Picture the scenario: After suffering sharp chest pains and nausea on a summer road trip, you head fearfully to the local ER. A man in a white coat asks questions, briefly examines you and orders some tests. Feeling that you're in good hands, you relax, wondering whether you may be experiencing a panic attack rather than a heart attack. Little do you suspect that the reassuring figure in whom you've just placed your trust and well-being may not hold the degrees or license that are indicated on the plastic name badge. Least of all do you imagine that the badge may not even show his real name.
Those real possibilities should set your heart racing. False credentials are a chronic problem in the health care industry, brought into focus most recently by the charges filed by federal prosecutors in Virginia against Perry M. Beale, who, authorities allege, inspected radiological equipment in Virginia, the District of Columbia, Maryland, West Virginia and Pennsylvania for 15 years even though he was never trained or authorized to do so. Beale has told the judge in open court that he intends to plead guilty. While a conviction may resolve this particular case, it does not address the larger problem of protecting patients or figuring out why routine background checks often aren't completed.
Charges of the kind brought against Beale come as no surprise to me. As a former federal and state prosecutor, I have investigated numerous instances where bogus health care professionals have provided patient care with little oversight. In 1997, I prosecuted a phony physical therapist, Diane Cannon, who had duped several Maryland hospitals and HMOs into hiring her despite the fact that she had only a high school education. That same year, I took part in another investigation, in which an unlicensed medical school graduate was accepted into specialized trauma care training in a Baltimore emergency room. I've also shared information with other prosecutors about organized rings that perpetrate credentials fraud -- the kind of scheme that led Michigan's attorney general to issue a warning in 2001 about an employment agency's attempt to staff nursing homes with unqualified certified nurse assistants (CNAs). Right now, I'm aware of several criminal investigations into patients unknowingly being treated by unlicensed health care professionals in the District.
Rectifying this situation requires not only some basic steps on the part of the health care industry to verify references and check forged documents, many of which are becoming harder to detect; it also requires government action. The laws protecting the public are pitifully lax. Look at it this way: Theft of a bicycle can be charged as a felony in the District and Maryland, but performing surgery without a license is only a misdemeanor in both jurisdictions.
Part of my frustration lies in the fact that there's nothing new about health care fraud. More than 20 years ago, Congress held hearings on fraudulent medical credentials. The investigators estimated that in the early 1980s there were 10,000 doctors with fraudulent medical degrees working in U.S. hospitals and clinics. They also estimated that there could be as many as 500 fraudulent credential mills supplying bogus credentials to anyone willing to pay the price. Sobering as such statistics are, it was the testimony regarding harm to individual patients that was truly disturbing. For example, in 1983 Abraham Asante was hired by the Army after stating that he had a Czech medical degree and a state medical license. He had neither. Nonetheless, he was assigned to Fort Dix, N.J., as an attending anesthesiologist. Asante participated in 83 routine operations with no apparent problems. However, during his 84th case, complications developed and he was not able to operate the machinery properly. As a result, the 46-year-old patient, Joseph Branda, left the operating room clinically brain dead. Only after that did Asante's lack of training and proper credentials come to light.
Asante was able to fool his employer only because no one performed an effective check of his credentials. We should have learned our lesson then. Why, 20 years later, are we still reading about people like Perry Beale in Virginia?
I'm often asked what motivates people to commit these crimes: The answer is greed and status seeking. Most health care professionals are well paid. The fake physical therapist whom I prosecuted was making about $50 an hour -- not bad money for a high school graduate. Doctors and other professionals can make far more, and bogus medical credentials also open the door to fraudulent insurance billings and other moneymaking schemes.
Other health care impostors are in it for more than the money. They suffer from what I call the "wannabe syndrome." Some flunked out of professional school; others could never pass a professional licensing exam. Either way, they are not about to let the lack of a certificate stand between them and a lifelong dream. These individuals generally believe that if they can only get established in the profession, they have sufficient knowledge to practice with their secret undetected.
Some carry it off for quite a while. Generally, they have had enough exposure to the discipline to demonstrate at least superficial mastery of technical matters. Like most good con artists, phony medical professionals present a smooth and charming personality. What's more, like cat burglars and computer hackers, they will exploit weakness in the health care industry's defenses: If rejected on occasion, they try and try again until they succeed.
With her engaging personality, the phony therapist I prosecuted had always done well in interviews. Despite her crudely forged educational and professional documents, Cannon had an acting ability that made her a strong candidate. For references, she either used the names and phone numbers of friends or associates whom she had coached, or gave a false name and a phone number connected to several lines in her house that she or a family member would answer. Not surprisingly, her employers received nothing but glowing reports when they called these "references." Cannon gained so much trust that she was assigned to be a visiting therapist, where she performed her services in elderly patients' homes with virtually no oversight. Her scheme did not begin to unravel until it was discovered that she had not made some of the home visits she had charged for and had falsified the relevant patient progress notes. It later turned out that she had had a previous criminal record.
The unlicensed medical school graduate had offered a continual stream of excuses when asked for the required documentation. For example, he told the personnel office that he had produced his license to his clinical director -- and vice versa. It took a considerable amount of time before both realized he had never produced a license. When he was finally required to provide his license number on a hospital form, he recorded his pager number, and later claimed he did so accidentally. It took months before this was noticed, and more time before he was asked to rectify his "mistake." Through this stalling strategy, he managed to work as a physician in a Baltimore emergency room for a year. Based on this experience, he then secured a position in another ER in Washington's Maryland suburbs. The second hospital gave his application limited scrutiny, assuming that his license had been thoroughly reviewed by his previous employer. Afterward, it was discovered that he had actually failed licensing exams 11 times in various states.
The weak laws -- and weaker punishments -- not only fail to provide a true deterrent, but often make prosecution more complicated. Cannon was charged with theft of her salary. This was the only means through which she could receive the jail time to which she was eventually sentenced. In Maryland, practicing physical therapy without a license is subject only to a fine. (Two years later, Cannon received a six-month sentence for federal health care fraud and tax evasion.) Similarly, Beale has been charged with mail fraud because he received some of his payments through the post office. Prosecutors are pushed to focus on the economic aspect of the crime, despite the fact that most would agree that the potential harm to patients is the more serious issue.
These laws should be changed both to send the appropriate message and to encourage vigorous prosecution. I'm not alone in believing this. Several years ago, the Maryland attorney general's office proposed legislation to upgrade the practice of medicine without a license to a felony. It was the rare piece of health care legislation that insurance companies, hospitals, medical professionals and law enforcement all agreed was a good idea. Unfortunately, no one saw it as important enough to lobby for. As one state delegate told me with revealing candor, "The merits of a bill have little to do with what gets passed around here." That bill died of inertia, without a single word of opposition by anyone.
In its statement on the Beale case, the Division of Mammography Quality and Radiation Programs of the Food and Drug Administration said that it believes no patients were harmed by the scheme. That may be true, but Joseph Branda wasn't so lucky. He died after spending three years in a coma. Our local jurisdictions need to act now, before another patient is grievously injured at the hands of an unlicensed practitioner.