Hutchinson Clinic audit: Cancer doctor ‘unnecessarily’ treated patients
By Kelsey Ryan, The Wichita Eagle | |
McClatchy-Tribune Information Services |
It took days for anyone to answer Marian Rank's question, but by then she knew.
Her mother had breast cancer. Her sister had it.
Now she did.
It was 2010, and Rank went to the
Fesen told her she needed to start chemotherapy immediately, said Rank, who was 66.
"
She had to make a decision about trusting her doctor -- a decision nearly all of us have to make at some point.
As she learned more, Rank began to question her doctor's orders.
She sought a second opinion, then a third and ultimately was advised that she didn't need chemotherapy.
That same year, the
Internal audits, requested by the clinic, stated that Fesen treated some patients for cancer who didn't have it and "unnecessarily" and "inappropriately" treated others.
The auditor questioned Fesen's competency in treating some cancers.
The audit and other documents also said that Fesen: -- Did not follow established national cancer-treatment guidelines in about 40 percent of the patient cases reviewed. -- Treated some patients with lymphoma and cancers of the blood "unnecessarily" and "often too early, too much and too long." The auditor suggested that Fesen should either not be allowed to treat those patients or be required to get board certification in that area. -- Frequently split doses of chemotherapy and other drugs, without documenting why. -- Overprescribed support IV therapies, such as minerals and antibiotics, and gave patients with blood cancer an excess number of bone marrow tests. The auditor questioned whether an external insurance audit would find documentation to justify the treatments. The clinic worried that some of Fesen's actions might be "interpretable" as
It is unclear whether the clinic told patients about the review or its findings.
Fesen practiced at the
Now he practices in
Both the
"Here is what I can say: My whole professional life has been dedicated to providing the utmost in quality, compassionate, consistent care to my patients, and I categorically and vehemently deny ever doing anything other than that. If someone works harder or longer to care for cancer patients, or to stay abreast of the latest and best medical advances to do so, or to consult with experts nationwide when necessary, I don't know who that is.
"Part of providing that level of care is abiding by the laws that keep medical information private, and I will honor the law even if others for their own businesses or personal reasons might decide not to do so.
"The bottom line is that I am passionate that my patients -- no matter what their demographic, geographic or economic situation -- have access to the best care I can provide. That is not just what I do, that is who I am."
'He's a great doctor'
Fesen has no record of medical malpractice lawsuits or disciplinary action by the
Originally from
Fesen has hospital affiliations with
Fesen also was appointed to a congressional advisory committee on health care earlier this year by Rep.
Since he left the
"There's really nothing that has impacted us in the least. He's practicing perfectly well," said
"We have zero knowledge or understanding of what
"I was treated with efficiency and kindness by
About a year after her treatment, Murphy joined the oncology staff at the
"His decisions and practices demonstrated to me that he always had the best interests of his patients and his staff in mind," she wrote. "We respected and trusted him and he respected and trusted us. One of the nurses that I worked with described our working relationship in this way: 'Dr. Fesen always had our backs and we had his.' "
'God-like' status
In 2010, physician
The Wichita Eagle obtained copies of two audits, which contained aggregate data about the practice, communications between the auditor and clinic executives and several case reviews that looked more in-depth at patient diagnoses. Patients' names were redacted.
Gingrich, the auditor, has since retired and would not discuss the audits.
The audits, conducted in 2010 and 2011, stated there were major compliance issues with the National Comprehensive Cancer Network guidelines, which are based on research from the top 25 cancer centers in the country and are generally accepted as the basis for the treatments physicians prescribe.
The auditor reviewed 108 of Fesen's cases that were randomly selected, according to an internal document. In about 40 percent, the auditor cited issues with inappropriate diagnosis or treatment.
For example, one patient was treated for more than four years as having lymphoma, a cancer of the lymphatic system. The patient didn't have cancer, according to the auditor.
Another 86-year-old patient had MGUS. Monoclonal gammopathy of undetermined significance is a noncancerous condition that usually causes no problems and generally requires no treatment, according to the
In another case review, the radiological diagnosis of active lymphoma in an 83-year-old "is a fantasy," Gingrich wrote. That patient was given Rituxan, an antibody drug used with chemotherapy, almost continuously for eight years. Because it can damage the immune system, the manufacturer says that the drug should not be used for more than two years.
"There is no body of medical evidence that would justify using Rituxan in this patient as
Some patients' records were too poorly documented to tell whether they were compliant, according to the audits.
Gingrich also questioned whether Fesen was competent to treat patients with lymphoma and blood cancers. "A significant fraction of them are being unnecessarily treated -- often too early, too much and too long," he wrote.
Gingrich also reviewed records of the clinic's other oncologist,
The clinic, which is owned by about 70 physicians, would not say whether it contacted individual patients about the auditor's findings.
The clinic responded with an e-mailed statement through its attorneys: "
If a health care organization finds that a certain level of harm may have occurred, it has an ethical obligation to disclose its findings to patients, said
"I think there's a general duty to be open," Mitchell said.
"There is an obligation to inform patients when they've got enough clarity from an internal investigation to know that there was a very strong likelihood of harm to patients -- alerting them that an audit was done, in general what the findings were and making sure they connect with their current physicians and look at records, treatments and do a thorough assessment of how they're doing now. That would be a starting place.
"It's harder to contact patients if they have a concern about opening themselves up to potential liability," Mitchell said.
In a 2010 internal document, Gingrich wrote to the clinic's chief financial officer,
"Fesen's decade-long solo practice created a 'god-like' status where mid-level providers and nurses did not question his practice style and this atmosphere still creates difficulty," Gingrich wrote. "
The document went on to state that the clinic had raised concerns that some of Fesen's actions "might conceivably be interpretable as fraud" by
In
According to public records from Fesen's divorce, his gross annual income as of
Cancer 'merry-go-round'
Marian Rank, the breast cancer patient, is a retired English teacher who lives in a farm house outside of
"I went to
In 2010, Rank had a lumpectomy to remove the tumor with another physician at
"They both said, 'You're not doing anything without a second opinion.' "
So she went to the
According to medical records that Rank shared with The Eagle, both Paul and Dakhil told Rank the best practice for cancer patients such as her who meet certain criteria is a genetic test called the Oncotype DX, a test that has been around for about 10 years that can help determine whether chemotherapy is necessary.
The test analyzes 21 genes and predicts the chances of cancer spreading to other organs.
Scores less than 18 have a low risk of the cancer spreading or coming back.
Scores from 18 to 31 have an intermediate risk, where it's unclear whether chemotherapy would help.
And those who have scores greater than 31 have a high risk of the cancer coming back and a greater benefit from chemotherapy.
Rank said she was told by Fesen that she couldn't have the test and that
The results of Rank's test -- recommended by Paul and Dakhil and paid for by
The low score meant that with or without chemo, the chance of cancer returning wouldn't change, making the chemo unnecessary, Dakhil said.
"It's a merry-go-round. You don't know where you're going next," Rank said.
"Before the test (was created), a lot of people got chemo, and we found out that half did not need it," Dakhil said. "If you accept the science and believe that only people who need chemo should be offered chemo, then you should offer the test to the patient."
Chemotherapy has a lot of side effects, according to the
Those side effects include fatigue, nausea, vomiting, hair loss, infection, memory impairment, swelling and pain -- not to mention the psychological impact.
Instead of chemotherapy, Rank had radiation treatment for her cancer ("It was a snap") and was prescribed an anti-hormone pill by Dakhil to take for the next five years.
Radiation treatment is a concentrated dose that attacks a tumor, whereas chemotherapy moves throughout the body.
"The idea that a doctor would prescribe chemo to somebody who didn't need it -- who it would only harm -- is so unconscionable that I couldn't imagine it was really happening," Rank said.
In
Dose splitting cited in audit
Dose splitting -- also called dose-fractionation -- was a frequently cited issue in the 2010 audit.
Fractionation is where a physician splits the dosage of chemotherapy or related drugs and administers them over a period of days or weeks. In Fesen's case, he was often splitting doses and administering them seven days apart, according to the audit.
With every office visit, lab and dose, physicians can bill
Dose splitting is acceptable if, for example, the patient can't tolerate a full dose, Dakhil said.
But that would need to be documented in the patient's record, he said.
"The high frequency for choosing the day 1-8 fractionation scheme suggests a rationale in
Cancer drugs and related therapies are expensive.
The
Each typical dose of the drug is 800 milligrams, which for some cancers is given 12 times over two years, Dakhil said, totaling about
When the dosages are split, physicians can bill
"So if you give a patient a treatment on Day One and Day Eight, your administration reimbursement would be twice as much than if you gave the whole thing on Day One," Dakhil said.
"The problem is if you have to dilute the treatment to a point that it becomes ineffective. That becomes an issue. If you have to fractionate a treatment because of tolerance of a patient, that's justifiable."
By the time the auditor did another round of reviews in
The auditor also found that Fesen's compliance in following national guidelines had "greatly improved."
However, the audit said there was clear continuance of excessive use of IV therapies and excessive bone marrow tests without documentation of necessity.
Both audits mentioned the extended use of the drug Rituxan, in some cases for as long as six to eight years.
The drugmaker's website, the National Comprehensive Cancer Network and studies from the
Dakhil, who said he has seen several of Fesen's former patients, said he has also observed extended use of Rituxan.
"I have seen patients who have requested a second opinion or transferred care to my practice, and my impression was very similar (to the auditor's)," Dakhil said.
"I have seen patients who have received Rituxan for many years and there was no clear documentation why they were getting it or what was the indication of getting it."
Declining
The data showed that in 2009, Fesen's practice was reimbursed slightly more than
At the time the audits began, the
'Treat, treat and treat some more'
In 2009, Fesen wrote a book called "Surviving the Cancer System," in which he describes his philosophy: "Treatment recommendations are educated guesses. Guidelines are not perfect. Many new developments have come about because some brave proactive oncologist has not limited his treatments to only approved guidelines and has tried something, anything, in a desperate situation."
In the 2011 audit, Gingrich questioned Fesen's judgment on when to quit treatment with patients and to bring in end-of-life care.
He mentioned a patient with metastatic ovarian cancer that was to be treated with her ninth different chemotherapy regimen after eight others had failed.
"Reasonable oncology judgment would dictate a strong consideration if not a mandatory switch to best supportive care with a palliative care -- hospice team on board. This option is apparently not considered by
In the same audit, he wrote, "A clear and honest appraisal of the goals of therapy might suggest that consideration for stopping therapy/referral to palliative care -- hospice should come earlier in many of
'Blind trust'
Every few months after filing her complaint, Marian Rank -- who is now 70 -- received a letter from the
She called several times to ask what was taking so long since she first complained more than three years ago.
"I think if it is lack of help -- lack of people who can do it -- they need to hire more people, because this is serious," Rank said. "No investigation should take this long."
Earlier this month, she received a letter from the board saying the investigation had been completed and the results would be reviewed. The letter did not say whether there were any findings.
Officials from the
The board, formed in 1957, serves as the licensing and regulatory agency for medical doctors and some other health care providers in the state. It has 15 members, who are mostly health care professionals, and they are appointed by the governor.
From
In 2013, the board took about 240 actions against providers.
Patients should question their doctors, Dakhil said.
"Cancer patients have complete trust in their cancer physician," Dakhil said. "And that trust has to be earned, not imposed.
"Unfortunately, right now the way things work is patients have a blind trust of their cancer physician. They don't check things out. They don't ask questions. They don't ask the communities about the credentialing of that person. And there is no way you can justify that trust."
Everyone should get a second opinion, Rank said. But that can be difficult.
"We trust our doctors. It's hard to question as a patient," Rank said. "For my generation, it's hard to question a doctor, because they're supposed to know what they're doing. ... I would have just gone along like everybody else.
"It's hard to get a second opinion and say to your doctor basically 'I don't believe you.' "
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