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Hospital and Doctor Battle to a Bitter End

Posted on: Sunday, 2 October 2005, 06:00 CDT

By Bill McKelway

In early October 2001, Dr. John Raviotta's tenure at Community Memorial Healthcenter was barely salvageable.

Under investigation for months by in-house committees and on probation, he was facing a formal hearing that could end his practice at the South Hill hospital and possibly end his medical career.

But Raviotta fervently believed he could convince hospital authorities they were justified in keeping him on staff and that his longstanding allegations of patient harm held merit.

He was delivering as many as 12 babies a month, despite the arrival of two new obstetricians, both of whom were getting financial help from the hospital, said Raviotta, who'd also been helped financially. Both new doctors had recently finished their residencies.

"It was pretty clear to me that given the amount of business in this area, this was an effort by the hospital to put me out of business or at least reduce my patient load enough to make it impossible to keep going," said Raviotta, who had been the lone obstetrician in a 50-mile radius.

"What the hospital didn't count on was that my patients stayed with me."

Raviotta had never backed off from his bullish push for improvements to patient care at Community Memorial or from his allegations about hospital mismanagement and policies that endangered patients.

Sitting in the cool rush of a window-unit air conditioner at his document-laden temporary home outside South Hill early this summer, Raviotta said he has no regrets about his conduct and efforts at reform. "I'm still confident that what goes on at the hospital will eventually result in sanctions by state and federal investigators.

"It's a tragedy that conditions have been allowed to continue without any penalty whatsoever."

But the business of medicine was making it more and more difficult to survive financially in late 2001, especially for a sole practitioner in a region where poor people make up much of the patient load. Community Memorial absorbs almost $9 million a year in charity care; providing obstetrical services accounts for losses of about $1.5 million annually, the hospital says.

In South Hill, Raviotta never cleared more than $150,000 a year and for 2002 and 2003 he paid himself no salary. His annual medical malpractice premium reached $100,000 in 2000 even though he had never been successfully sued. But he'd been named in two medical malpractice cases since his arrival in South Hill, and for much of his five-year stay he hadn't had another doctor to back him up.

Increasingly in debt from legal fees and business expenses, Raviotta nevertheless pressed his campaign for change and the defense of his conduct.

"The system the hospital used to get rid of me hides from the public what is going on, and it's filled with persons whose well- being depends on the administration's wishes," he said.

Raviotta maintains that medical professionals are being pressured by business interests who control hospital operations and who focus on cost savings at the expense of quality care.

"Let the administrators make sure the lights are on and let doctors do what they are trained to do," he said in one interview. The situation in South Hill is just one example of a national problem, he said.

Hospital officials at Community point to its array of services, its cooperative affiliations with larger hospitals and to a lack of sanctions by investigative agencies as evidence that it provides quality care. In the past five years, only one doctor's privileges have been revoked, hospital Chief Executive W. Scott Burnette said, without specifically naming Raviotta. Suspensions or reprimands have been almost as rare.

On Nov. 28, 2000, state investigators began an unannounced inspection of emergency department procedures at Community Memorial.

A month earlier, Raviotta had filed a complaint that a high-risk patient who was 32 weeks pregnant and bleeding had been left alone and ignored when she came to the emergency room by ambulance in the early morning hours of June 27.

"She and her baby were in danger and when I got there, there was no doctor with her," Raviotta said. "Under the sheets, the bed was full of blood."

At issue was a hospital policy that shifted primary responsibility for patients more than 20 weeks pregnant from the emergency room to the obstetrical department. Patients needed to be immediately assessed by the ER when they arrived at the hospital, Raviotta argued.

Raviotta also had reported to investigative agencies that the hospital had no effective backup plan to perform emergency deliveries when operating teams already were occupied with another case or were not on duty.

He alleged that a patient had to wait three hours for an emergency surgical delivery of her child because a scheduled non- emergency orthopedic case was given priority. That incident dated back to December 1999.

He had compiled a list of similar delays with other patients.

Records compiled by Raviotta show he had made complaints through hospital channels for months about these apparent problems, at one point writing a long letter of alarm to Wayne Parrish, a business executive who was chairman of the hospital's board of trustees.

"I have been very reluctant to write directly to the Hospital Board, but feel I have exhausted all reasonable hospital processes in an effort to make CMH a safer, more welcoming hospital for the patients we serve," the May 2000 letter began.

"The ER-OB policy will not instill trust in pregnant patients in this community. I regret that I have not more effectively communicated the seriousness of these issues and as a result have perhaps been looked upon more as part of the problem rather than as part of the solution."

Parrish said in a telephone interview that he is barred by law from discussing Raviotta's complaints. Raviotta provided letters from the hospital showing that it repeatedly asked him to work through the system to find solutions to his concerns, but Raviotta said he was rebuffed by other doctors.

The nine-day inspection turned up no evidence to support Raviotta's allegations.

Instead, it found that Raviotta may have delayed the delivery in December 1999 because he refused to follow hospital procedure by working out with the orthopedic doctor which case should get priority.

Nor was it clear that the hospital's policy considered the woman's condition an emergency, according to investigative reports.

Investigators also concluded that the bleeding patient from June 2000 was adequately cared for. Her emergency-room care and response times by Raviotta and nursing staff assured that the woman was promptly attended to.

Raviotta did not know at the time that a complaint also had been filed against him. It alleged that he had refused to attend to a patient who had arrived in the emergency room after delivering her 11th child at home.

"He stated that he was refusing to accept this patient, that she had not had any prenatal care, she was not his patient, and that he would not take care of her," an emergency-room doctor told investigators about the June 1999 incident.

Almost two years later, on April 9, 2001, Raviotta learned from Burnette, the hospital chief executive, that federal health agencies were threatening to drop Medicare coverage for the hospital because of Raviotta's failure to promptly attend to the mother in the home- delivery case.

Raviotta's actions, in other words, had jeopardized a core source of hospital funding that could shut down the facility if not addressed by the hospital, according to federal regulations. Burnette notified Raviotta that any further violations of hospital policy would force the hospital to suspend his privileges.

Just days earlier, Raviotta had been called into Burnette's office and told that he was being ordered to undergo a thorough examination of his physical and mental status by outside doctors. Failing to agree to the assessment would force termination of his privileges, Raviotta was told.

"This is a process for impaired physicians," Raviotta said in an interview. "It can be a great program for doctors who suffer addiction and other problems, but it can also be a punitive process that shakes your confidence, your trust in your abilities. It can be a way of going after somebody."

Raviotta temporarily lost his hospital privileges on April 17, 2001, because he filed a release agreement for the assessment a few minutes late. He had also missed an earlier deadline. The privileges were returned 10 days later, but Raviotta remained on probation.

"I got a clean bill of health," Raviotta said, referring to findings that he was not impaired.

Throughout 2001, Raviotta continued a letter-writing campaign, trying to draw attention to alleged hospital shortcomings.

He wrote the state health commissioner in January 2001 begging that an investigation be reopened into his allegations that the hospital remained unable to handle emergency deliveries within 30 minutes when the operating-room staff was handling another case.

And he charged that two new obstetricians had prematurely been given privileges to practice without supervision; he questioned operations and procedures they undertook and said four nurses had left the hospital because of "continued harassment" by one of the doctors.

"CMH Administration seems to be giving [the two obstetricians] preferential treatment presumably because of CMH's financial investment" in them, Raviotta wrote.

Raviotta saw himself as expendable.

His collection of hundreds of pages of documentation, letters and allegations resembled more a paper highway than a paper trail. But it hardly led to the destination he intended.

In August 2001, another in-house committee voted to recommend that Raviotta's privileges be immediately, permanently revoked. That came in the wake of new problems with nursing staff. Bylaws afforded Raviotta an opportunity for a full hearing, so the revocation was held in abeyance.

The call for revocation focused on the belief of the executive committee of the board that nothing so far had seemed to alter Raviotta's conduct, not even suspension.

So conduct that earlier had produced only warnings and probation now carried consequences that threatened permanent revocation of Raviotta's privileges. His career was on the line.

Particularly troubling, the hospital's Medical Executive Committee reported in August 2001, was Raviotta's "lack of insight into or acceptance of responsibility for his inappropriate conduct and his apparent propensity to misrepresent as facts (whether knowingly or involuntarily) things that are demonstrably untrue."

Facing a hearing before selected board members and medical staff that would exonerate him or uphold the decision to fire him, Raviotta stepped over the line again.

In late October 2001, Raviotta copied the records of two patients who were not his own, an activity prohibited by hospital regulations. Then he lied about the copying to Burnette.

Raviotta later explained that he lied because he was intimidated by Burnette and simply wanted to avoid him during a hallway confrontation. He and his lawyer also argued that he had authority to copy the records because bylaws permitted "responsible" people to do so. Raviotta was chief of obstetrics.

Burnette recommended that Raviotta immediately lose his privileges, and the board backed him up.

Barred from treating patients at the hospital, Raviotta tried to make ends meet by continuing to see gynecological patients in his office. He also offered cosmetic procedures.

"It was a hard time for me, but I couldn't help thinking that all of this would be worked out in the end," Raviotta said.

His patients stayed with him as best they could, he said.

On Jan. 12, 2002, a five-person Hearing Committee convened to formally consider a list of allegations dating back five years.

The confidential proceedings would consume more than 90 hours of testimony and argument; they would involve eight full days of hearings that occurred over four months. There were 39 witnesses; the transcript is 3,200 pages long.

Elemental to Raviotta's defense was the argument by his lawyer, Nicholas Kadar, that the case against Raviotta had been fabricated.

"The evidence, I am sorry to say, demonstrates that there is no fact that this hospital was not prepared to fabricate or distort, no statement too false for its witnesses to testify to under oath, and no yarn too outrageous for its attorneys' spin to deceive or confuse you," Kadar wrote in a post-hearing summation.

In a proceeding that demanded clear and convincing evidence, Raviotta's career would hinge largely on the testimony of patients and of nurses and doctors who worked at the hospital. He also faced a panel made up of doctors with close ties to the hospital or whose medical careers were linked to their own privileges to practice there.

Presiding was former state Attorney General Stephen D. Rosenthal, now a highly regarded lobbyist and Richmond lawyer who specializes in medical disciplinary matters. Hospital bylaws also afforded Rosenthal a vote.

Raviotta alleges Rosenthal was paid tens of thousands of dollars by the hospital to oversee the proceedings and to write the Hearing Committee's final recommendations.

Rosenthal declined to answer any questions about the proceeding or even to acknowledge that it occurred, saying he is barred by state law from commenting on peer-review matters. The hospital, through a spokesman, declined to say if Rosenthal was paid for the work.

Some of Raviotta's harshest assessments against the hospital were upheld.

Rosenthal's report concluded, for instance, that state investigators may have been misled about existing policies regarding emergency deliveries, especially about in-place backup procedures for when the operating staff is occupied with another operation.

The backup plan wasn't formally approved until months after state investigators actually finished their late 2000 inspection. Nurses testified that they were not trained in the rarely used backup plan until inspectors had left.

While Raviotta was portrayed by some nurses as a wildly unpredictable man who threatened nurses' licenses and, according to one witness, made her fearful for her life, others filed glowing assessments.

"Working with a highly skilled, experienced obstetrician provides confidence to me as a staff nurse. I am comfortable to ask him questions and he is always willing to explain to me medical information that I may not have knowledge of," wrote one nurse, who said another doctor at Community threatened and scolded her and falsely promised that his own license would protect her from liability if a bad outcome ensued.

The Hearing Committee heard some of the most vehement testimony from a nurse whose conduct had been challenged years before by Raviotta in a suit involving a lost sponge. And a nurse who was Raviotta's own witness gave some of the harshest and then most supportive testimony heard by the panel.

But more than a dozen staffers complained about his conduct, some of which dated back to his earliest days in South Hill.

Doctors who had assessed Raviotta's judgment and skill as a physician, based on cases chosen by the hospital, were somewhat divided.

"There is no more widely recognized standard of care [than] the requirement to get a Caesarean under way in 30 minutes," a respected Richmond physician wrote, backing Raviotta's longest-standing concern. "There is no way around this."

He also supported Raviotta in the matter of the woman who delivered at home. "The challenge of this case was that the patient did not want to be admitted to the hospital and the OB unit was understaffed," the doctor wrote.

And while state investigators concluded that Raviotta was at fault for refusing to attend to the patient, testimony at the hearing suggested that Raviotta had never been specifically asked to see her until later in the day, which he did.

She left the hospital shortly afterward against medical advice.

Another obstetrician from Norfolk questioned Raviotta's medical decisions in some cases. Yet even this doctor acknowledged that the hospital's list of conditions warranting emergency surgical deliveries was incomplete. The "bumping" policy was not clear when it came to identifying obstetrical emergencies.

One witness who spent long hours in the operating room with Raviotta described him as close to average in terms of temperament. "He is confrontational, stands up and speaks his mind," this doctor testified.

Many doctors exhibit similar behavior in the operating room, he said, but "if you are asking has he ever been so unable to control his emotions and actions that he is a detriment to the patient or nurses, I would say, no, I haven't seen that."

He had voted against revocation as a member of another committee. "I thought there was a lot of factual dispute with a lot of the material presented, a lot of he said-she said, a lot of gray area."

Riveting testimony came in the case of the bleeding, pregnant patient who state investigators said had not been subject to harm despite Raviotta's accusations that she had been left unattended.

The testimony came from a nurse who hadn't been interviewed by investigators.

She described an emergency situation in which the mother was bleeding profusely and the unborn baby was quickly losing its heartbeat.

"The fetal heart tones were going down, and I was nervous, and being a Christian woman, I started praying ..."

She and Raviotta rushed the patient to surgery while ER staff just watched, "dumbfounded," she said.

"Everybody was sitting at the desk. Nobody was in the room with her. Nobody was helping us, and I remember that I was slightly panicked because of that much bleeding, and because of the fetal heart tones."

The mother and baby survived and were sent to Richmond for emergency follow-up care. The mother testified that she later got a call from someone who claimed to be at the hospital urging her to sue Raviotta. She couldn't remember the man's name.

But the woman testified that Raviotta had saved her and her baby's life.

"If he hadn't have run in that door and run me down the hallway, me and my baby might not have made it."

The Hearing Committee concluded that allegations that Raviotta's behavior was detrimental to patient health and safety were not proved.

But other charges -- including the copying incident, threats to nurses, the accusation that he interfered with the delivery of quality care and had impaired the community's confidence in CMH -- all were upheld.

The 110-page summary placed enormous emphasis on Raviotta's seeming inability to acknowledge that he helped create dissension and on his repeated failure to strictly follow policy in the face of his own alternate view.

"He is a true advocate for his patients, but his advocacy knows no boundaries and he appears unable or unwilling to conform his behavior to what is properly expected and appropriate," Rosenthal's report summarized.

When asked if he shared the blame for any of the incidents reviewed in the eight days of hearings, Raviotta told the Hearing Committee:

"Well, I think it's an unfair question to ask at all because there is no right answer. If I say it's all my fault, then obviously I'm admitting something, and if I say none of it's my fault, then I'm an arrogant SOB."

The committee report, which Rosenthal produced eight months after the final hearing, recommended that the revocation of Raviotta's medical privileges at Community be permanent. A few weeks later the hospital's full board approved.

Raviotta was gone.

Because the findings are posted on the National Practitioner Data Bank that can be viewed by hospitals and doctors around the country but not the public, Raviotta said his ability to find work was destroyed. The listing includes a long repetition of the Hearing Committee's conclusions, and labels the reason for the revocation of privileges as "unprofessional conduct."

As the months and months of hearings and examinations of Raviotta's conduct secretly played out at Community Memorial, the real world pressed on.

Part of that real world involved a woman named Danielle Moore. Just a few weeks after Raviotta had been suspended over the copying incident, she felt something had gone wrong with her pregnancy. It was Thanksgiving Day 2001.

A single mom with a beautiful young daughter, she was close to delivering a second child. A sharp pain shot through her stomach and Danielle Moore headed for the emergency room at Community Memorial.

There is no decision in her life that she has regretted more.

Timeline

This is a chronology of events linked to Dr. John Raviotta's medical career and actions taken against him at Community Memorial Healthcenter in South Hill.

August 1977: Raviotta opens an office in his hometown of New Orleans after practicing obstetrics as a Navy officer-physician.

August 1991: He joins a two-doctor practice in Fairfax County after the economy crashes in Louisiana.

February 1996: After a falling out with his partners, Raviotta leaves Northern Virginia for an opening in a South Hill practice.

June 1997: Raviotta learns from the state Board of Medicine that it has found no violation after investigating an anonymous complaint alleging unprofessional care and a violent temper. He has started his own practice, prompting a damages suit against him by his former partner.

June 7, 1999: A multimillion-dollar suit is filed against Raviotta, the hospital and others alleging negligence in the death of a patient.

November 1999: Raviotta's testimony helps bring a $175,000 judgment against the hospital in a "lost sponge" case.

December 1999: An in-house investigation begins of Raviotta's alleged failure to follow various policies and for "potentially hostile behavior."

November-December 2000: State Health Department investigates complaints from Raviotta but finds no violations; a complaint against Raviotta is substantiated.

February 2001: Raviotta gets a letter of warning and is placed on probation by the hospital board.

April 2001: The hospital informs Raviotta that it may lose Medicare funding because of his failure to promptly treat a patient.

October 2001: Raviotta's privileges are suspended when he copies records of patients who are not his own.

January 2002: Formal hearings begin into proposed revocation. The hearings would take place on eight days over the next four months.

February 2003: The hospital board, made up of 21 people, most of them nonphysicians, votes to revoke Raviotta's privileges and rejects an appeal.

Summer 2004: Raviotta and his wife appear before governor's task force investigating access to obstetrical care in rural areas.

May 2005: Raviotta is among whistle-blower doctors testifying at a hearing in Washington at the Capitol.

Aug. 29: As Hurricane Katrina barrels through her former home of New Orleans, Judy Raviotta undergoes surgery in Fairfax to prepare her for months of chemotherapy.

Sept. 1: The deadline to refile a wrongful-death suit against Raviotta passes with no new legal action.

Sept. 23: Raviotta learns that the hospital has filed a complaint with the state Board of Medicine alleging that he illegally used copies of the peer-review proceedings as the basis for complaints he filed against various witnesses against him.

For a video interview with Dr. John Raviotta, click on this story at TimesDispatch.com

Source: Richmond Times - Dispatch

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