By Andrew Ford Published July 10, 2023 by The Arizona Republic.
Sex, drugs and harm to patients — the Arizona Medical Board determined more than 300 actively licensed doctors committed misconduct over the last decade, but their records were largely hidden from the public, an Arizona Republic investigation found.
The board identified doctor misdeeds that went far beyond bungled paperwork, yet the doctors received only a slap on the wrist in the form of strongly worded letters.
The board rebuked Dr. Nicholas J. Argyros for “removing insufficient skin during a circumcision” — he said the complaint to the board derived from another doctor’s actions, the incident happened long ago, and the amount of skin to remove in a circumcision is a judgment call.
“There’s not a dotted line where it says: cut here,” he said.
The board wrote up Dr. Ernesto R. Cruz for “soliciting an act of prostitution.” The board admonished Dr. Shilpa N. Atodaria, saying “that practicing medicine without a license will result in further Board action.” It reprimanded Dr. Sally T. Wareing for “failure to follow up following spontaneous miscarriage.” It scolded Dr. George H. Webb “for taking photographs of a patient’s vagina without gloves on a personal cell phone.”
Those doctors couldn’t be reached for comment.
Hearing about some of that misconduct, Helen Haskell, president of the patient safety organization Mothers Against Medical Error, let out a laugh.
“I’m sorry,” she said. “That’s unbelievable.”
The patients of those doctors would have little way to know about their past. For each of those doctors, the online profiles maintained by the state misleadingly say “none” under board actions.
Asked about the hidden misconduct, Kristina Jensen, deputy director of the Arizona Medical Board, pointed to the meeting minutes and advisory letters that are public record and state law that restricts what the board can put online.
The board is also bound by law to scrub discipline from the site after five years. The mild reprimand from the board often comes after it concludes it lacks evidence to go further or it doesn’t think formal discipline is warranted.
Asked whether the present arrangement serves the board’s stated mission to protect public safety and whether the “none” on a troubled doctor’s profile is misleading, Jensen did not respond.
Pat McSorely, executive director of the Arizona Medical Board, pointed to fine print at the bottom of a doctor’s profile detailing how a patient could request more records.
Transparency is key for patients selecting doctors
Haskell said the records of doctor misconduct should be more available to the public.
“Obviously they should be,” she said. “So that people can judge who they want providing their medical care.”
As a solution to those misleading profiles and obscure records, The Republic built a tool to allow patients to get a glimpse at doctor misconduct they’d otherwise have little chance of finding. Readers can search using the tool below.
The Republic exposed in December hundreds of actively licensed doctors who had been issued an advisory letter. The letters describe misconduct but stop short of formal discipline. The board sometimes determines discipline isn’t warranted or it lacks evidence to proceed. A 2017 ABC 15 investigation similarly raised concern about hidden doctor misconduct.
By mining the board’s meeting minutes, The Republic revealed more doctor misconduct than it did in December.
Doctors scolded for misconduct include:
- Harm to patients: Dr. Leona M. Martin failed to recognize the onset of heart failure. Dr. Steven C. Simon got a letter for a surgical injury “leading to patient death.” Dr. William R. Kelley failed to recognize on a medical scan a sponge left in a patient after surgery. He told The Republic he probably should have better communicated with the surgeon, but noted he didn’t do the surgery. He said his responsibility was reviewing the image and he didn’t make a big mistake.
- Misdiagnosis: Dr. David B. Bowne failed “to take appropriate action on a tonsil specimen that demonstrated cancer.”
- Failure to report crimes: Several doctors were reprimanded for failing to promptly tell the board about DUIs. Other doctors were rebuked for failing to report misdemeanors, including two involving “moral turpitude,” but board minutes don’t say what that entails.
- Access to drugs: Dr. Rosemary S. Browne was written up for failing to control access to her computer after a “patient self-reported using large amounts of opiates and that she had access to Dr. Browne’s computer allowing her to fill prescriptions through electronic prescription writing.” Dr. Browne said she was not aware of what was happening at the time and described the situation as learning the hard way about new computer processes for filling prescriptions online. She added that all this happened long ago — the board voted to issue Browne a letter in 2015 — and nothing like this has happened since. She described her other good work, including serving as the board president of the Arizona Geriatrics Society.
The Republic reached out to each of the doctors named in this story and added comments from those who could be reached.
Despite their histories, their profiles on the board’s website appeared clean as of June 30. That’s likely the only glimpse patients would have into a doctor’s past.
The Republic revealed in February that Gov. Katie Hobbs and all but one of the lawmakers who sit on the House and Senate health and human services committees took money in the past from the Arizona Medical Association’s political action committee, which backs “physician-friendly candidates.” The medical association pushed for the law that hides doctor advisory letters.
Asked recently about doctor misconduct in advisory letters, Rep. Patricia Contreras (D-Phoenix) said in an email that a lot of information is available online. She added, “Sexual misconduct is a serious offense that needs greater scrutiny. We are requesting more information from the Boards in order to investigate this further and make recommendations.”
Christian Slater, a spokesperson for Gov. Hobbs, reiterated Hobbs’ commitment to transparency and noted Hobbs signed a law that creates a searchable database of health professionals whose license was revoked in the past five years. But it doesn’t directly address the issue that advisory letters are kept hidden.
Arizona Republic launches tool to help patients see doctor misconduct
To make up for the government’s shortcomings, The Republic’s searchable database of state medical board meeting minutes will allow patients to find out if their doctor has been scolded.
Before now, the state medical board website limited patients to meeting minutes going back only to 2019; it was kept in a format that was not searchable. The Republic’s tool exposes misconduct back to 2013 and brings to a patient’s fingertips documentation of doctor misconduct.
“I’m really glad you’ve built this tool,” said Haskell, the patient safety advocate. “I think that will be immensely helpful.”
For example, searching “Brannan” reveals the board’s admonishment of Dr. Scott M. Brannan, who rose to prominence as a star at Modern Vascular, a chain of clinics that focuses on clearing vascular blockages in the lower leg and that was also the subject of a Republic investigation. The Republic’s story was later quoted in a Department of Justice complaint against the company, which filed for bankruptcy in May.
The board minutes show Brannan landed on probation after the board’s medical consultant determined he “deviated from the standard of care” by failing to promptly send a patient to a hospital, who later died. The board minutes outline his positive test for steroid usage and for prescribing medication to his father-in-law, which doctors aren’t supposed to do.
The minutes show Brannan’s attorney later tried to get him off, arguing “the probation has affected Dr. Brannan’s credentialing with insurance companies and now he is unable to provide services.”
But the board shut him down, denying a motion for a rehearing.
Looking at his profile on the state board’s site, Brannan’s prospective patients would know none of that.
Misleadingly, as of June 22, Brannan’s profile appeared clean. The board said that’s because of a technical issue, rather than the laws restricting what the board can put online.
Alerted to the issue, the board’s executive director said it would fix it:
“Thank you for calling our attention to Dr. Scott Brannan’s profile that should have listed disciplinary action in the box under ‘orders.'” McSorely wrote in an email. “As you pointed out, that box reads ‘none.’ Staff has researched this issue and has located a computer coding error that occurred during a recent major IT change to our database. The correction to the coding error has been made a high-priority task and was sent on June 28 to be corrected by our vendor. The coding error should be corrected within seven days and the discipline accurately displayed.”
McSorely wouldn’t say whether that issue affected other doctors’ profiles.