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Stanford Report, April 26, 2000

Inaccurate press coverage provokes concern at the Medical Center  

BY RUTHANN RICHTER

In the past month-and-a-half, four newspapers have carried lengthy front-page stories detailing wide-ranging allegations against three Palo Alto gynecologic surgeons who practice at the Medical Center, all brothers and members of the voluntary clinical faculty.

The allegations against physicians Camran, Farr and Ceana Nezhat focus to a large extent on incidents that occurred before they began an association with Stanford in 1993. But the stories, carried locally in the San Francisco Chronicle, San Jose Mercury News and Stanford Daily, nonetheless have provoked concern -- and some outrage -- on the part of many Stanford faculty members.

"It is our feeling that the various reports, which have appeared in the Philadelphia Inquirer, the Chronicle, the Mercury and the Daily, present a very distorted perspective," said Lawrence Shuer, MD, associate professor of neurosurgery and chief of staff at the Medical Center. "These reports rely primarily on one attorney from Ohio who has been sanctioned in Georgia and on two ex-faculty members who are direct competitors of the Nezhats and Stanford's gynecology services."

Mary Lake Polan, MD, PhD, professor and chair of the Department of Gynecology and Obstetrics, said she believes the newspaper stories could harm women who might not seek care from the Nezhats for problems that few other surgeons in the world have the skill to handle. "I am concerned that patients won't seek appropriate care because there's been an inflammatory newspaper campaign that has frightened them," Polan said. "I think there has been an enormous disservice to women who may not seek the care they need."

Stanford Hospital has conducted several investigations into various allegations against the Nezhats and found no support for the claims, said Eugene Bauer, MD, dean of the School of Medicine and vice president for the Medical Center.

"Throughout their affiliation with Stanford, the Nezhats have provided excellent care to patients at our hospital. Their skill in performing minimally invasive surgeries has also been of great benefit to physicians who come here to train and learn from their expertise," said Bauer.

The Nezhats are pioneers in the field of laparoscopic surgery, a form of treatment in which doctors operate through a tiny incision while monitoring their progress on a video screen. The technique avoids the need for a major operation and is now being used in a wide range of surgical procedures. The Nezhats have focused on applying the technique in the treatment of endometriosis, a disease caused when the cells lining the uterus migrate to other parts of the abdomen, causing pain and often leading to infertility.

Because of their expertise and widely recognized surgical skill, the Nezhat brothers are sought out worldwide by physicians who come to Stanford to train under them. "Patients do not go to the Nezhats because they want standard care, and physicians do not come to them because they want to learn routine laparascopy. They come to the Nezhats from all over the world because they want the very best," Mark Vierra, MD, an assistant professor of surgery and co-director of Stanford's Endoscopy Center for Training and Technology, wrote in a letter to the editor to the San Jose Mercury News.

In the press, however, the Nezhats have been cast in an altogether different light. The newspaper stories go back to the late 1970s, when Camran Nezhat came to this country from his native Iran to complete a reproductive endocrinology fellowship at the Medical College of Georgia. He then established a practice at Northside Hospital in Atlanta and was soon joined by his brothers.

While at Northside, Camran Nezhat performed surgery on endometriosis patient Stacey Mullen who suffered severe complications. Mullen hired Ohio-based attorney James Neal to represent her in a malpractice case against Camran Nezhat, beginning what Neal has acknowledged in the press as an "obsession" with the Nezhats.

Neal was ultimately disqualified from the Mullen case by a Georgia judge for "unethical behavior." He no longer represents any clients in litigation involving the Nezhats. But he has doggedly pursued the case through the media, sending out large packets of material to media outlets throughout the country and making wide-ranging allegations against the Nezhats.

Meanwhile, in September 1993, Camran Nezhat came to Palo Alto, joining the voluntary clinical faculty at Stanford and obtaining medical staff privileges at the hospital. Two years later -- in December 1995 -- he became director of the Stanford Endoscopy Center for Training and Technology. Newspaper accounts have claimed that he was recruited to Stanford to rescue the gyn/ob residency program, which was allegedly "on probation" because it reportedly lacked surgical volume.

In fact, the program was never on probation, Polan noted. The relatively new residency program was continued on provisional status by the Accreditation Council for Graduate Medical Education in July 1994. The only issue raised about volume was concern about inconsistent record keeping on the number of surgeries performed. Once record keeping was improved, it was clear that enough surgeries were being performed to train the residents, according to Maurice Druzin, MD, professor of gynecology and obstetrics and associate director of the residency program. Records show that the program received full accreditation in June 1995.

News accounts also have described the Nezhats as "rainmakers" for the department, providing needed income for its programs. But because the Nezhats are in private practice, they provide no income to the department, Polan said.

"[Camran Nezhat] doesn't serve as a money-maker for the department. The department doesn't derive income from his practice," Polan said. "What he does instead is to enhance the endoscopic expertise of everyone in this hospital."

And Bauer noted, "The suggestion that Stanford has engaged in a 'cover up' because it benefits financially from the Nezhats is not true. The Nezhats do not pay anything to Stanford. And any surgeries they perform at Stanford for which the hospital receives reimbursement from patients, insurance or Medicare is a small fraction of the revenue generated by all of the physicians that utilize Stanford for their patient hospitalizations."

Over the years, Nezhat has collaborated with surgeons in other subspecialties, sharing his expertise in use of minimally invasive techniques and assisting colleagues in areas such as general surgery, urology, gynecologic oncology, neurosurgery, vascular surgery and cardiothoracic surgery.

In one such case, in 1993, Nick Spirtos, MD, a former faculty member who is now on the voluntary clinical faculty, objected to Nezhat's involvement in the removal of a pelvic cancer even though Nezhat consulted a gynecologic oncologist who assisted with the procedure. Spirtos said cancer surgery was outside Nezhat's area of expertise.

Spirtos told the press that he complained to the hospital's gynecology and obstetrics Quality Assurance Committee. Thomas Margolis, MD, a member of the committee and now in private practice with Spirtos, said in news reports that Polan had pressured the committee to clear Nezhat's name and that he went along with the other committee members to clear the Nezhats of all charges.

Polan strongly objects to the charge.

"There has been no pressure put on anyone in the quality assurance process to exonerate the Nezhats -- or anyone else, for that matter," she said.

Bauer wrote in a letter to the editor to the San Jose Mercury News that the allegations were "patently false and undermine the credibility of this strong, independent process. The hospital takes the work of its quality of care committees seriously; and we take strong objection to any suggestion of impropriety in the process."

It is common practice for surgeons of different subspecialties to work togeether in the best interests of a patient. That practice has been no different for the Nezhats. Both Polan and Shuer noted that whenever the Nezhat brothers have been involved in surgeries outside their gynecologic specialty, they have served as assistants or co-surgeons to the primary specialist in charge of the patient.

"Any time they did a procedure with any subspecialty -- whether it be thoracic surgery, gynecologic oncology surgery, general surgery or neurosurgery -- there was a thoracic surgeon, a gynecologic oncology surgeon, a general surgeon or a neurosurgeon there," Polan said.

In a separate incident reported in the media, Margolis claimed that he witnessed Farr Nezhat deliberately cut into a patient's ureter during the course of a laparoscopic procedure in 1996 to remove endometriosis. Margolis claimed the cut was unnecessary, as he saw no endometrial tissue on the ureter.

He brought the incident to Shuer's attention. Shuer asked him to supply information, such as the patient's name and medical record number, so he could have the Quality Assurance Committee review the case. Shuer said Margolis never provided him that information. Following up on information in press reports, the case now is scheduled for review.

Richard Popp, MD, senior associate dean for academic affairs and a professor of medicine, also conducted a review into allegations of academic misconduct by Camran Nezhat. Neal had requested an investigation in June 1997, claiming, among other things, that Nezhat had made key omissions in a paper involving 16 women with endometriosis. Although the research and alleged misconduct took place before the Nezhats came to Stanford, Popp agreed to review the matter. "I concluded that there was no evidence supporting the allegations and that a further, formal scientific misconduct investigation was not warranted," Popp said. A second review of allegations made by Neal took place in 1999 with the same result.

Popp also noted that all of the patients had been treated in Georgia, and Stanford could not obtain access to their records because of patient confidentiality. He said the Georgia authorities were best suited to conduct a full, formal investigation.

Neal has recently provided additional information, which the University is reviewing.

Stanford officials are concerned that, despite many hours spent with the reporters, the articles contained so many errors and unsupported innuendo. Letters to the editor were sent by many people to the newspapers in an attempt to clear the record and the Stanford Daily and Mercury News issued follow-up stories that were more positive.

"We are providing the highest level of care to our patients, and it is sad that the newspapers would ignore that in favor of sensationalist reporting," said Bauer. "We will continue our efforts to see that we are treated fairly in the press so that irresponsible media reports do not destroy the trust we have with our patients and colleagues." SR