Eight missed cases found among 7,482, VA says
Doug Thompson
dthompson@nwadg.com
Pathologists from as far away as the Air Force Academy in Colorado have joined a review of 33,806 cases analyzed by a pathologist at the Veterans Health Care System of the Ozarks. At least 80 veterans and family members were updated at a town hall meeting on Aug. 20.
So far, eight of the 7,482 cases reviewed show a missed diagnosis, according to interim medical center director Kelvin M. Parks. Parks presided at the meeting, the second such gathering since the initial June 18 news conference announcing the problem. At least one misdiagnosed veteran is believed to have died as a result of test results being misinterpreted, though, according to the initial announcement of the problem June 18.
“In the Navy, if you come to work drunk, you’re gone,” veteran Buddy Boyd told Parks. “This guy got a second chance — it’s killed a veteran.” The pathologist involved in these cases had been allowed to go to a treatment program and return to work after a review of the initial incident found no missed diagnoses that time, according to the Veterans Department.
Parks assured the audience there would be no repeat. “We do not have any doctors on their second chance now,” Parks said. He also told the audience the department couldn’t confirm or deny alcohol caused the impairment.
“No one can work at this hospital without my signing off on it,” said Parks, who wasn’t interim director until after the pathologist in question was back at work after completing an impairment program.
“What we have is a bad actor who has marred the reputation of a staff that provides excellent care,” Parks said.
The Veterans Affairs Office of Inspector General is investigating the retention of the pathologist, Parks said. There’s no timeline on the inspector general’s report, he said. In addition, Parks has launched an internal investigation to find “who knew what when,” he said.
Kay Kitterman of Fayetteville, also a Navy veteran, said the real problem was discouragement of reporting substance abuse and other problems. “We wouldn’t be here if the reporting process was better,” she said.
Family members of veterans who died since treatment at the Ozark system are distraught after receiving letters those cases are under review, Darrell Darner of Gentry told Parks. Darner, who is a member of the Veterans of Foreign Wars, had his diagnosis of cancer missed and had to undergo reconstructive surgery on his nose. He asked Parks to provide counseling to those anxious family members. Parks assured him the system would.
With more than one test run on some veterans, the 33,806 cases involve 19,794 veterans, Parks told the crowd. There’s a procedure in place for veterans and family members in affected cases to get their test tissue samples reviewed by outside pathologists and be reimbursed by the Veterans Department, Parks confirmed in questioning by veteran and Libertarian congressional candidate Michael Kalagias, who attended the Aug. 20 meeting.
Parks expects pathologists to finish the review by Dec. 31, thanks in large part to an agreement signed with the University of Arkansas for Medical Sciences to provide nine pathologists to work at the Fayetteville veterans system site full time. Another contract is under negotiation with another university-based system in another state, Parks said. That contract should be announced soon, he said. No pathologists from the Ozarks system are participating in the review, but pathologists from other systems in the U.S. Department of Veterans Affairs are, he said. A final report will be made public in January, he said.
The review began after administrators discovered a pathologist at the system’s hospital in Fayetteville tested samples while impaired, administrators said at a June 18 news conference. The pathologist, Dr. Robert Morris Levy of Fayetteville, denies he worked impaired. Levy acknowledged he’s the pathologist involved although the system won’t say because it’s a personnel matter, spokeswoman Wanda Shull has said.
The cases under review are prioritized by risk, Parks has said. Tests for the most serious possible diagnoses, such as prostate biopsies for cancer, will be reviewed first, he said. Other risky conditions earmarked for priority are CT-guided needle biopsies, breast biopsies and endoscopies.
Bringing UAMS pathologists and others into a full-time review will speed the process considerably, Parks said.
Levy was fired in April, according to administrators. He had been suspended in March 2016 for being impaired, but he returned to work that October after counseling and after a check of his work found no errors at the time.
Levy was again taken off clinical work in October 2017 after what the hospital described as a second instance of working while impaired. His dismissal in April came after a personnel review.
The Veterans Health Care System of the Ozarks serves veterans in 23 counties in Northwest Arkansas, southwest Missouri and eastern Oklahoma.
Levy confirmed in an earlier interview he worked while impaired with alcohol in 2016 but said he didn’t work while impaired afterward.
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FYI
Pathology Review
Veterans and family members with questions about the pathology review at the Veterans Healthcare Center of the Ozarks can call a hotline at 866-388-5428 and locally at 582-7995. Another town hall is set for 8 a.m. Sept. 24 in the same auditorium at the system’s main facility in Fayetteville.
