At 65, Paul Phillips was ready to retire. He'd raised his four kids, sold his Phoenix produce company, and even bought a 40-foot RV to drive across the country with his wife LuWanna.
Phillips was working on his golf game, in anticipation of all the free time he'd have. Even more, he enjoyed playing ping-pong and catch with his grandkids.
But on March 13, 2001, Phillips found himself at the Mayo Clinic in Scottsdale, waiting to see an ophthalmologist. The vision in his left eye had suddenly gone blurry, and he was seeing floating specks of light in the same eye. Phillips has diabetes; he's had it for 18 years. He and LuWanna knew failing vision could be related, so she insisted he get the best help available. As LuWanna later recalled, she called the Mayo Clinic and scheduled an appointment with Paul's ophthalmologist.
Read the rest of the "Prescription for Disaster" series.
Phillips fidgeted anxiously in the waiting room, wringing his hands — still leathery and calloused from 40 years of handling boxes of fruit and vegetables.
Then a nurse called him to examination room number 9, where she asked him to read an eye chart. After the nurse left, a man wearing the standard tie and suit coat of a Mayo physician — a trademark in the healthcare company's facilities — entered the room. He held an Executive Glaucoma Screening Form and Phillips' chart in his hand. He asked a number of questions and then examined both of Phillips' eyes.
That man, Paul Hughes, diagnosed Phillips on the spot with "K. sicca" or eye inflammation. He explained that the problem was simply dry eyes and Phillips need not worry about his left eye. Hughes recommended over-the-counter salve and drops, known as "tears." Then he walked Phillips to the billing desk, shook his hand and thanked him for visiting the Mayo Clinic.
On the way home, with LuWanna behind the wheel, Phillips wondered aloud why the doctor hadn't dilated his eye. He concluded the doctor knew more about eyes than he did.
He used the drops, but they didn't alleviate the blurriness or floating flashes of light.
Two weeks later, the Phillips were sitting in a movie at the Deer Valley Harkins Theatre on Bell Road when Paul's left eye went completely dark — as if somebody had dropped a veil over it.
The retina in his left eye had detached. The symptoms Paul Phillips reported at Mayo were classic signs of a tearing retina; according to the Mayo Clinic's own literature, if caught at that point when he'd visited the clinic, the condition has about an 85 percent chance of successful treatment with retinal reattachment. Once it had detached, it was much tougher. And today, after a series of surgeries, Phillips is permanently blind in his left eye.
So why did the Mayo Clinic fail to properly diagnose Phillips' run-of-the-mill malady?
Could be because Paul Hughes, the man who treated him — who held his chart and looked in his eye and recommended drops — isn't a doctor at all. He's not a physician's assistant or a nurse, either.
In fact, Hughes has no formal medical training and has never been licensed to provide healthcare or even sell glasses in Arizona. And yet, for almost 20 years, Paul Hughes "triaged" eye patients in the Mayo Clinic's ophthalmology department, deciding which doctor, if any, they should see. Some patients, like Phillips, never did see a doctor — or any other licensed practitioner beyond a nurse. Phillips says he wasn't told this. He assumed he'd seen a doctor; his wife had asked for an appointment with one; he'd been seen by a nurse, then by a man in a coat who certainly looked like a doctor and never said otherwise.
Even after Phillips' catastrophe, when the case had gone to court — where a jury would eventually award Phillips $3.5 million — Paul Hughes apparently had no contrition.
"I don't feel like I need to be certified in something I'm efficient at," Hughes said to the jury about the treatment he gave Phillips.
When Phillips learned that he was misdiagnosed by a non-doctor, he and his lawyer told the Mayo Clinic they could donate $2 million to the blind, or they could brace for a lawsuit.
Mayo chose the lawsuit, and lost.
In July 2006, a jury found in Phillips' favor; the judge lowered the medical malpractice judgment to $750,000, an amount that matches similar cases involving blindness.
Phillips says he has yet to spend a penny of it. (After the emotional turmoil of the trial, he's decided to keep the money.) Instead, he's spent the last year mourning the recent death of his wife of 50 years, as well as the loss of his depth perception.
Phillips' story is a case in point that when you visit the doctor, you can't assume you're seeing a doctor — or even a trained practitioner. Not at the Mayo Clinic. Not anywhere. New Times reported the details of this case mainly from interviews with Phillips, court pleadings, depositions, and transcripts from the trial.
It's hard to fault Paul Phillips for assuming that a practitioner in a suit and tie, holding his chart at the Mayo Clinic, was qualified to give a diagnosis. After all, Phillips had gone to the best. He knew of Mayo's international reputation for leading the way in cancer research. And Mayo had just been named the number one choice of hospital by consumers in the Phoenix area for the third year in a row, according to the National Research Corporation.
Beyond that, the Mayo Clinic — founded in Rochester, Minnesota, in 1888 — is an icon, considered the gold standard of medical care. When the company opened an outpost in northeast Scottsdale almost 100 years later, in 1987, Mayo drew patients like bees to honey.
But the standards in place at the Mayo Clinic's ophthalmology department when Paul Hughes was hired — standards clearly not reviewed as the years went on — were hardly golden.
As revealed in court testimony, Paul Hughes was more than just a non-doctor who had his own office located between the spaces of Mayo physicians. Hughes came to Mayo as a convicted felon; his offenses included forgery and cocaine possession.
Not that Hughes was qualified to practice medicine in the first place; he doesn't even have a college degree.
If Hughes wasn't pretending to be a doctor, he was clearly allowed to see and treat patients in a way other non-doctors were not. (And in a way not allowed by Arizona law.) That's because Hughes was working for a longtime friend, then Mayo's director of ophthalmology, Dr. John Creasman.
Contacted for this story, Creasman says he trusted Hughes, regardless of his lack of official training.
"All technicians in our department become pretty good diagnosticians. You could take any one of them, and 95 times out of 100, they could tell the doctors what the patients had. They were right most of the time, so that was part of their responsibility," Creasman says.
Neither Creasman nor Hughes works for the Mayo Clinic now.
Creasman says that Hughes, still a close friend, was devastated by the lawsuit and would not comment for this story. Other attempts to reach Hughes were not successful.
Mayo employees testified that Creasman's trust of Hughes resulted in Hughes' seeing six to 13 ophthalmology patients per day at the Mayo Clinic, usually without any physician supervision.
Hughes worked in that capacity at the Mayo Clinic for 18 years.
No other lawsuits against Creasman or Hughes surfaced in a search of lawsuits at the Maricopa County Superior Court and at Arizona's U.S. District Court. Creasman has a spotless record with the Arizona Medical Board, too. (At least, to the extent that the medical board keeps such records. For more information about the Arizona Board of Medical Examiners and other state-regulated boards, see the earlier stories in this series, "The Doctor is Out," March 6, and "Dr. Loophole," April 10).
Even if Creasman and Hughes aren't contrite, the Mayo Clinic certainly is.
Speaking publicly about the case, apparently for the first time, the CEO of the Mayo Clinic admits that Phillips' care was not ideal. He says it was a fluke that won't happen again.
"I've been in this position six years, and I've been with Mayo 31 years. Personally and representing the organization, I feel bad and take responsibility when things go bad. We see about 100,000 patients per year. We know this wasn't the optimal," Dr. Victor Trastek says.
"Today we have a lot more policies and procedures in place," he adds. "I hope the point comes out that these are different times, and we're all trying to give the best healthcare to every patient."
It goes without saying that a non-doctor shouldn't be seeing patients alone, says Katherine Hatwell, a spokeswoman for the American Medical Association. Hatwell says she's heard of optometrists (who fit patients for glasses) working as ophthalmologists (who operate on eyes), but she's never before heard of a non-doctor diagnosing patients in an ophthalmology department.
"We think people should practice to their education and training and not beyond it," Hatwell says. "If you don't have a medical license, you shouldn't be able to practice medicine."
Paul Hughes was officially trained to do one thing — fit people for lenses that an eye doctor has prescribed. That's equal to the guy at Costco who works the glasses counter filling prescriptions, not writing them. (In fact, even those salespeople at Costco are licensed by the Arizona State Board of Dispensing Opticians. Hughes has never been a licensed optician in Arizona, according to Lori Scott, that board's executive director.)
Even if Hughes were a licensed optician in Arizona, he couldn't treat or diagnose patients. He could only put their glasses together or order their contacts.
So why was Hughes allowed to see Paul Phillips? The answer starts about 40 years earlier, when Paul Hughes was convicted of his first crime.
Hughes was born in 1939 in the rural farming town of Friona, Texas — a panhandle community with a population of about 800, according to A History of Parmer County. To this day, the average male in Friona doesn't achieve more than a high school education. So Hughes' journey to the Mayo Clinic, where he had an office and dressed in a suit and tie, was remarkable — in more ways than one.
In his deposition in the Phillips case, Hughes explained he flunked in an attempt to earn a degree at Southwest Junior College in Texas. He added that his medical training wasn't official, per se.
"I guess the rest of the education wasn't done in a classroom setting. I suppose it was mostly on-the-job training," Hughes said.
What Hughes left out was that his on-the-job-training started as an inmate at a prison in Sugar Land, Texas, as he would later confess to Judge Anna Baca.
Asked under oath whether he'd ever been arrested or served time, Hughes initially forgot to mention his years in prison. He answered, "Yes, speeding and changing lanes without a proper signal, and just everyday things that . . . I seemed to be in a hurry everywhere I went, so I accumulated a few traffic tickets."
Attorney: "Have you ever been to jail or in jail?"
Hughes: "Yeah. I went to jail because I didn't pay the fines."
Attorney: "How may times?"
Attorney: "How long did you stay?"
Hughes: "One day. Actually, not a full day."
Attorney: "Anything else?"
During the trial, it was revealed that Hughes hadn't told the whole truth. He had actually been to jail multiple times and prison once, and had been convicted of two crimes: forgery and possession of cocaine. The forgery conviction landed him a six-year prison sentence. Turns out that's when Hughes first learned about the human eye.
In the prison infirmary, Hughes met an ophthalmologist. He says he worked under him as a volunteer inmate for almost two years. When Hughes walked out of prison, he had one asset he didn't have before — a two-year prison education about the eye.
He applied for a job at Lee Optical in nearby Amarillo. "That's where I began my optical profession, in a store with something like five doctors and 60 people," Hughes said in his first deposition. Hughes was in charge of making and distributing the glasses that doctors prescribed.
Hughes then learned how to craft prosthetic eyes. He worked the Texas area as a "traveling eye salesman," selling (not installing) prosthetic eye implants to Vietnam vets who'd lost eyes in combat.
Hughes regularly solicited his prosthetic wares to eye doctors. During a cold-call sales pitch in Houston, he met an ophthalmologist by the name of Dr. John Creasman. The two became close friends.
Around 20 years later, the same Dr. Creasman got a call from an old medical school friend. Did he want to start an ophthalmology clinic in Scottsdale? Creasman agreed to assemble a staff at a for-profit business — the Mayo Clinic. The year was 1987.
The next year, Creasman hired Hughes to work as a technician at the brand-new Mayo Clinic's ophthalmology department in Scottsdale. Hughes apparently didn't even interview for the position.
"He just hired me and put me in charge," Hughes said in his deposition. For Hughes, it was a dream job. The Scottsdale region and the Mayo Clinic both enjoyed a decade of rapid growth. By 2001, Hughes was seeing between six and 13 patients per day, without any direct supervision from doctors, according to Mayo receptionist Cheri Chandler's deposition.
Attorney: "When you schedule [patients] with Hughes, are those patients seeing Dr. Creasman after?"
Chandler: "They are usually just scheduled with Paul."
That testimony aligned with Hughes' own words about his role as a near-doctor at Mayo. "The procedure is that the patient calls into the ophthalmology department, and they're triaged over the phone, best they can. And then they're scheduled with me . . . they're just scheduled on the schedule for either a doctor or myself."
Department head Dr. John Creasman also testified that Hughes was the only technician to see patients without a doctor present. He said none of Mayo's other six technicians saw patients alone, but Hughes did. According to Creasman, Hughes actually had a patient schedule.
It's that appointment schedule that Paul Phillips somehow landed on — even though his wife specifically requested an appointment with Dr. Thomas McPhee, an ophthalmologist.
On the night of March 11, 2001, Paul and LuWanna Phillips were watching TV. Phillips had never met Paul Hughes, but the two shared more than a common first name. They were both born in the late 1930s. And like Hughes, Phillips also grew up in a farming family.
Phillips spent most of his life picking oranges and building a wholesale produce business. He eventually sold his Phoenix-based Wholesale Produce and invested the profits into commercial property — mostly west Phoenix storage facilities built in the early '80s.
In 1979, Phillips had a 3,600-square-foot home built on the border of Glendale and Phoenix. When the Mayo Clinic opened in 1987, Phillips was one of their first customers. He and LuWanna knew the clinic's prestigious reputation. So they took their most serious concerns to Mayo — battles with cancer, other maladies, and, eventually, Paul's eyesight.
Phillips was first treated at Mayo's ophthalmology department in 1999. There he met Dr. Thomas McPhee, a reputable ophthalmologist who became his eye doctor. In 2000, Dr. McPhee left Mayo to practice on his own. Phillips says he would have followed McPhee to his private practice but didn't know McPhee had left.
As it turned out, Phillips' vision problems began a few months after McPhee left Mayo. Phillips recognized the symptoms as a possible detaching retina, only because his son once suffered the same serious problem. Phillips also knew his diabetes made him particularly susceptible.
LuWanna called the number for Dr. McPhee's office at the Mayo Clinic and booked the earliest available appointment, two days later. As LuWanna and Paul drove the 50 minutes from their home to Mayo, they both thought they'd be seeing Dr. McPhee.
They had been to enough appointments to know the routine at Mayo: fill out paperwork, get escorted by nurse to exam room, wait for doctor in a suit and tie, get diagnosis and/or treatment, and leave.
Phillips was soon called back by a nurse. The nurse asked Phillips to read the letters on an eye chart. Phillips couldn't read them with his left eye, he says. He answered some initial questions and then sat with LuWanna, waiting to see the doctor.
The next and last person to enter the exam room was Paul Hughes. (Mayo's records confirm that.) In his deposition, Hughes says he introduced himself simply as "Paul Hughes" and told Phillips that Dr. McPhee wasn't available.
According to the depositions of both Hughes and Phillips, here's what happened next:
Hughes tugged the sliding doctor's stool over to Phillips, took a seat and rolled within a few inches of Phillips. Then he examined both eyes. In addition to Phillips' medical records, Hughes held a form labeled Executive Glaucoma Screening.
Phillips and his wife assumed Hughes was a doctor because he replaced Dr. McPhee, dressed like McPhee, and performed an examination. Hughes then wrote a diagnosis of "K. sicca" and treatment of "tears." He explained that the problem was simply dry eyes. Records show no ophthalmologist or eye doctor saw Phillips at Mayo that day.
"Thank you, doctor," LuWanna Phillips told Hughes on the way out. Hughes, she testified, did not correct her.
In court, Mayo Clinic attorneys argued that Hughes only "assessed" Phillips. But medical records show Hughes wrote "K. sicca," the diagnosis for inflamed eyes, where the form indicates "Present Rx," the Latin abbreviation for prescription. With that, Hughes sent Phillips home.
Despite Phillips' complaints of severe blurriness and flashes of light, Hughes didn't dilate the problematic eye. Not that he should have known to; he isn't a doctor.
Hughes said he didn't dilate the eye because he thought Phillips was only in for a standard eye exam. But given the written diagnosis (in Hughes' handwriting), the documented complaint of symptoms, and the form that reads "Executive Glaucoma Screening," the jurors didn't buy Hughes' story. Even if Phillips had come for a standard eyeglasses exam, Hughes wasn't licensed to give one (and he documented the exam on a glaucoma screening form).
Two weeks after Phillips asked the Mayo Clinic to examine his eye, his retina detached completely. Doctors hired as expert witnesses for Phillips testified in court that Phillips' retina could have been fixed had it been diagnosed during his Mayo appointment.
The same doctors said the two weeks of additional scar tissue buildup made repair by surgery nearly impossible. That's why Phillips is blind in his left eye today.
Scottsdale attorney Mark Wesbrooks represented Phillips. He says his client's case against the Mayo Clinic is one of the most outrageous medical malpractice cases he's ever seen.
"This guy was a two-time felon. They actually created a separate schedule for him. Mayo tried to keep it hush-hush," Wesbrooks says. "It was a non-doctor who was allowed to practice medicine. He testified that he learned all about the eye while in Texas prison."
These days, it's common to go to the doctor and not see an actual doctor. That's not necessarily a problem. Many non-doctor practitioners are trained and licensed to diagnose patients. For example, physician assistants (P.A.s) and nurse practitioners (P.R.N.s) routinely see and treat patients. Both P.A.s and P.R.N.s receive years of medical training and residency before diagnosing patients in their area of specialty. They're also licensed and disciplined by state boards.
Even without any such training or certification, it's possible to legally work with patients, under Arizona law. There's a state law on the books that allows doctors to name anybody a "medical assistant." Medical assistants aren't allowed by law to see patients alone or to diagnose them.
Sometimes, however, they do. The state trusts physicians to be honest about the duties they give medical assistants, says Roger Downey, spokesman for the Arizona Medical Board.
For this reason, Downey says, medical care in this state is a swim-at-your-own-risk situation. "Patients may be offered a quicker appointment if they wish to see a physician assistant or a nurse practitioner at the doctor's office. Otherwise, patients should not assume the unfamiliar practitioner is a doctor. They should ask if they don't know. That's part of being an informed patient," Downey says.
"For elderly patients, most healthcare professionals recommend that an 'advocate' accompany them when they visit the doctor. An advocate in this sense is a relative or friend who can ask questions the patient doesn't think of asking. The advocate can also take note of the healthcare provider's instructions and information that the patient may not remember later."
That didn't help Paul Phillips.
Medical assistants sometimes go by the name "technician" in ophthalmology departments. The American Academy of Ophthalmology says technicians and assistants should never diagnose patients. Spokeswoman Christina Curas says ophthalmic assistants "are not licensed to practice medicine." Curas adds that it's a violation of the Academy's bylaws and ethics to let technicians diagnose patients alone.
Despite those known standards, Creasman assigned Hughes to triage. Creasman knew Hughes was a convicted felon with no formal medical training when he hired him. But in an interview for this story, Creasman still says Hughes is qualified to work at the Mayo Clinic.
"Paul was the only one that did triage when [doctor's] appointments weren't available. He was the only one that had the expertise," Creasman says. "It's absolutely okay for Hughes to be working triage because he has more experience. In our department we don't have P.A.s."
Dr. Creasman also says the Mayo receptionist told Phillips he'd only be seeing a technician. (Phillips says otherwise, so it's his word against Creasman's. There's no recording of the conversation.) Creasman says Phillips was the negligent one, by assuming a technician was a doctor.
"There's no way Mr. Phillips could have misunderstood who he was seeing, because the secretaries make that really clear. Maybe he hoped he could see a physician after triage," he says.
National advocates say patients should never assume they're seeing a doctor, and patients shouldn't be afraid to ask for practitioners' credentials. Technicians and medical assistants shouldn't ever diagnose patients.
"One of the best ways for patients to help ensure that they receive safe and appropriate care is to be informed, ask questions, and make sure that they understand what is going on," says Diane C. Pinakiewicz, president of the National Patient Safety Foundation. "Patients and their families need to be viewed by all as part of the healthcare team and, as such, should be encouraged to speak up and actively participate in the care process."
Exactly two years after Hughes diagnosed Phillips with dry eyes, Phillips filed a lawsuit against the Mayo Clinic. His March 13, 2003 complaint alleged that the clinic overlooked his detaching retina and that they did so because Paul Hughes — a non-doctor — diagnosed his problem.
The case dragged on for three years, at a cost of tens of thousands of dollars. It was shaping up to be a boring malpractice case, packed with medical terminology and detailed time lines, but ultimately, it came down to one man's word against another's.
Had Paul Phillips actually complained of retinal symptoms? Had Paul Hughes really held himself forth as a doctor?
During the trial, Paul Hughes retired from the Mayo Clinic. It was June 6, 2006 — exactly 18 years after he'd started. Days later, an anonymous tipster sent a mysterious fax to Phillips' attorneys.
The fax clearly tipped the scales. It came from a number inside Mayo and outlined the criminal past Hughes had hidden during his first depositions under oath. Judge Baca reviewed Hughes' sworn claims that he'd only been arrested for speeding.
"He clearly testified to the contrary, and it goes to his credibility. So he can be impeached with those," Baca ruled.
Baca called Hughes to the court, showed him the fax and told him to come clean. Hughes then said his first criminal conviction was for forgery. He explained that his eye education actually started in prison. Hughes then said his second criminal conviction was "a conviction for possession of cocaine, about 20 years ago."
Hughes was testifying in July 2006, making "20 years ago" about 1986 — roughly when Mayo hired him to work triage and see patients alone as a "technician." Hughes then said that, among other things, he learned how to spell the word "ophthalmology" while in prison. "He gave me a real good training," Hughes said of the infirmary doctor.
To make matters worse, Hughes was caught in a second inconsistency. The medical record from Phillips' appointment was a one-page form. Hughes testified multiple times that he never modified or added to that record.
Phillips had requested and saved the same document back in 2001. When Mayo produced the same record — three years later — it had additional comments about Phillips' condition. Those comments were clearly in Hughes' handwriting and were obviously added some time after Phillips received his copy.
Between the additions to the medical record and the half-truth about his prison time, Hughes' credibility before the jury was obviously shot.
"It was never about the case beyond that point," Creasman says. "It was always about the personality of the individual."
Creasman thinks Hughes' criminal past should have been left there. "I practiced for 40 years. Never did I work with someone who had his expertise, his savvy, his honesty, his integrity. I've never worked with a technician that was as good as he was."
The jury disagreed.
March 19 is an obscure Catholic holiday, Saint Joseph's Day, honoring Joseph, the husband of Mary and foster father of Jesus. Paul "Joe" Phillips, his son Joe, and his grandson Joe consider it their own holiday. They celebrate together every year. And so on a Wednesday this past March, the three Josephs have gathered at Phillips' home to celebrate their holiday with cake, food and a family party in the backyard.
Sitting at the kitchen table, Phillips describes the struggles of life with one eye. Some days he trips on the stairs in his home of 29 years. When Phillips' grandson Joe makes for the backyard, Phillips says he'd like to play catch with him. He can't.
Now 72, Phillips is otherwise healthy. He walks without a cane or other assistance. His hair is still dark, his skin tanned. His left eye is cloudy. Sometimes he wears a patch over it, particularly for reading, but he's not wearing a patch today.
"It takes me forever to read. You lose the line, and then you have to start the paragraph over again," Phillips says.
LuWanna, Phillips' wife, recently passed away after a long battle with cancer. Phillips says he regrets spending the last years of LuWanna's life fighting a court case. He says there's no price you can put on an eye.
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Outside the house, Phillips' RV sits unused. He's tried to drive it twice. But after a minor accident each time, he decided it was too dangerous to drive the motor home with his damaged depth perception.
"We thought we were going to see Dr. McPhee. He's a good doctor," Phillips says. "Now I can't play golf. Some days I trip over the stairs in my own house. It's tough because the eye wants to see, and it takes away from the good eye."
Third in an ongoing series. Read the rest of "Prescription for Disaster" here.