By Amy Silverman
By Olivia LaVecchia
By Monica Alonzo and Stephen Lemons
By Chris Parker
By Michael Lacey
By Weston Phippen
They say everyone deserves a second chance. At last count, Dr. Bipinchandra Jadav has had 15.
The doctor, a general practitioner in Mesa, has had more than a dozen complaints filed with the state Board of Medical Examiners (BOMEX). He has had his license restricted once, has been ordered not to practice in Arizona for a period of six months and to take a medical competency exam--he failed the first time, passed the second. He is currently on probation for prescribing hundreds of potentially dangerous and addictive painkillers to a single patient, and making false statements about his hospital privileges.
According to his probation, Jadav may no longer practice anesthesia--his former specialty--and is either supposed to reenter a residency training program or have a management consultant help his practice. He is not allowed to prescribe certain drugs.
BOMEX even threatened to take away Jadav's license once. Instead, the agency let him keep practicing because he agreed to go on probation--the board's equivalent of a plea bargain.
Considering his record, you might wonder why the state agency that is supposed to protect the public from unqualified and incompetent doctors hasn't simply pulled his ticket.
That's undoubtedly something that the parents of 8-year-old Jessica Felker would also like to know. Their daughter died of pneumonia, after she'd been brought to Jadav with a severe cold and coughing.
Jessica suffered from Down's syndrome, but the pneumonia was apparent on her x-ray--which no one read until two days after she died. Jadav ordered it, but never bothered to look at the film.
Jessica Felker's death speaks volumes about serious problems at BOMEX, the state's most important health-care regulator. The agency is supposed to be the thin white line between Arizona's 15,000 doctors and a vulnerable public, protecting patients from abusive, incompetent and dangerous doctors.
For Jadav--and many other doctors with multiple complaints and disciplinary actions who continue to practice--BOMEX is a home of second chances and procedural delays.
New Times analyzed about 14,000 complaints, against about 5,500 doctors, using a computer database of records dating back as far as 20 years. In addition, the newspaper interviewed current and former board and staff members, local and national experts and political leaders responsible for overseeing BOMEX. The newspaper also reviewed court records, documents on file with other agencies as well as BOMEX's own files. The investigation revealed:
* Dozens of doctors have been investigated by BOMEX time and again. In fact, 79 doctors have had a dozen or more complaints against them; 69 are still practicing. These doctors account for 10 percent of all of BOMEX's complaints. One doctor, eye surgeon Gary Hall, has had 121 complaints lodged against him since he began practicing in 1982. He recently lost a malpractice verdict and has settled out of court on numerous other lawsuits.
* In nearly 90 percent of its cases, BOMEX takes no disciplinary action at all.
* BOMEX has a significant backlog of cases. Nearly 1,000 complaints are still open, some dating back several years. Other state medical boards that regulate as many or more doctors than BOMEX have significantly fewer open cases.
* BOMEX is operating nearly the same as it was four years ago, when the state auditor general released a critical review of the agency. Since 1995, it has taken BOMEX an average of 16 months to resolve a complaint. That's three times as long as recommended in the 1994 audit.
* Accusations of sexual misconduct take even longer to resolve, despite BOMEX's self-proclaimed "zero tolerance" policy. There have been 42 sexual misconduct complaints filed with BOMEX. It's taken the agency nearly two years, on average, to resolve the complaints.
* Last year, BOMEX sent only two cases to a state administrative law judge for possible license revocation. The state Office of Administrative Hearings says it could easily handle more cases, except BOMEX isn't passing them along. Only three have been scheduled for hearing so far this year.
In addition, BOMEX has been struggling with internal staff turnover. BOMEX's former executive director, Mark Speicher, was asked to resign after what some BOMEX insiders say was a behind-the-scenes power struggle with the agency's legal counsel. Four of the board's seven medical consultants have resigned, and one of the agency's six investigators has also quit, leaving BOMEX shorthanded in the investigation of complaints.
Most of BOMEX's 12 members are doctors, asked to police their own. The board now has seven doctors from a variety of specialties, one nurse and three lay members representing the public. One position remains open.
By law, the board is supposed to discipline physicians who violate medical practices and ethics, including revoking a doctor's license if necessary. The agency has a staff of about 30 and a $3 million annual budget.
The prognosis for BOMEX is uncertain. Those who oversee the agency--from the Legislature to the governor to the chairman of the medical board--aren't demanding much in the way of immediate improvements. Instead, they say they'll wait as long as another year to see if a new executive director can bring the agency back to health.
Meanwhile, if the trend holds, another 1,000 complaints will be filed with BOMEX while officials watch.
At first glance, Dr. Gary Hall is the American dream wrapped in a doctor's white coat. Educated at Indiana University and the University of Cincinnati, he took a year off from med school to compete as an Olympic swimmer. He was a member of three Olympic teams. The father of an Olympic gold medalist, he's also the son-in-law of Charles Keating, who built a billion-dollar financial empire before it crumbled in lawsuits and federal indictments. Hall came to Phoenix in 1982 with his family, and since then has built a successful and well-known ophthalmological practice.