Loyola University Chicago School of Law, LL.M. 2019
In December 2018, Dr. Christopher Duntsch lost his appeal and the court upheld his life sentence. The name may not sound familiar, but to the medical community in Dallas, Texas, Christopher Duntsch represents what happens when every part of the medical regulatory system fails to protect patients. Christopher Duntsch was given the nickname “Dr. Death” in November 2016 when the DMagazine ran a cover story on him and his victims. In 2018, Wondery produced a six-part podcast series named “Dr. Death” detailing Duntsch’s educational and medical history and the acts that led him to incarceration.
Christopher Duntsch’s Medical Career
There is some dispute about the level of training and education Duntsch acquired prior to relocating to Dallas, Texas. Shortly after completing his residency at the University of Tennessee Health Science Center College of Medicine (UTHSC) in Neurosurgery, he relocated to Dallas, Texas. ProPublica reported that during his residency Duntsch completed fewer than 100 surgeries. The American Board of Neurological Surgery has reported that a neurosurgical resident should be exposed to at a minimum 240 spine cases. It’s important to note that neurosurgery, and as a result neurosurgical residency, involves much more than spinal surgeries. Neurosurgical surgery includes function or activity that affects the central nervous system, peripheral nervous system, autonomic nervous system, supporting structures of these systems and their vascular supply.
The following facts were compiled from the cover story published by DMagazine in November 2016, and the investigative story published by ProPublica published in October 2018. Between 2011 and 2013, Duntsch received surgical privileges at Baylor Regional Medical Center of Plano (“Baylor Regional”), Dallas Medical Center (“Dallas Medical”), Legacy Surgery Center (“Legacy”) and University General Hospital Dallas (“University General”). During this timeframe, Duntsch managed to severely injure approximately thirty patients. The following are just a few of Duntsch’s behavior in the surgery room includes, removing a problem disk with his hands rather than a scalpel, slicing an artery, cutting a major vessel in a patient’s spinal cord that led to death, placing a metal fusion hardware into the patient’s muscles in her lower back, left bone fragments in the patient’s spinal canal, and unnecessarily amputated a nerve root. Duntsch left one of his patients paralyzed from the waist down; another patient with paralyzed vocal chords; and left his best friend a quadripalegic.
Duntsch was charged with six criminal counts but tried and convicted in regard to one patient. The patient, an elderly woman, woke up screaming from pain after a vertebrae fusion surgery. Dr. Duntsch had placed the spinal fusion hardware in the patient’s muscle, severed the nerve root, made several screw holes throughout her spine, and ultimately left a screw in the nerve root at the bottom of her spine. A jury found him guilty and Duntsch received a life sentence on five counts of aggravated assault injuring an elderly person. It came as no surprise that his attorneys file an appeal. Duntsch’s defense counsel focused on whether the state proved his culpable state of mind beyond a reasonable doubt and that the improperly introduction of salacious evidence led to a conviction. The Texas appellate court did not agree with his argument and upheld his conviction. Duntsch still has option to appeal to the Texas Court of Appeals, but it doesn’t have to take his case.
Health Care System Failures
Review of the facts surrounding Christopher Duntsch’s actions reveal that hospital institutions can make choices to protect their patients and provide quality care.
- Internal Reporting
The best way for a hospital to protect its patients is to create a culture of safety. Christopher Duntsch conducted surgery alongside supervising physicians who observed mistakes in the operating room, but there is no evidence that these physicians reported Duntsch to his supervisors. While at Baylor Regional, Dr. Mark Hoyle watched Duntsch cut out a ligament that did not need to be disturbed. Senior surgeons were also called in to perform revisionary surgeries. These surgeons found bone fragments left in the patient’s spinal canal, failure to order tests or re-operate in a timely manner. These incidents and observations should trigger a response for employees to report potential problems for investigation. The Office of Inspector General, in the Federal Register in regard to establishing a compliance program in hospitals, states that early detection and reporting will help minimize the loss to the Government and a hospital’s exposure to civil claims.
- Policies and Procedures – Dismissing a Physician
Federal programs, such as the Centers of Medicare and Medicaid, will recommend that hospitals establish policies and procedures to be followed when granting or hiring medical staff. Dismissing a physician should trigger a similar review of a physician’s files. When Baylor Regional decided to end its relationship with Christopher Duntsch, the reasons were overwhelming. Duntsch had injured three patients, one of which was left paralyzed and two missed drug test appointments. Yet, when it came time to end their relationship Baylor Regional allowed Duntsch to resign with full clinical privileges. This decision allowed Duntsch to seek employment at another hospital without fear of being reported to the state medical board or the NPDB.
- External Reporting
Each state’s medical board has different required reporting standards. Texas Medical Board Rule 176.2 requires that a report must be filed with the medical board for each physician against whom a health care liability compliant has been filed or settlement has been made. The NPDB requires that a hospital report (1) any professional review actions that adversely affect a physician’s clinical privileges for a period of more than 30 days, and/or (2) any surrender or restriction of clinical privileges while under investigation for incompetence or improper professional conduct, or in return not conducting such an investigation. At each institution, Duntsch’s behavior never met the required reporting standard. However, an institution may always make a voluntary disclosure. The choice to voluntarily report a physician is a difficult one, but an institution should keep in mind that the core purpose of these reporting institutions is improve quality and protect the public.