy

          Everybody is scared to have to answer and rather stays out of it, letting things run its turn! Too bad. Every nurse knows a doctor VAMPIRE!

        • Guest

          They do it all day long, every day! No one tells on anyone and the AMA only makes recommendations that they do. Doctors are not required by law to report a bad doctor. If they stopped worrying about what they might lose and started putting patients as their first and most important priority, bad doctors would be reported! Money is more important to most doctors, I’d say. No one gets punished for anything they do in medicine, unless of course, you are a nurse.

          • mmr

            That’s not true, doctors are absolutely required by law to report malpractice. How well they are actually held to that standard is another issue though

    • strod

      Well, there is another part of the article that is not fully explored, and that may help explain how Duntsch graduated and why there seems to be no obvious track of previous misdeeds due to him:

      It’s not clear how such a well-trained surgeon could have performed so disastrously, but the June 26 Medical Board report offers a hint: “Respondent is unable to practice medicine with reasonable skill and safety due to impairment from drugs or alcohol.”

      Why would the board come up with such a specific reason to disqualify Duntsch… unless they actually had some evidence to sustain it? Perhaps during his residency Duntsch was an OK doctor and surgeon. Maybe bottom of the class yet competent enough to graduate. Then, in late 2011/early 2012 he may have cracked and become extremely sloppy and incompetent. And for all we know drugs or alcohol may have indeed taken a part in this development.

      • dudewithlogic

        the news is always a lie never gathering the facts before slandering an individual. dr Duntsch will continue practicing in 6 months via TMB. Aqusations are just that the investigation is closed.

        • wkreese

          People might believe you if you could use correct punctuation and realized that words with a red squiggly line underneath after you type means you have misspelled a word.

      • Katelyn Bradwell

        From another article: “But Duntsch’s alleged drug and alcohol use, stretching back to his residency program at the University of Tennessee, is at the center of the new suit. And it names former colleagues and patients of the neurosurgeon as witnesses.

        During the fourth year of his sixth-year residency, a nurse “witnessed him using cocaine” and he was sent to an impaired physician program for several months, the suit says. But he was allowed to complete his residency in 2010.”

      • Jeffrey Briggs

        Addiction doesn’t suddenly make you a technically incompetent bumbling
        surgeon with lousy hands . This guy sucked long before he got to Texas.
        Tennessee just took the easier softer way and graduated this idiot
        rather than addressing the obvious. I guarantee you everyone there knew
        this guy was a disaster. Plus he has a personality disorder of some kind
        I suspect. Baylor Medical Staff should be ashamed. They could have
        intervened quickly and did not.

      • Fred Garvin

        I’m surprised it wasn’t covered here, but earlier stories by other news outlets (DMNews, Dallas Observer) have reported that he had substance abuse problems during his training, and this resulted in his training being delayed. He was allowed to graduate, but the information was not passed on, which would not be unusual, as that information is usually confidential.

        Also, what’s remarkable about Dr. Duntsch is that he was making these mistakes right off the bat, just after training; he had a handful of succesful surgeries, but mostly terribly botched surgeries.

    • dudewithlogic

      the news is always a lie never gathering the facts before slandering an individual. Dr Duntsch will continue practicing in 6 months via TMB. Aqusations are just that the investigation is closed.

    • Patient Safety

      You bring up a really good point! He couldn’t have passed his clinicals without someone either falsifying his results or the attending just was not present. Someone should have witnessed something along the way prior to this horrible trail of injuries. Even so, how many people should a doctor be allowed to injure before their hospital takes action? If this is a sign of how little hospitals care about patients getting maimed by doctors, we are all in danger.

  • ImaginaryD

    A lot of people are pushing for publication of statistics about outcomes but that is not a solution. That would cause an immediate and understandable risk-avoidance in surgeons who would avoid taking any patient with complicating factors. After all it only counts if they suffer the bad outcome on your watch so it behooves you to pass the parcel on potential bombs.
    There are surgeons who currently specialize in tricky surgeries, senior staff take over patients who seem more risky etc. From the medical point of view these are more prestigiousinteresting and from the patient point of view, it is better to be in experienced hands for these surgeries. But if we start incentivizing “perfect records” then we will lose all that.
    Transparency would work if patients could effectively evaluate the skills of the doctors and consolidated statistics are not going to do that especially since you cannot reveal the details of individual outcomes for patient privacy reasons.

  • jimbo701

    What strikes me most about this article is how a guy like Duntsch ever got his license to begin with. I wonder if when they contacted the University of Tennessee Health Science Center’s Department of Neurosurgery to check on his education if they sent a picture to verify it was actually him. There is no way a reputable medical school would allow a person like this to get his license. His gross negligence would have gotten him tossed into the street in a week if only because you can’t hide that kind of stupidity. That said I’ve met frauds in my lifetime and one trait they all seem to excel at is marketing themselves. Many are also certifiable sociopaths.

    • Elliott
      • lidia17

        Write to the BBB. He’s got their insignia on that site.

        Also (amazing arrogance, he must be insane) a group called “Best Docs”.

        From the site above:
        “Texas Neurosurgical goes National: To review the link, go the homepage, > The Institute > Texas Neurosurgical Institute, scroll to the bottom. A
        formal program is planned and will be in place soon. We have created
        this paradigm because we have so many patients coming into Dallas for
        spine care from all over the US, and because they have different needs
        than patients that live in Dallas.”


        There’s also a link so that you can send in a review. How ’bout we all submit links to this article…

        • lidia17

          Never mind… “” is a dummy dead end.

    • Patient Safety

      I doubt it! I think the schools don’t care as long as they get their tuition. You can hide it if your attending doctor falsifies your clinical grades, and doesn’t document mistakes. The real interesting thing to find out, would be, who did he do his clinicals on, and were they injured and not notified that he was the culprit.

  • Scott Lederhaus

    Most state medical boards are impotent in pulling licenses of docs. I am a spine surgeon and have seen it all. In a hospital setting a physician can kill and maim patients with little punishment other than a possible letter from the peer review committee at their hospital and occasionally not even a letter from the peer review committee. More often than not the death or injury is lamely explained away and nothing even happens with the peer review process. Most medical boards are nothing more than licensing agencies and do little to deter or prevent abuses. Any action done by a state medical board takes forever and is more often than not disappointing and usually amounts to nothing more than a non-punitive action (taking a billing course, taking a ethics course, etc.). What can get a doc kicked off the medical staff would seem pale in comparison. For example, a bad or distasteful joke, looking at a medical record of a patient who is not a patient of the physician (occasionally even accidentally), a DUI, not paying income taxes, any felony conviction, any sexual harassment. Reporting issues to the state medical board is a start and without any reporting then for sure nothing happens. Perhaps reporting to the attorney general of the state may be useful. It is truly frustrating for the honest and ethical docs to have to watch the actions of horrible docs go unpunished. How many lives need to be affected before egregious docs are stopped?

    • Cyndee Malowitz

      God, you are so right.

  • April D. Korbel

    I’m often amazed at the anarchy of the medical system in that there seems to be little real relationship between doctors and hospitals. Sure, the doctors get priveleges to do surgeries at the hospital, but the relationship is loose enough for the hospitals. to distance itself from responsibility. Seems to me if the doctors were actually employed by the hospital then there would be a lot of built-in incentives for monitoring and quality control.

  • Randy Yansen

    the hypocratic oath has been replaced with the financial oath. This article should be a wake up call to all doctors. They are self regulated and the self regulation has failed.

  • Kathy

    This is unfortunate, it happens more than we realize. Look at Nadal Hassan. We, the taxpayers, paid for his undergraduate education, medical school, training through his internship and residency, further education on trauma counseling, salary and fantastic benefits while advancing in his military rank. Just recently when he was found guilty was when “we..the taxpayers” stopped paying his military salary. People looked the other way…pretended that situations did not happen. Happens all the time. How many lives have been affected?

  • April Wallace

    Wow I know this guy. I use to work for Neurosurgery at UTHSC.

  • Dafna Yee

    This was an excellent article and I learned a lot from it. But what still bothers me is that the worst that happened to Duntsch and doctors like him is that they lose their licenses. They should be prosecuted on criminal charges for murder, attempted murder, and at the least, malicious injury. In this country, not only in Texas, receiving a medical license is equal to being given a license to maim and kill with no fear of criminal prosecution.

  • Gary Denton

    WTF! “In 2003, the Republican-dominated Texas Legislature capped pain-and-suffering damages in medical malpractice lawsuits at $250,000. Even if a plaintiff wins the maximum award, after you pay your lawyer and your experts and go through, potentially, years of trial, not much is left.”
    NO. Nothing is left.
    You won’t even get a lawyer to take your case against a Texas doctor or hospital because the medical defendants know it will be a bad mark on their record if they lose in Texas and they just pile on lawyers, experts and hearings until your lawyer will lose money on the case. Lawyers know this, malpractice cases in Texas result in no money for the plaintiff and nothing for the lawyer.
    Texas tort reform has not resulted in lower costs for medical clients and a free pass for bad, negligent and/or criminal medical practitioners.

  • Dr. Bradford Holland

    The one way physicians had to police themselves, such as when several docs witnessed dangerous incompetence, was taken away in the mid-1980’s. Medical socieities (and I am past president of one) had the ability to expel dangerous doctors from their ranks, and hospitals would not grant any physician privileges if they weren’t members of the local medical society. Thus, doctors at the local level could put an immediate end to a dangerous physician. That kind of power was deemed a violation of anti-trust statutes, and the ability of the medical society to police its own was taken away. Now, we rely on state regulation completely, though this behaves like any other state agency (slow, inefficient, and at best, barely competent). I long for the days when doctors who witnessed bad doctors could do something locally, but legal intricacies have taken away this most important aspect of medical policing, and have left us with such examples. If you truly want to stop this kind of doc, don’t lambast tort reform, that’s way off target. Give doctors the right to exclude bad guys from thier ranks when they see it. That will double the amount of oversight, and give doctors the authority to police their own. Without such authority, we raise a culture of physician that can easily turn a blind eye, since they have no authority to do anything about it. Doctors are a competitive and perfectionist bunch by and large, and though not universally true, a vast majority will do well overseeing and policing their brethren.

    • Truthteller108

      I think your ideas are mostly good, but short sided. Reversing tort reform, or making it less restrictive, would most definitely have put a dent in what this Doc was doing. Patients could have found out about the lawsuits with a simple search, and then could have gone elsewhere – in this case potentially saving their lives. Maybe his insurance premiums would have righty gone up, forcing him to close his practice. I have noticed, too, that doctors groups are a lot like fraternities and most will not “bad mouth” another doctor, even if they personally believe that doctor is practicing bad or substandard medicine. Most have to have personal, first hand knowledge before you can get a peep out of them. However, I think a combination of the Texas Medical Board, Medical Societies (with the power they used to have), and lawsuits would put a stop to Docs like this one. However, taking away two legs of this stool has made the current system ineffective and tragic for the victims. Until you or a family member are a victim, you lose your livelihood, and find your legal rights have essentially been stripped away or held to impossible standards, perhaps you’ll understand why Tort Reform, as it currently stands, is bad for all patients.

    • retired_sandman

      I resigned the AMA while still a medical student, some 26 years ago, after they turned their biographical databases on every physician and medical student in the country over to DOD. Inasmuch as I fell in that gap of individuals who had no selective service registration requirements, I took serous offense at that breach of my privacy and have been on strike against the AMA ever since. They regularly send me “invoices” for membership dues. I send the business reply envelopes back to them empty and circular file the remainder. 17% of physicians in this country currently belong to the AMA. Most of those are academic doctors and residents in training. The vast majority of praciticing physicians in the country feel the same way about the AMA I do.

      Most local medical societies have agreements wtih state and the AMA requiring you to belong to all three if you belong to one. So I choose to belong to none. I reserve that right, and take offense at any notion I should not have that choice.

  • Cyndee Malowitz

    I bet I’m the only person who wasn’t shocked after reading this article. This doesn’t surprise me in the least.
    I reported a pain management physician to the Texas Medical Board in 2007 and he is STILL PRACTICING. He’s fighting the TMB tooth and nail – even going so far as to sue them for “harassment,” just like he did me after I reported him for unethical and dangerous activities.

    Healthcare professionals should be held accountable for NOT reporting this type of incompetence. I know that I sleep very well knowing that I’ve saved lives by reporting what I witnessed. I applaud the physicians who reported this idiot.

  • Bob Blaskiewicz

    This is how that Houston cancer quack Burzynski has been allowed to milk the dying for decades with impunity.

  • Michael Bock

    This doctor’s errors rose to the level of assault, aggravated assault, and possibly voluntary manslaughter. I kept waiting patiently through this article for one of these astounded nurses/surgeons to indicate that they had gone to the police and informed them that this doctor had operated in the wrong locations and performed the wrong procedures, but I guess they did not. When you perform the wrong operation intentionally or recklessly, it’s a criminal matter, and I would think (knowing that he was still operating and maiming people) that they would take that step.

  • Janet Hill

    I think you might want to rethink the headline next time. It sounds like you’re saying the maimed and dead are NOT tragedies. Awkward wording…

  • Evil Greebo

    A system that’s built to protect the hospitals and doctors is not “unregulated”, it’s not “free-market”. It’s cronyism.

  • Blue jay

    The hospital itself is supposed to have mechanisms in place to maintain and monitor quality. It is called “self policing”. The present president of the premier neurosurgical association in America has emphasized patient safety as his most pressing issue. The medical board in each state is given the primary responsibility for patient safety.
    The effectiveness of all of these mechanisms is nil. It is nil for all of the same reasons: conflict of interest. Hospitals require volume, not quality to survive so that despicablel acts are tolerated as long as the perpetrator brings in the patients who can enhance the bottom line. Nurses are at risk of losing employment if bad practice is reported for the same reason. Malpractice premiums can reach $100’s of thousands a year for high risk surgeons, encouraging loose standards to permit incomes to match skyrocketing expenses which perpetuate medical malpractice. Medical societies are toothless due to the threat of triple damages from anti-trust suits against them. Medical boards are too starved for money through misguided tax policies, to hire staff and investigators to pursue often complicated cases.
    The cases described in Texas can be duplicated throughout America. It results in the tragedy of crippled, destitute and dead patients; and a goldmine for malpractice attorneys who are the last ones who want any change in the status quo.

  • RDR

    Agree with Steve Joffe below – is the Univ of Tennessee Neurosurgical program so bad???

  • Michael

    As a law student in this great State of Texas I would argue res ipsa loquitur which means “the thing speaks for itself.” In most tort cases, the injured plaintiff must prove four things:

    (1) that the defendant had a duty of care toward the plaintiff;

    (2) that the defendant breached that duty, usually by acting negligently or carelessly;

    (3) that the injury would not have happened but for the breach; and

    (4) that the plaintiff suffered damages of some kind, such as physical injury or loss of property.

    In a res ipsa loquitur situation, however, the court assumes that a duty of care exists and that the defendant breached it. Therefore, the plaintiff can skip over proving parts 1 and 2, and focus on proving that the defendant’s negligence caused his injury and that he suffered damages as a result.

    Dutsch clearly did not know what he was doing. He was negligent in performing such procedures without the proper care and procedure of those surgeries that injured patients. Like I said. Res Ipsa Loquitur means, “the thing speaks for itself.” In my opinion this is a straight forward negligence case that speaks for itself, in other words it is self evident that the “Dr” did not know what he was doing on more than one occasion, thus harming someone. He should lose his license for sure.

    • retired_sandman

      Get a refund on your law classes, sonny. In almost all cases you need somebody practicing in the same specialty to testify as to the standard of care, the breach, and the resulting damages.

      I’m not an attorney or a law student, and I don’t play one on tv. But res ipsa is applicable only in a small fraction of cases, such as a sponge left in a patient and the like. Expert testimony is absolutely essential to proving this guy’s negligences and resulting damages.

  • dudewithlogic

    Dont believe everything media puts in your face politics and misinformatiion had alot to do with this horrible mess up the news is always a lie never gathering the facts before slandering an individual. Dr Duntsch will continue practicing in 6 months via TMB. Aqusations are just that the investigation is closed.

    • retired_sandman

      Duntsch’s license was revoked end of last year. And they took his license in TN the start of this one.

      The system worked, albeit slowly.

  • hlang

    So let me get this straight. It’s O.K. to have 1 or 2 doctors killing people in Texas. The system that’s supposed to prevent it and protect citizens is working as intended. That’s the price the people there pay for freedom.

    But when it comes to voting, they have the strictest voter I.D. laws in the entire country, just to prevent the 1 or 2 cases of voter fraud that actually happens. And to prevent those 1 or 2 cases of voter fraud, they’ll regulate the hell out of voting.

    Seems to me that Texas just hate’s it citizens.

  • gfriesz

    As a nurse with almost 25 yrs of practice in Texas, there is another aspect of this that infuriates me.

    An RN in Texas can seriously have their license suspended for not reporting a Class C traffic ticket to the Board of Registered Nurses. A public intoxication charge can cause revocation. Those who had checks bounce for their biannual licensure payments are ostracized in the quarterly BRN newsletter.

    But we allow physicians to kill or maim and it takes forever to see action – if there is any. There is a physician here in southeast Texas who physically assaulted nurses multiple times in one of our hospitals. He paid a $2500 fine and was sent to San Diego for an anger management seminar. Another, a cardiologist, was accused of inappropriate touching of women during exams by multiple patients. Again – he paid a fine and was sent to a sensitivity class in California. We have a surgeon here who sounds like he could be soulmates with Dr. Duntsch – his National Practitioner database report bears out multiple patients who have been permanently injured or killed…and he still practices. I can mention multiple other physicians in my area with convictions for cocaine use, prescription drug abuse, DUI, et al…and they all continue to practice unabated.

    Any of these would have caused an RN to immediately lose their license in Texas. I would love an explanation as to why the state holds physicians to a much lower standard than their registered nurses.

    • Guest

      You are so right! Yeah, there’s plenty of physicians out there who are killing patients, but the medical board doesn’t do a thing about it. Could I ever tell you some stories.

      As far as that physician who physically assaulted nurses…why the hell isn’t he in jail? I would have pressed charged against him so fast, his head would spin…not to mention a lawsuit. Actually, if he laid a hand on me, it would be the last time he ever laid a hand on anyone. Justice Texas style!

    • Truthteller108

      I believe it’s because the laws only apply to the little people. The “big” people with big bucks like Docs have friends in high places.

  • ethanspapa

    It will get worse . The doctors protect each other up to a point, just as good law enforcement would a bad cop who is out of control psychologically or a politician on the take. When it gets to this point they try and put the fire out but do it quietly and discreetly. Meanwhile the people that get slaughtered are forgotten.


    I’m all in favor of bad physicians being punished and listing their license to practice medicine. That is a natter of public safety and common sense.

    Unfortunately the author of this article took this opportunity to blame the 2003 tort reform efforts as the cause of all that is wrong with the healthcare system in Texas, labeling them “conservative reforms”. The truth is the reforms had broad bipartisan support and passed both houses of the Texas legislature with large majorities. In addition the 2003 reforms were brought directly to the voters of the state who approved change to the state Constitution to accept these measures.

    This was done because the system that was in place before 2003 was unsustainable. Malpractice lawyers were out of control with their frivolous lawsuits. On average, 1 in 3 physicians were being sued every year. As a result their malpractice premiums were enormous, driving many to leave the state for greener pastures. That had a direct negative impact on access to care for many Texas patients, particularly those in the poor areas of south Texas. That is why Democrats supported the reform efforts. Some counties in south Texas didn’t have a single obstetrician or neurosurgeon. That’s a big problem if you need emergency treatment.

    The author would have been better off leaving his liberal politics out of the article.

    • Truthteller108

      This has nothing to do with liberal politics. The problem with Tort reform is that practically all medical mishaps are now considered “frivolous” and unless you’re dead or a paraplegic, there is no hope
      for you to seek recovery from a negligent and substandard doctor. Until you find yourself a victim of bad medicine, without any adequate legal recourse and your life and livelihood ruined, you’ll wake up and realize what an injustice the current Tort reform laws are to those who have been irreparably harmed by bad medicine and whose cases are deemed to frivolous to prosecute. Dealing with
      truly frivolous lawsuits should not be at the expense of the lives and legal rights of those who are truly victims. Signed – A CONSERVATIVE, non-progressive Republican. P.S. The Tort reform laws and campaign were funded by the insurance industry, who duped the voting public into believing their lies, and who are only so happy to take away your rights if it cost them a dime.

      • JJHLH

        Texas Medical Liability Trust (TMLT) is the largest provider of medical liability insurance for physicians. Per their website, “Texas Medical Liability Trust (TMLT) is a unique, not-for-profit health care liability claim trust owned by its physician membership. TMLT is not an insurance company, but a self-insured trust established by Texas Insurance Code Article 21.49-4 to provide coverage against health care liability claims to members of the Texas Medical Association.”

        Since tort reform has been in place medial liability premiums have come down dramatically.

        The tort reform laws were common sense solutions to out of control trial lawyers who didn’t police themselves. The reforms laws had large bipartisan support, and a majority of Texas voters agreed to change the state Constitution so they couldn’t be challenged in court. Trial lawyers outspent physicians 2:1 but Proposition 12 still passed. As I mentioned in my first post the prior system of frivolous lawsuits was unsustainable and was driving physicians out of Texas. If the trial lawyers hadn’t been so greedy the laws wouldn’t be necessary.

        • retired_sandman

          Quite correct. The reforms were badly needed. And there is nothing in the reforms to keep bad actors like this Duntsch from getting the pants sued off them. All you need to get the ball rolling is an affidavit from somebody practicing in the same field that there actually was malpractice and a patient was harmed as a result. Apparently there was an abundance of doctors willing to do that in this case. Without that affidavit, any suit is automatically dismissed with the POTENTIAL for damages against the plaintiff’s attorney. That’s why plaintiff’s lawyers hate these reforms.

  • Prescott E. Small

    Yet people will still vote for “Tort Reform”. How many more have to die or be maimed before they will stop voting against their own self intres.

    • retired_sandman

      Maybe you will die because a neurosurgeon is simply unavailable when you’re in a car accident and are bleeding into your tiny little pointed head? Such was the case in the RGV where there was not a single neurosurgeon practicing before the reforms, because the RGV was medmal mecca for the nation.

      The current law is absolutely no bar to suing a bad actor like this Duntsch. The article itself made clear there was absolutely no shortage of neurosurgeons willing to file a medical affidavit about his care. That gets a suit off the ground. Without it, 120 days after filing a suit, it gets dismissed automatically with the potential for sanctions against the plaintiff’s attorney. That’s why plaintiff’s attorneys hate the law & worked so hard for its defeat. Now, you want to talk about self-interest here? Well, do you?!

      • 2words1finger

        Sounds like typical Texas conservative drivel.

  • retired_sandman

    The problem isn’t resources, or what the MPA allows the medical board to do. Rather, the problem is one of focus. The medical board spends vast resources getting involved in what amount to billing disputes between doctors and insurance companies, while really awful doctors like Duntsch malpractice with reckless abandon.

  • retired_sandman

    Doesn’t this “Doctor” Duntsch look like Yanosh, the museum curator from the Ghostbusters movie… Maybe it’s just my imagination…

  • Cecilia Watt

    I am an injured worker who has been maimed and battered by the medical provider(s) in the workers compensation insurance carrier’s “network of medical providers”. After filing a workers comp claim, injured workers seek treatment. Unfortunately, some injured workers are maimed and battered by the very medical provider(s) that they are sent to. Deliberate harm to a patient is called medical battery and is happening to injured workers. Some of the medical providers offices are “workers comp insurance mills”, wherein most of their patients are injured workers. In order for the Doctors to keep their place in the network, they must comply with the insurance carriers and/or employers “needs” so to speak.
    I was forced under anesthesia for simple lumbar epidurals. At the 2nd epidural procedure, after objecting to anesthesia, I was told I had no choice, that it was the policy of the surgery center that all patients must undergo anesthesia. I awakened from that with severe neck pain and slight left arm pain. My Doctor had injected my neck, left side of my spine, left leg with some sort of chemical that tingled and popped like Alka Seltzer. In fact, the tingling went from my lower left lumbar down my left leg all the way up my back and felt like a popping sensation in my head. I was there to receive a lumbar steroid epidural injection and “trigger point shots” in the left side lumbar area.
    The next epidural procedure, I made it clear I that I did not want to be placed under anesthesia not only on the phone (a day prior to the procedure) but also before the procedure in pre-op and I re-stated the same in the operating room for everyone to hear. I restated that I was to get a local pain blocker (just as I had during the first lumbar epidural). Instead, my Doctor abruptly shoved the needle into my back without any pain blocker whatsoever. I could feel the needle going through the textures of my back (not precisely or with care into the spinal area where the disk is). My head flew up as I screamed “Wait!” or “Stop!”. He would not relent! As my head hit the operating room table (where a towel and prop to lay my head was), he moved the needle inside me to the nerve in my back next to my spine and held it against the nerve! The pain was so excruciating that I bit into the towel that was for my head to rest on and screamed with the towel in my mouth. Pure agony! He would not stop! I had no choice once again but to give into anesthesia. When I awakened, I thought to myself, Oh my God, they didn’t! I had injuries now throughout my back, neck, shoulders and arm. I could feel the nerves firing all over my back and next to both sides of my spine from the injections of some sort of chemical (the Alka Seltzer feeling again) that over the coming months, burned and corroded the ligaments in my spine, tendons and muscles in my back. It felt as though I was being burned from the inside out. PAIN from burning, PAIN from damage and maiming! I can now and then could feel that some of the tissue/muscles were pushed away from my spine creating the feeling of divots or holes on both sides of my spine. I could feel what seemed to be a muscle pushed away and hanging down on to the right mid side of my person. The ligaments that are in my neck and run up into my skull feel damaged, sore. My spine felt “chiseled” in specific areas most prominently in the top of my back and neck and the bottom near the lumbar sacrum area. I now have instability in my spinal column. I can feel the vertebrae in my spinal column moving not in sync with the other vertebrae. There is much more damage that I could continue to describe but will refrain.
    In order to get treatment, I had to see the AME designated for my WC case. I demanded to see him. Efforts to delay that ensued. Eventually, I was able to see him on August 12, 2013, more than 2 months after the procedure described above after my insistent efforts to move the date up from what I was originally informed was the earliest available date of September 9, 2013. Incidentally, I contacted the AME’s office and spoke to the appointment desk myself, I was told that there were dates available in July and August however, the insurance carrier and MY attorney agreed that I wasn’t to see the AME any sooner than August 26, 2013. Odd? After seeing the AME on 2 occasions and describing to him and his historian what happened to me verbally and via color sketches and in written description, his report indicates, Yes, somehow my neck was damaged during the procedure(s) however, the pain, the holes etc, that I describe in my back and spine is “medically improbable”! Above, is just a little of the battery that has occurred.
    COOPERATION OF MEDICAL PROVIDERS: Not only was the Ortho Surgeon involved. It was also the surgery centers and the anesthesiologists and others that have been involved. After informing my then attorney via e-mail and several conversations, the attorney who runs the WC division in that law office, called me on the phone and begged me not to file a grievance with the California Medical Board and allow him and the AME to handle this! Then, later he called me again and told me to file for permanent disability right away! My attempts to get help through other means have been stalled. What has been done to me and the continued efforts to interfere as I try to seek treatment even outside of the WC system, has been a well-orchestrated effort on the part of more than just the medical providers. Through injured workers associations, I have come to find out that what has happened to me has happened to many other patients through the years but is being ignored due to the outrageous and maliciousness of the crime. To think that a field of medical professionals would participate in the maiming and battery of patients is something out of a movie, but it does exist!
    HELP STOP MEDICAL BATTERY: Now, I’m trying to prevent what has happened to me from happening to others. 1. Please support a medical battery disclosure and law in all workers comp cases! Only a few states have a medical battery law or disclosures. I wish that I had been presented with a disclosure indicating something to the effect of: “Some injured workers have reported having been harmed, maimed or battered while receiving treatment for their injury. The injured worker is advised to educate themselves regarding the prescribed treatment and the results of said treatment.” 2. Please support a law that provides the option for an injured worker to require a patient advocate to be present (NOT AN ADVOCATE FROM THE INSURANCE CARRIER’S MEDICAL PROVIDER NETWORK) should the need for anesthesia arise. I wish I had known that I had the right to remain awake during the 2nd epidural. The third epidural wherein I was forced brutally to accept anesthesia, I don’t know what I could have done differently. I couldn’t scream loud enough that he (the Doctor) would stop pressing the needle against the nerve in my back! I couldn’t get off the table with the needle in my back either. My back is ruined.
    Should you have any ideas or would like to lend a helping hand to injured workers, most importantly to bring to light the horrible and brutal method of harming injured workers for strategic reasons, please contact me. Your help is greatly appreciated by many! I feel confident that I can speak for many injured workers when I say, “We hope that you will help!”
    The above comments I have written and re-written over the last nearly year. I have sought out help through law enforcement who tells me that there is nothing in the penal code regarding the maiming and battery of a patient. So therefore, they will not take a statement or complaint from me. I have contacted the FBI as well. They don’t seem to want to help.
    Because workers comp being a separate law, has inhibited my ability to get a med mal attorney as well. Even though what has happened to me and others is a brutal, I can’t find anyone who seems to care.
    I understand that the next step for the defense attorney, insurance carrier and the Doctors & physical therapists is to destroy my credibility.
    What is an injured worker and/or patient to do in this circumstance?

  • shuston

    A few decades ago, federal law made it difficult for drug users to remain in the trucking industry by mandating pre-screening and random drug testing. Isn’t it about time government similarly regulates surgeons and physicians? Also, as far as I’m are of, there’s nothing preventing privately owned hospitals from creating their own drug-testing policies and disciplinary measures including immediate termination of privileges. No one has to “bad mouth,” it’s just policy…sorry Dr. So and So, your privileges were contingent on this policy and refusing a random test is immediate grounds for loss of privilege. Public School Boards can mandate random drug tests for educators and their work carries far less risk than that of surgeons when it comes down to impairment of visual acuity and mental focus. Until society realizes that a medical degree does not automatically confer super human ability on those who are just normal frail and weak bumpkins like the rest of the workforce, we can all take responsibility for Dr. Duntsch’s medical tragedies.

  • Carol Levy

    Because the doctor in my case was a “name” he essentially got away with it. Video of my story:

    Public Citizen has estimated that 15% of doctors commit 85% of the malpractice. It is time the thin blue wall of silence was breached and felled as well as way past time for medical societies and state and medical licensing boards to stop ignoring malpractice.If they got rid of the bad apples it would be a fine and noble profession again.
    Unfortunately because of the refusal to sanction and other docs to step up to the plate, and other personnel: Doctors said “I will not testify against Dr. Jannetta.” Nurses said “I could lose my job if I came forward.” people like Duntsch and others are enabled rather then stopped.


    A Nursing Officer has experienced challenging episodes with a stubborn patient resulting into an
    altercation. In the process the Nurse insinuated to the patient in public that “you will soon die like the others”. The patient wants to institute legal action against the Nurse.

    a) Advise the patient on appropriate legal cause of action,

    b) Based on (a) above,advise the Nurse on available legal defences.

    please discuss this.

  • NoCellPhones

    This scares the hell out of me. I am going to try my best never to have any kind of surgery. While I know there are good physicians out there, I’ve seen too many incompetent and unethical doctors in my lifetime such that my trust is completely gone.

  • Iris Hobson

    That is what conservatism does to the public safety, Vote democratic to safe your life.

  • AnAcupuncture Nurse

    If other surgeons and co-workers knew this guys technique sucked they should’ve found a way to order him to more training. Or they could’ve said “Part of Hospital policy is 3 month reviews.” Offering to retrain a person is a way of problem solving. Maybe this guys hands were shaky, maybe he viewed things backwards, or maybe it was drugs & alcohol. Either way, by him being observed, it could’ve caught mistakes, and if possible taught him how to correct those mistakes. Why does it always got to be bad that a person needs some constructive criticism or re-training? If we continue this mind set, people will never see their own faults. People become defensive when they are feeling threatened, so with this in mind approach these complicated situations in a “concerned for your career” approach.

  • Cindy

    The level of education in this country has severely fallen. I’m not surprised at all that this barbaric hack graduated From med school. I am taking University medical courses & I am appalled at how dumbed down education has become. The first 4 years of US college classes are simply standard High School subjects for the rest of the world!

  • Texas Neuro