The case of George Richards is exemplifies how hard it can be for doctors to diagnose bad doctoring.

The hospital where Richards worked first launched an internal review of his practice in 1968, after Bernice Hutzler, a hospital trustee, heard rumblings about his problems at a dinner party, according to a deposition.

One of the people who participated in the review was Dr. John E. Adams, chief of pathology at Greater Baltimore Medical Center. Adams testified in a 1982 court deposition that he complained at the time of the review about some of Richards' methods.

Adams said he and Richards argued over Richards' practice of beginning radiation treatment before completing tests to confirm diagnoses of cancer. He testified that in "one or two cases a year," his department would get tissue samples that tested benign from patients of Richards who were already undergoing radiation treatment.

Adams also testified that his department did autopsies on some of Richards' patients and found that some of them had died from complications of radiation therapy. While the autopsies caused concern, he said, some complications in radiation therapy are inevitable and there was no objective way to judge how many radiation complications should have been considered excessive.

Many of those who have sued Richards allege that he failed to keep up with advances in radiology and overradiated patients, using what attorney Howard Janet characterized in an interview as "a blowtorch approach to cancer."

Despite these concerns, the hospital panel concluded that Richards' practice was adequate.

A few years later, in the early 1970s, Adams became a member of the Commission on Medical Discipline.

He had been on the board for seven years and had ascended to the chairmanship when the commission heard the Richards case -- in 1980. He recused himself.