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Monday December 4, 2000

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UMC, doctor investigated

By Jennifer Levario

special to the Arizona Daily Wildcat

A chief surgeon at the University Medical Center is under investigation by the Arizona Board of Medical Examiners, but experts say patients have no reason to jump to conclusions about the safety of his practice.

"We can't release the allegations because the actual violations could be much lesser or much worse than the allegations," said Pete Wertheim, spokesman for the Board, about a June 26 complaint made against Paul Nakazato, chief liver transplant surgeon at UMC.

In addition, an unrelated complaint sparked criticism against Nakazato for decisions he made surrounding patients on the UMC transplant waiting list.

In the past few months, reports have surfaced that Nakazato placed liver patient David Rasmussen on "status 7," - temporary inactive status - after Rasmussen did not comply with hospital policy on one occasion. Nakazato is also accused of ignoring pleas from a former patient to be reinstated on the liver waiting list.

That patient later died.

"(The media) has focused on cases in which liver transplant patients who were listed for transplant at UMC were placed on status 7, one for repeated inability to comply with the program's criteria; the other for serious life-threatening medical reasons that the team agreed would make transplant at UMC impossible," said Richard Lemen, vice president for medical affairs at UMC, in a written statement.

Steve Nash, the Pima County Medical Society executive director, said the pending complaint could range anywhere from rudeness to incompetence, but that most investigations brought before the board are dismissed.

Of 769 investigations so far this year by the Board of Medical Examiners, 81 percent have been dismissed, according to a June report published by the Board.

Nash compared Nakazato's track record - which consists of a dismissed complaint and the current investigation - to a basketball team, saying star players miss more baskets than their bench-warming counterparts because they are in the game more often.

"Some doctors may have more complaints because they have more patients," Nash said. "But I would rather have the more experienced basketball player in the game, like I would rather have the more experienced doctor."

Despite negative press in the past months, Nash praised Nakazato for his efforts to find organs for his patients.

"Dr. Nakazato is an excellent surgeon," Nash said. "He actually flies to get the liver, checks it out and makes sure it will work, and then he brings it home and does the surgery. I've never heard of that before. Most doctors don't go themselves. They send a team member."

"Most people don't have that kind of stamina," he added.

Though UMC officials insist that Nakazato made the right decision in these cases, the hospital is reviewing the past five years of patients who have either been taken off the waiting list or who have been placed on "status 7."

"That is done so if there is a problem, they could fix it," Nash said. "The process is completely confidential, even to lawyers."

But critics think the hospital should make that information public.

"I always wondered how many people are in the position of getting removed from the list," said Stephen Palevitz, an attorney with the Arizona Center for Disability Law.

Palevitz has reviewed Rasmussen's case, but would not elaborate on the extent of his consultation. He added he did not know specifics about the Board of Medical Examiners investigation.

After receiving added scrutiny last month, UMC published information about its patients on "status 7."

Hospital documents show 15 are listed inactive, and of those:

  • Four people apparently got better and no longer need a liver transplant.

  • Three refused transplant or "indicated they are no longer interested in a transplant."

  • Three people became too sick to benefit from liver transplant according to doctors.

  • Two patients transferred to another transplant program.

  • One lost insurance coverage.

  • One patient was moved to inactive status "because of repeated non-compliance."

Comparable figures concerning "status 7" are not available from the United Network for Organ Sharing research department, a non-profit, charitable branch of the U.S. Department of Health and Human Services that writes policies intended to protect people on organ waiting lists.

However, UMC statistics regarding patients removed completely from the waiting list resemble those reported by the network for the Southwest region and the United States.

At the University Medical Center, 1.9 percent of patients were removed from the transplant list because of "other reasons." These reasons include, but are not limited to, patient recovery and patient transplanted to another center.

In the region that encompasses Arizona, New Mexico, Utah, Nevada and California, 5 percent of patients are removed from the waiting list for these reasons, and in the United States, 4 percent were removed, according to numbers from the United Network of Organ Sharing as of Aug. 5, 2000.

"UMC seemed to be not out of the ordinary or that out of line," Palevitz said of Nakazato's decision to remove Rasmussen from the transplant waiting list. "But they claimed that Mr. Rasmussen was never taken off the list, just put on a different status. It's a matter of what information is being reported to (the United Network of Organ Sharing). How many people has UMC done this to for non-medical reasons? How widespread a problem is this? I'd imagine these are not the only two people this has happened to."

However, some say that under national policy at the time, Nakazato's decision to remove patients from the list was permitted.

According to the organ transplant guidelines published by the American Medical Association's Council on Ethical and Judicial Affairs, doctors need to consider medical need, likelihood of benefit, urgency of need, change in quality of life, duration of benefit and, in some cases, the amount of resources required for successful treatment.

The treating physician should be "objective, flexible, and consistent to ensure that all patients are treated equally," according to the American Medical Association.

"The reason for this policy is (doctors) are the ones who have to determine whether the patient will take care of the organ," Nash said. "Compliance becomes a judgment call based on experience. (Patients) could be wonderful people who missed one appointment, but the organ would have to go to someone else. They'd have to give the organ to racists and people they loathe but would not waste the organ."

The association holds medical directors to placing the patients' interests above their own and helping the patients get adequate medical services - a criterion that could mean going out of their ways to work with the patients' employers to establish ample health care.

But those standards are changing.

To avoid questionable cases of patients being named inactive or removed from organ waiting lists, the United Network of Organ Sharing recently recommended a change in the liver distribution system.

Together with the Organ Procurement and Transplantation Network, the United Network of Organ Sharing Board of Directors approved a change for prioritizing patients awaiting a liver transplant. The proposal was submitted to the U.S. Department of Health and Human Services for consideration under federal regulation.

"This is a tremendous step forward in ensuring that the needs of liver patients with the most urgent need are met," said Dr. Patricia Adams, United Network of Organ Sharing president, in a statement. Adams said she hopes the proposal will help ensure the fairness of organ distribution over as broad an area as possible.

"We will continue to examine and encourage broader allocation areas as we proceed," she said.

The new scale to identify medically urgent liver transplant patients would rank people on the waiting list based on medical test results that show the patient would die without the transplant. The network said this route is more refined than the current medical urgency codes used in liver distribution.

The proposal was a result of written public comments and feedback at a September public forum sponsored by organ-sharing networks in Irving, Texas.

United Network of Organ Sharing officials say they hope this will reduce the number of people who die on liver transplant waiting lists.

As of August, two of UMC's 105 liver transplant hopefuls died - 3.8 percent of the patients who had registered for the waiting list since the beginning of the year, according to reports from the United Network of Organ Sharing.

Likewise, 3.45 percent died in the region, and 4.1 percent died in the country.

"Sadly because of the unavailability of donor organs, more than 1,700 people die each year in this country waiting for a liver transplant," Lemen said in a statement.

"Because issues of life and death are at stake, it is not surprising that patients who never make it onto the transplant list, or patients who are listed and then placed on inactive status, feel frustration, anger - and perhaps even resentment - toward the transplant program. Their family members will share those feelings. This is an unfortunate reality that all transplant programs face," Lemen added.

In the past year, 13 people received liver transplants at UMC, and 84 patients remain on the waiting list. Nationwide, 4,478 people have undergone the same operation.

More than 16,000 people are still waiting.