If there is anyone out there reading this who hasn’t heard of “Dr. Death,” I suggest you listen to the Podcast, watch the documentary “Dr. Death Undoctored,” watch the “American Greed” episode about the case, or heck … just Google him. You’ll likely catch me on there talking about the case and the multiple patients of his I had the privilege of representing. And, if you get hooked on the story, you’ll also likely hear me talking about the institutional issues which allowed him to keep hurting patients.
Duntsch is now residing in Huntsville where he is serving out his life sentence. He can no longer hurt patients. But, what about the healthcare system which allowed him to continue practicing long after they knew or should have known he was highly likely to kill, disable and maim other patients?
The “Dr. Death” cases were a rallying cry for much needed reform. Lessons should have been learned. But, what reforms have actually occurred as a result?
None. Zip. Zero. Nada. Zilch. Nill.
Why does this matter? Because hospitals and the Texas Medical Board are supposed to be that precious thin line to protect patients from dangerous doctors. They are the ones in possession of all the information. Information that by law must be kept from patients.
So, patients are at the mercy of hospitals and the Texas Medical Board to protect them.
For literally decades, I and others in the patient safety community, have been saying, “It’s not a matter of IF, but WHEN.” What we mean is that there are a host of factors which give hospitals pretty much unfettered self-regulation. We know many hospitals do not follow the law. Yes, the laws that were designed to protect patients. We know and have known for decades that the Texas Medical Board does a pitiful job of protecting patients.
So, I for one was not surprised to learn about the Dr. Ortiz tainted IV bag cases.
Why? Because the system is set up so there is no transparency and no consequences for bad behavior.
When you have for-profit businesses essentially self-regulating with no consequences for violating the law, and you have laws that allow them to conduct their business in absolute secrecy, you are going to have problems. Bottom line.
Since my work on the Dr. Death cases, I have joined with other physicians, hospital industry experts and patient safety advocates to try and reform the system. So, what have we been able to accomplish?
None. Zip. Zero. Nada. Zilch. Nill.
But, why? Well, the truth of what I have learned is that there is simply little appetite for reform. Patient safety has become a political issue. The healthcare industry has a lock on dominating their preferences for legislation and are very resistant to any improvements in patient safety, even if it does not negatively affect healthcare providers. It’s astounding actually.
There are very few politicians who think the issues are worth focusing on over other “hot button” issues at this time. And, those who do want to do the right thing are in the minority and can’t overcome the power and influence of the healthcare industry.
Now everyone can watch and read in shock and horror about the tale of Dr. Ortiz and the saga of his scheme to taint IV bags. But, will anyone care enough to stand up and say Enough is Enough?
I am sorry to say this, but I’ll say it again as I have been saying for decades. “It isn’t a matter of if, but when.” I hate to be the one to say, “I told you so.” But … “I told you so.”
If Dr. Death wasn’t enough to demand reform, do you think the Dr. Ortiz case will be enough? How many more victims will there have to be before someone with the power to make the changes demands it?
For my sake and yours, I sure hope it’s today.
