1. Provide the title of your story or series and the names of the journalists involved.
Our yearlong investigation into patient harm and doctor training is called "First, Do No Harm."
There are FOUR reporters on the project: Sue Goetinck Ambrose, Reese Dunklin, Brooks Egerton and Miles Moffeit. Photographer Mona Reeder produced a video documentary about one of the patients we profiled. Maud Beelman is the investigation's editor.
2. List date(s) this work was published or aired.
We published 23 stories in The Dallas Morning News, numerous posts on the DMN Investigates blog and an online video documentary between March 25 and Dec. 24, 2010. Our complete package can be found here.
3. Provide a brief synopsis of the story or stories, including any significant findings.
Our investigation focused on lax supervision of doctors-in-training, patient harm and alleged billing fraud at Dallas' premier medical school complex and its primary teaching hospital, which are financed largely by taxpayers. We also examined more broadly questions about medical training, patient care and healthcare fraud at teaching hospitals around the United States.
Among our major findings: "Surgery patients at the hospital, Parkland Memorial, were misled into believing they would be operated on by an experienced faculty doctor from the medical school complex, UT Southwestern Medical Center. In fact, those doctors might not be in the operating room or even in the hospital building during surgery. " Most patient care at Parkland was provided by doctors-in-training – first-year interns and other medical residents – with little supervision. Some key aspects of care were delegated to students who had not yet graduated from medical school. " Institutional policies allowed faculty to claim they were supervising some procedures, including major surgery, if they were available by cell phone. When some faculty tried to exert direct supervision, residents complained about losing autonomy – and management sided with the trainee doctors. "While junior staff members were tending to poorer, uninsured patients at Parkland, UT Southwestern's faculty physicians often were treating privately insured patients at the medical center's other hospitals or doing research. "Some doctors complained that the lax supervision at Parkland created unsafe conditions and brought specific examples to their bosses. They were ostracized, and most left for other jobs. "Patients were harmed during surgeries by resident physicians, including a young mother whose common bile duct was severed during a gallbladder operation and a former Parkland employee who eventually had her leg amputated after a botched knee replacement." Parkland, by its own internal estimate, seriously harmed on average two patients a day. Most of the harm was deemed preventable. "The head of one UT Southwestern residency program told colleagues that higher rates of patient harm were an acceptable price to pay for doctor training." If patients and family ever learn they have been victims of medical error, which many don't, medical malpractice damage limits in Texas ensure that they often have little recourse." Supervision standards are not a part of the federal government's safety guidelines for hospitals. Thus, regulators rarely investigate whether patients are harmed by unsupervised residents." Federal regulators, instead, let the industry police itself – but many hospitals fail to document or investigate serious incidents. When they do investigate, the law allows them to keep the results secret." There are no accepted "best practice" standards to guard against patient harm at the nation's teaching hospitals, which treat more than half of all patients and account for about 70 percent of all charity care costs." The kinds of problems identified at UT Southwestern and Parkland have occurred at medical schools and their affiliated teaching hospitals across the country." Medicare billing fraud was found at two dozen academic medical centers and teaching hospitals in nationwide audits conducted several years ago – until the industry managed to quash the federal reviews. As a result, patients have suffered avoidable harm nationally because the business and culture of medicine have resisted meaningful change." Alleged billing fraud by UT Southwestern and Parkland goes back decades. The institutions had previously been investigated for falsely billing the government insurance programs for the poor and elderly and are under current investigation by the U.S. Justice Department.
4. Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?
We relied heavily on government, research, hospital and medical center records, obtained via open records requests and online research, as well as on medical records obtained from patients. We also extensively reviewed and corroborated information included in depositions from a whistleblower lawsuit. We filed dozens of FOI requests, primarily under the Texas Public Information Act and, to a lesser extent, under the federal Freedom of Information Act. The two Dallas medical institutions fought most of our records requests, triggering lengthy and time-consuming reviews by the state attorney general_s office. We also encountered some initial resistance in getting records from the federal agency that oversees Medicare. We have spent thousands of dollars to obtain what records we could and have hired a full-time public records attorney to help us fight for the rest. The newspaper has filed four lawsuits against the hospital and medical center, seeking to compel them to follow Texas open records law. All of the cases are pending in state courts.
5. Explain types of human sources used.
We tapped into sources from across the health-care spectrum and around the country, including patients, doctors, nurses, hospital executives and trustees, regulators, government investigators, academic researchers and lawyers. Internal whistleblowers were essential to our early reporting. We had been looking into other allegations involving UT Southwestern Medical Center when we learned of a whistleblower lawsuit filed by one of its trauma surgeons who supervised at Parkland Hospital. Not believing that Dallas media would investigate the community_s two leading institutions, the doctor had started a blog. We read what he posted, contacted him and convinced him that we would take a hard, but fair look to see whether his allegations withstood scrutiny. He agreed to cooperate and his lawyer shared with us some depositions. We interviewed several of those deposed, as well as doctors and former employees of UT Southwestern and Parkland who shared similar concerns about lax resident supervision and patient harm. We then quickly expanded our reporting, identified major themes and began filing the first of dozens of open records requests. We identified and tracked down knowledgeable sources (including an earlier whistleblower whose whereabouts were initially unknown) in part by publishing small, incremental stories and by using our DMN Investigates blog to interact with readers and flush out potential sources. This was essential because Parkland and UT Southwestern had ordered their employees not to talk to us.
6. Results (if any).
Our reporting led the U.S. Justice Department to reinvigorate a dormant investigation of possible Medicare billing fraud. This occurred after one of our records requests produced evidence – previously unknown to authorities – that Parkland had estimated it owed the federal government up to $50 million for Medicare overcharges, paid only a fraction of that amount and withheld information from its own auditors to shield it from subpoena. In December, the Joint Commission, which accredits hospitals nationwide, confirmed that it is investigating a patient-harm case we brought to light in November – that of the knee-replacement patient who had to have a leg amputated after a resident botched her surgery. In January, two members of the Dallas County Commissioners Court, which appoints members of the Parkland Board of Managers, publicly called for the institutions to address the problems we had identified and present a timeline for correcting them. Additionally, there are emerging indications of other fundamental changes at Parkland and UT Southwestern, in policies, practices and top personnel.
7. Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.
Leaders of the two institutions and their industry supporters have fiercely criticized our work. They have suggested, for example, that we don't understand the realities of medical care, teaching and training; that we_ve paid too much attention to disgruntled current and former employees; that we've made too much of patient-care tragedies. They have hired outside PR and law firms, including one headed by a former Texas Supreme Court justice, in an effort to stymie or discredit us. But they have cited no errors, and we have run no corrections or clarifications. Our managing editor has written three, lengthy "Ask the Editor" columns, addressing the criticism, which are linked from the project's homepage here.
8. Advice to other journalists planning a similar story or project.
Be prepared for a high degree of difficulty and a significant investment of time and resources. Many of the records created about patient care are confidential and safety data are difficult, if not impossible, to obtain. In addition, the medical industry is insular, well-funded and media savvy, so such reporting requires time and money. Keep detailed records of all your document and data requests, and set up calendar alerts for various response deadlines. Carefully review everything you receive as soon as possible after it arrives for insight into other material that should be requested and as a check that all releasable documents have indeed been handed over. Be persistent and patient: Even in heavily redacted records we found unexpected information and wisdom. And there have been a few instances in which we got the unredacted set of documents. Develop a comprehensive filing plan early in the process, and meet regularly so reporters can share tips and information and brainstorm reporting approaches with their editor. If you_re taking on a subject that is a sacred cow locally, expect resistance from big-name readers and even within your own newsroom.