note: for ease of use, utsw''s statements are reprinted here in dark

The Dallas Morning News�’ response to UTSW�’s summary of concerns

The Dallas Morning News�’ response to

UTSW�’s �“summary of concerns�”

Note: For ease of use, UTSW�’s statements are reprinted here in dark gray type. TheNews�’ responses are embedded below them, in dark blue type.

I. Important key facts, contextual background, relevant UTSW responses about resident physiciantraining, and favorable performance data contradicting The News�’ assertions were omitted.

In response to questions from Dallas Morning News reporters in early July �– i.e. several weeks before thepublication of the first patient care focused story �– UTSW sent a 19 page document to The News,whichincluded broad background information about resident medical training and detailed responses to 12 specificquestions from reporters. UTSW also provided written answers to several follow up questions. UTSW tookthese steps to ensure that The News�’ reporters had complete and relevant factual information as the basis fora fair and balanced view of issues related to Parkland resident physicians in whatever stories they ultimatelywere going to publish.

The News’ perspective: In our experience, Parkland Memorial Hospital and UTSW, whose faculty physicians work at the hospital, have not sought to provide complete and relevant factual information. Among other things, Parkland has sued the state attorney general's office to prevent release of information that state officials have deemed to be public. UTSW and Parkland have refused to share the routine statistical reports they generate regarding patient safety or patient mortality. Parkland has argued that it has no duty to share with the public even such basic information as papers generated during hospital audits, or how many babies are born at the hospital every year. Far from ignoring UTSW’s 19-page letter, we read all 8,000 words closely, took the relevant portions to heart, and posted the entire document on our Web site. We included portions of UTSW's responses in several stories. See, for example, “Human costs of training doctors,” and an accompanying sidebar, “Consultants urged Parkland to depart from doctor-training model” (Aug. 1 publication). We did not use the entire document in print, partly because Parkland officials granted interviews for some stories, while UTSW did not. Where Parkland's comments were more concise and relevant, we used them instead of UTSW’s written responses. Also, UTSW generally refused to comment on the specific allegations made by its critics, or to provide specific statistical performance data. That substantially reduced the relevance of its written response to us.

As detailed below, The News ignored most of the backgroundmaterial and responses provided by UTSW,omitted key facts essential to forming a full picture of Parkland, and failed to include up to date quality andpatient safety data. As a result, The News�’s coverage was unbalanced and incomplete.

The News’ perspective: Our series included the best available data on quality and patient safety. See, for example, a sidebar on Page 19A of our Aug. 1 edition, which carried University HealthSystem Consortium benchmarking data for the year ended March 31, 2010. We posted the full two-page report to our Web site. http://res.dallasnews.com/localnews/uhcdata.pdf These UHC data are what Parkland uses for its own benchmarking. It denied these reports to the public. This particular report was made available to us by sources. See also our full page of statistical benchmarking comparisons among Parkland and other local hospitals on Page 4-A of our Aug. 2 edition.

http://res.dallasnews.com/localnews/uhcdata.pdf


A. Lack of relevant key facts about Parkland�’s surgical and emergency services

The News�’ series revolved around two patient stories, each of which examined a single, unfortunatemedical outcome. Missing entirely from these stories were vital facts that would have put the two casesin perspective. Neither story, for example, includes any basic numbers about the extensive patientvolume Parkland handles in its role as a public hospital, or about assessments by outside regulatory andother third party national organizationswhich evaluate hospital quality �– highly relevant information in aseries that relied on two cases to suggest widespread deficiencies in the training and supervision ofresident physicians.

The News’ perspective: Our series contained more than two dozen stories, charts, and sidebars. Some are never mentioned in UTSW’s correspondence to the Pulitzer committee. Those include reports of a jury verdict against UTSW in a discrimination case that involved allegations of potential billing fraud; two ongoing billing fraud investigations; the investigation of the death of a Parkland patient who waited 17 hours for emergency room care; the widespread theft of pharmacy narcotics; and the federal government’s finding that Parkland needed to revise its flawed surgical consent forms. The two case studies UTSW mentions were significant because they put a human face on the problem of patient safety, and because medical records provided to us by the patients illuminated significant gaps between the stated policies of Parkland and UTSW and what actually happened to these patients. For example, one of the patients, Jessie Mae Ned, lost her leg after three days of post-operative care during which she never saw a faculty physician. Some comparative data appeared in these case studies. The Jessie Mae Ned story included information from Parkland’s safety officer saying the institution lagged its peers across the board in measures of safety culture. It also cited the relevant benchmarking data regarding the department that treated Ms. Ned. To the extent that either case study may have lacked the information cited by UTSW above, those data appeared elsewhere in the series.

After the two stories were published, along with several sidebars, it took The News�’ editorial page tocite key facts the series neglected. Commenting on the second story, which focused on a patientnamed Jessie Mae Ned, the November 19th editorial stated that �“It is true that Ned�’s story must beconsidered in full context. In fiscal 2009, Parkland admitted 41,364 patients and performed 13,537surgeries. More than 108,000 patients entered the emergency room.�” (emphasis added)

The News’ perspective: The “By the numbers” sidebar on Page 4A of our Aug. 2 edition included data on Parkland’s patient load, and on the patient load at other UTSW hospitals. More importantly, UTSW seeks here to re-frame the issue in ways that we believe would be misleading. It argues that Jessie Mae Ned, who lost her leg after a botched knee surgery, should be seen as just one patient among thousands. That is both a truism (all our readers are well aware that Parkland is a huge hospital) and a false comparison. Ms. Ned was noteworthy because she was willing to share her full medical file with us, but she was not the only patient to be harmed at Parkland. A full, in-context comparison requires both a denominator (the number of patients treated) and a numerator (the number of patients harmed), so as to yield a rate, which could be compared to Parkland’s peers. We provided that comparison, via UHC benchmarking data. As our series indicated, UHC data rated Parkland “substantially below target range” among its peers for its performance on orthopedic surgery. The full report, published to our Web site, ranked Parkland’s orthopedics “product line” 100th among 107 peers for the year, and included a “quality alert warning” for the first quarter of 2010. The UHC report is available here: http://res.dallasnews.com/localnews/uhcdata.pdf We recently learned that based on Medicare mortality data Parkland’s total knee replacement surgery was ranked in the lowest performance category by HealthGrades.com, which rates hospitals nationally.

The editorial added another important point ignored in the series: �“It�’s also true that there is a differencebetween bad outcomes and bad medicine. Bad outcomes happen even with the highest level ofphysician competence, decision making, and attention to patients.�”

The News’ perspective: This point was addressed in the series. Under the subhead “Missed


diagnosis” on page 19A of our Nov. 14 story on Jessie Mae Ned, we quoted UTSW spokesman Tim Doke saying, “every surgical procedure has known complications.” However, Ms. Ned’s case study was noteworthy because the records Ms. Ned provided us showed that Parkland and UTSW failed to provide the highest level of physician competence, decision-making, or attention to patients. Our story cited a 2006 bulletin published by the American Academy of Orthopaedic Surgeons saying that even when risks are foreseeable, that “does not necessarily absolve the surgeon of responsibility after a vascular injury.” It said surgeons should have a postoperative monitoring program for “immediate recognition” of such damage. In Ms. Ned’s case, medical records indicate that she was operated on by a resident with only about six weeks’ experience and suffered an extremely rare injury in surgery. One study mentioned to us by an experienced local surgeon placed the typical rate of injury at about 0.17 percent, or 17 patients out of 10,000. The damage should have been correctable. But Ms. Ned was not seen by a faculty physician until three days later. During those three days, less-experienced staff missed or misinterpreted critical signs of the surgical error. Eventually, the resulting damage required amputation of her left leg.

B. UTSW�’s responses and other important explanatory material were not fairly presented.

The News�’ two case studies, as well as the sidebars that accompanied them, implied �– based on thispatently insufficient sample �– that serious problems exist with respect to the supervision of Parklandresidents, the extent of their autonomy, the circumstances under which they are permitted to operate onpatients, and their participation in post operative care.

The News’ perspective: There is no question of implication. Our stories were quite straightforward. We quoted several former UTSW faculty members who believed Parkland’s patients were put at needless risk because UTSW residents practicing at the hospital received too little supervision from UTSW faculty. Some of them cited specific cases of patient harm. We did a good-faith examination of available evidence on the supervisory question. We quoted sworn testimony from Dr. Ron Anderson, Parkland’s president and CEO, saying residents at Parkland had more autonomy than those at other medical schools. We also quoted Dr. Anderson acknowledging he had heard UTSW faculty saying things to the effect that it was OK to make mistakes treating Parkland patients, for the sake of medical education. We found a consultant’s report from 2004 that said Parkland’s residents had in the past received only “nominal” supervision. We cited an annual UHC benchmarking study that said Parkland trailed its peer institutions in 14 of 25 product lines. Our reporting found that in the two case studies we examined, Parkland apparently failed to comply with its own guidelines for investigating patient harm. We tried to develop even more hard evidence of supervisory practices among UTSW faculty at Parkland, but received word from staff members that UTSW and Parkland told their staffs (apart from their public relations offices) not to communicate with us. They also denied public access to additional benchmarking data or to faculty time sheets that might help resolve the question of when faculty surgeons were in the operating rooms. We did obtain charts of surgical privileges at Parkland, which indicated that UTSW residents were allowed to remove a gall bladder, in an operation like Sara Limon’s, without faculty supervision. We have included a copy of that chart with this submission (see “DMN document number 2”) and posted the chart online when we published the story. It can be viewed here: http://www.dallasnews.com/database/2010/parkland_view.html

However:

The August 1st story �– an examination of a 2007 gallbladder surgery, mixed with a critique of residentsupervision and autonomy based on complaints from a demoted surgeon and a few of his supporters�– simply did not demonstrate that residents operate with little or no supervision, that the case was inany way a representative outcome, or that there were deep divisions within UTSW and Parkland over theresidency training program. Indeed, the presence and involvement of an attending senior surgeon isdocumented for every surgical procedure by non physician operating room staff.

The News’ perspective: This story was just one part of our series. Among the documents we obtained (and posted to our Web site) was a privileges chart from Parkland indicating that residents could perform nearly 100 surgical procedures with no faculty supervision. As noted above, one of

http://www.dallasnews.com/database/2010/parkland_view.html


those procedures was gallbladder surgery. Parkland’s president, Dr. Ron Anderson, said the chart was simply a “guide” for nurses who monitor operating room procedures. The “demoted surgeon” was the head of the Burn, Trauma, and Critical Care (BTCC) division of the UTSW surgery department. The evidence shows he was demoted after residents complained that he was not allowing them enough autonomy. Colleagues who shared his concerns – UTSW refers to them as his “supporters” – amounted to roughly half the faculty in that division. He and they produced information for an internal review showing harm or poor quality of care in surgeries and post-op. Parkland and UTSW refuse to release benchmarking data that might indicate how representative this kind of error is. However, on the UHC report we were able to obtain from sources, Parkland was “worse than target range” for both general surgery and gastroenterology. As for “deep divisions,” the series shows that half the BTCC faculty ultimately resigned and that a senior UTSW administrator and the trauma division chief both filed whistleblower lawsuits over false-billing allegations related to supervision of residents. We don’t know what it means when UTSW says “the presence and involvement of an attending senior surgeon is documented for every surgical procedure by non-physician operating room staff.” The sentence raises several questions. For instance: In past documents we have seen Parkland and/or UTSW describe “supervision” to mean a

faculty physician somewhere on campus is immediately available for consultation. Doctors have told us that means reachable by phone.

Residents have served as the surgeon of record even though they were not fully-licensed physicians.

We don’t know whether “is documented” means that records show this always to be the case, either now or in the past, or that as of today UTSW seeks to document whether this is true. Nor do we know whether UTSW asserts that this is documented for all of the procedure, for all important parts of the procedure, or for some part of the procedure.

The narrowest reading of this sentence is that Parkland’s staff keeps records of when physicians enter and leave the operating room. We believe this to be true. Parkland, however, refuses to share this information with the public.

In the case of Sara Limon, the un-contradicted testimony of the faculty member involved is that the operation started before he was even informed that she was in the operating room. Several of his colleagues also cited situations in which residents operated on patients without faculty knowledge or supervision. Parkland’s official chart of surgical privileges said residents could perform this type of surgery unsupervised by faculty. Parkland’s leadership claims the chart was only a “guide,” and did not necessarily reflect actual practice. This matter could be resolved if UTSW and Parkland released the time sheets showing when surgeries begin and end and when faculty members enter and leave operating rooms. Parkland has declined to do this. Earlier this year, UTSW provided time sheets, unrelated to the Limon case, for one surgeon’s operations at university hospitals.

The story relied heavily on Dr. Larry Gentilello, the attending physician who supervised the gallbladdersurgery (and who, prior to the series, was demoted due to performance issues). In doing so, The Newsfailed to critically examine Dr. Gentilello�’s own actions before and during the operation. Instead, itallowed him to focus blame on the chief resident, in effect, converting his inadequate and erroneoussupervision as a faculty physician into a version that fit its story line.

The News’ perspective: Even a cursory reading of the story will show that it did not rely heavily on Dr. Gentilello. This was a careful reconstruction of her case based on the medical file that Ms. Limon obtained from Parkland, and then provided to us. We did interview Dr. Gentilello, and he himself conceded that he had failed to properly supervise the residents who performed the surgery. He said that they began the operation without his knowledge or consent; that by the time he got to the operating room they were well underway; that the senior resident urged Dr. Gentilello to let them proceed; and that he acquiesced to that request precisely because the surgery was already so far along. “In retrospect,” he said, “I wish I would have said, ‘I don’t care. Open the patient up.’” This admission by Dr. Gentilello is in our story. We attempted to interview the chief resident, as well as other officials of Parkland and UTSW, about this case. Our requests were either refused or ignored. There can be no doubt that the senior resident shared responsibility for the surgery, based on our interview with the father of the patient’s children. He recalled the senior resident tearfully telling him that something had gone wrong. The reasons for Dr. Gentilello’s demotion are a matter of dispute.


UTSW says it acted “due to performance issues.” We requested and examined his UTSW personnel file and found no indication of poor performance as a surgeon. University records show that Gentilello was criticized by residents for not allowing them sufficient autonomy, and then demoted for failing to get along with residents and fellow faculty.

The story gave little space to UTSW�’s responses and backgroundmaterial about the residency program,but provided ample voice to Dr. Gentilello and the handful of complaining doctors. UTSW�’s responsethat only a small group of doctors was behind the complaints was noted, but not its basic point thatthese doctors represented a �“tiny minority of the nearly 2,000 clinical faculty at UT Southwestern. . . .�”Moreover, the story excluded responses from UTSW that directly challenged the few complainingdoctors, as well as The News�’ implication that Parkland was an outlier among teaching hospitals.

The News’ perspective: This particular aspect of the series did not concern the entire clinical faculty of UTSW, but primarily the surgeons working in the BTCC division. At the time Dr. Gentilello was demoted, there were approximately 10 of them, plus Dr. Gentilello. Five said they shared Dr. Gentilello’s concerns about the lack of resident supervision. Many of them spoke on the record during a faculty grievance process, putting their own careers in some jeopardy. That was just within BTCC. In other clinical areas, we found at least 7 staff members who expressed concern about a lack of faculty supervision. The story included rebuttal and perspective comments from Parkland and UTSW starting in the sixth paragraph. In total, it contained 31 such paragraphs. We are unsure what UTSW means by “outlier,” but Dr. Ron Anderson, Parkland’s president and CEO, confirmed under oath and in an interview with us that Parkland grants UTSW residents more autonomy sooner in their careers than do most other programs. Faculty members who had studied or worked elsewhere said they agreed with that characterization, and were disturbed by it.

For example, UTSW informed The News in its July 9th document that:

o Althoughminor variationsmay exist between and among general surgery residency programsthroughout the U.S., these variations by definition are inconsequential, because of the stringentrequirements imposed by the Accreditation Council for Graduate Medical Education (ACGME).Indeed, the ACGME had recently reviewed the residency program at Parkland, as it does routinelyon a periodic basis, and had given it accreditation for five years, the most positive outcomepossible.

The News’ perspective: ACGME told us that it does not “micromanage” resident supervision, but instead lets member hospitals set their own standards. The national Institute of Medicine has not found ACGME to be “stringent.” It has called for ACGME to tighten its standards for resident supervision. See, for example: http://books.nap.edu/openbook.php?record_id=12508&page=134 Because we knew UTSW’s written assertion was false, and because we wished to avoid an argument that would divert readers away from the key points of our story, we chose to publish this portion of UTSW’s remarks only on our Web site.

o UTSW�’s evaluation process for resident physicians is robust and thorough and the generalresidency program involves close and consistent faculty supervision in the operating room.

The News’ perspective: Our story included mention of UTSW’s claim that residents are well-supervised, and prominently discussed the residents’ high rates of passage on professional certification tests. Parkland, however, refused to provide documents that would indicate precisely how long UTSW faculty members were present in the operating rooms at Parkland. Hospital rules for resident surgical privileges, which we obtained, showed that first-year residents were permitted to perform at least 100 surgical procedures at Parkland with direct supervision provided only by a more senior resident. Supervising faculty in those instances needed to be only somewhere on the sprawling UTSW campus and “immediately available for consultation,” presumably by phone. At least a dozen current and former Parkland and UTSW doctors and staff said it was common for residents to operate on patients without faculty members being physically present.


o Since 1990, faculty physicians, known as attending, have been physically present in Parkland 24hours a day, seven days per week. New admissions, consults, and patients with new problems areevaluated by the faculty physicians.

The News’ perspective: As UTSW notes, Parkland is a very busy place. To say that there are faculty physicians present at the hospital is not to say that patients will be able to rely upon those faculty members for treatment or supervision of residents. For instance, Parkland’s newest standards for surgical supervision continue to permit residents to operate with no faculty supervisor present in the operating room. Our case study of Jessie Mae Ned indicates that at least until very recently Parkland and UTSW also relied on residents to determine when patients had “new problems.” In Ms. Ned’s case, the resident apparently lacked the ability to properly interpret her symptoms, so her case was not called to the attention of a faculty member. By the time a faculty member did review her case – three days after her surgery – her leg was so damaged that it eventually required amputation.

Readers were entitled to know UTSW�’s responses, as well as relevant background about its residenttraining programs, which include extensive simulated surgical sessions to ensure that residents areready to perform actual operations. The Newswas free to challenge any of this material with itsreporting. Instead, in a story that ran for thousands of words, it simply omitted the responses andbackground that contradicted its premise.

The News’ perspective: The story contained 31 paragraphs of responses and background from Parkland and UTSW, amounting to 1,071 words. We posted the full contents of UTSW’s response to our Web site, and alerted readers to its availability there.

A related story on August 2nd implied two standards of care �– one for indigent patients cared forprimarily by residents and a higher standard for private patients. In fact, there is only one standard ofcare, and UTSW included extensive background information in its responses that challenged this elementof the paper�’s story line. UTSW cited historical reasons, which continue as regulatory and fundingconstraints, for differences in the number of residents working at Parkland, a public hospital, and its twoprivate hospitals. UTSW also explained that patients access the facilities differently. The great majorityof Parkland patients are admitted through the emergency room, with no prior relationship with a facultyphysician, while the great majority of inpatients at the private hospitals have such relationships. Even so,each patient admitted to Parkland is assigned a faculty physician, who is ultimately responsible for theircare.

The News’ perspective: The story did not imply two standards of care. It quoted several UTSW faculty members who had worked at Parkland as saying there were two standards of care between the public and private hospitals. Dr. Raminder Nirula said, “Even though these two hospitals are under the same roof, there’s two different levels of care.” Dr. Terence O’Keeffe said, “There was definitely, as far as I’m concerned, a two-tier system of management.” The story mentioned the points UTSW cites here. It said that residents at the private hospitals are fewer in number and that UTSW claimed they were less experienced than the residents at Parkland. It noted the historical differences among the hospitals (“Smaller, with fewer residents assigned there, Zale Lipshy and St. Paul were part of an effort to retain faculty during the last two decades by giving them a home for research and revenue-generating private practices. Patients are mostly insured and referred by other physicians or hospitals…”) It noted that Parkland, “as the county hospital, takes in three times as many patients, accepting the poor or uninsured. More than half first arrive through the busy emergency room.” The story also noted a critical point that may be obscured by UTSW’s language: Patients admitted to Parkland, like those at the private hospitals, would be assigned a faculty physician. But, at Parkland, that faculty physician would not provide the care. That would be done by more junior residents. For instance, Dr. Robert Rege, chairman of UTSW’s surgery department, was quoted in UTSW records saying that at Parkland “the faculty member is the supervisor, not the primary caregiver. In private practice, the faculty usually is the primary caregiver.” Finally, we disagree with UTSW regarding the fundamental question at issue here. UTSW focuses on the number of residents available at each facility. We believe the more important question is how well those residents are supervised and the resulting effect on patient care.


Rather than present a full and accurate picture of how Parkland and the private hospitals operate, TheNews instead relied on many of the same doctors it quoted in the August 1st story to inflate its twostandards of care theory. None of these doctors specifically alleged that Parkland patients are receivinglesser care than those at the private hospitals, but the story carries the clear implicationthat they are. The Newswas seemingly writing the story from a preconceived conclusion, rather thana true investigative perspective.

The News’ perspective: Simply reading the doctors’ quotations makes it clear that they were concerned about the two different systems of providing care precisely because they were concerned about “lesser care.” Other circumstances also indicate patient welfare was at the root of their worries. According to documents we obtained, several of the physicians reported to their superiors specific cases of patient harm resulting from the fact that Parkland’s residents were not closely supervised by UTSW faculty. Dr. Nirula said that at Parkland it was accepted practice for residents to care for poor patients “with little or no attending [faculty] involvement.” This would “never occur” in the private hospitals, “where the attending always met the patient preoperatively, was an active participant in the surgical procedure, and in the postoperative care.” His resignation letter said, “I disagree with your philosophy that residents at Parkland be given increased autonomy compared to what they receive at St. Paul or Zale… I have no wish to continue working in such an environment, or with individuals who wish to support such practices.” Dr. Terence O’Keeffe said, “there was definitely, as far as I’m concerned, a two-tier system of management… that makes me mad… if it’s good enough for the patients at Zale Lipshy, it’s good enough for the patients at Parkland.” We checked publicly available Medicare data about Parkland’s performance versus that of UTSW’s private hospitals, and reported that Parkland lagged their performance in three out of five areas. This was reported in our story.

Again with its August 2nd story, The News fell far short of making its case.

The News�’ story on November 14th leads with the dramatic assertion that Parkland, by its owncalculation, seriously harms two patients a day. The implication is that unfortunatemedical outcomeslike the case described in the story, which ended with the amputation of the patient�’s leg, are commonbecause residents are poorly supervised.

The News’ perspective: This was not a “dramatic assertion,” but a straightforward account drawn directly from a report Parkland’s safety officer made to the hospital’s board of directors. The precise quotation was, “We harm two patients a day in a significant way.” The story took great pains to note, early on, exactly what this meant, and exactly how such harm came to pass. We also posted a full copy of the report on our Web site, to help readers draw their own conclusions. Given that Ms. Ned’s medical records say she was injured during surgery, and given that she suffered both prolonged stay in the hospital and loss of her left leg, we cannot imagine how she would not be counted among the harmed patients.

However, the document The News relied on for the assertion was taken out of context, as the storyitself demonstrated. The doctor who wrote the analysis included such broad categories as�“prolongation of hospital stay,�” and her report covers a limited, 14 month period, ending in December2009. Moreover, the story�’s �“two patients per day�” assertion fails to place that claim in the context ofa public hospital, which, over roughly the same time period, sawmore than 100,000 patients in itsemergency room (nearly 275 patients per day), admitted more than 40,000 patients (over 100 patientsper day), and performed some 14,000 surgeries (approximately 40 per day).

The News’ perspective: We note that UTSW accuses us of taking the report out of context, but then quotes from context that was provided in the story. We believe any fair reading of the report would show that we fully reflected the report’s findings and significance in our print editions. We also provided the full report online. See: http://www.scribd.com/doc/42201638/Pages-From-BOM-02-23-10 The story noted that the report said that in “culture of safety” measurements, compared with its peers, Parkland “performs a little worse than average across all dimensions.” With respect to


UTSW’s comments on “the context of a public hospital,” we had previously reported on Parkland’s patient load. We had also shared the full findings of Parkland’s UHC performance benchmarking studies compared with its peers, across many practice areas. This particular story dealt only with a case of orthopedic surgery, so in this installment of the series we discussed Parkland’s performance in that area: “Parkland ranked near the bottom among peer institutions in orthopedic clinical outcomes, according to 2009-10 consortium data....” In other words, it seemed to us that the critical question was not the number of patients Parkland treated, but the rate of injury there on a per-patient basis, relative to peer hospitals. We also believed it was significant that Parkland’s safety officer said harm potentially could have been avoided 74 percent of the time.

Nor was any referencemade to a study widely reported at the same time by many nationallyprominent papers (but not by The Dallas Morning News) that revealed that as many as 18% ofpatients experienced an adverse event during hospitalization in the U.S., or to another study from theCenters for Medicare and Medicaid Services (�“CMS�”), also broadly reported in the national media(but again, not in The Dallas Morning News), that there are more than 100,000 adverse events in U.S.hospitals each month.

The News’ perspective: Neither study had been published or reported upon before we printed our Nov. 14 story. The 18 percent figure came from a study the New England Journal of Medicine published on Nov. 25. See: http://www.nejm.org/doi/full/10.1056/NEJMsa1004404 We cited it in our Dec. 19 story, “Dying on the learning curve.” The Health and Human Services study, which UTSW refers to as a CMS report, (see: http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf ) was released on Nov 15. We blogged about it the next day (see: http://watchdogblog.dallasnews.com/archives/2010/11/report-finds-harmful-medical-c.html) and cited it in our Dec. 19 story. (The New York Times wrote about it in its print editions of Nov. 16. See http://www.nytimes.com/2010/11/16/business/16medicare.html ) UTSW does not mention this, but another study was also cited in our report of Dec. 19. That study found that hospitals fail to document 93 percent of all patient-harm incidents. This raises the likelihood that Parkland’s two-per-day number falls significantly short of reality. We agree with UTSW’s general point that rates of injury in American hospitals are high. That is why we have pursued this story so energetically.

The weakness of relying on a single, limited analysis to suggest widespread problemswasunderscored by data later provided to The News by Dr. Mark Keroack, Senior Vice President and ChiefMedical Officer of the University HealthSystem Consortium (�“UHC�”), which collects quality and safetyinformation from 110 academic medical centers. The UHC as an organization is a disinterested thirdparty with deep expertise in quality of care assessment. Dr. Keroack reported that Parkland�’s use of theUHC�’s safety reporting systemwas highlighted at the organization�’s annual quality and safety meeting inthe fall of 2010, attended by 93 hospitals. He noted that �“the safety team at Parkland showedoutstanding results in acting on safety reports to make systematic improvements.�” At the time of theteam�’s presentation, Dr. Keroack added, Parkland �“had gone 69 days without a serious safety event asdefined by the National Quality Forum.�”

The News’ perspective: UHC is not “disinterested.” It receives funds from member institutions. Dr. Ron Anderson, Parkland’s president and CEO, sits on UHC’s board. Dr. Keroack’s mention of Parkland’s safety team results should be viewed in the context of the hospital safety officer’s report from February, which said Parkland lagged its peers and was systematically addressing such issues “for the first time.” We might well have reported on Parkland’s presentation to UHC this fall, but we were not made aware of it. Parkland and UTSW have consistently refused to share UHC data with us, or even to discuss with us the UHC data already in our possession. Our series was not based on “a single, limited analysis.” In fact, it was based partly on a full UHC benchmarking report obtained through sourcing. It was also based on many audits, internal reports, statistical studies, case studies, legal records, and other documents obtained under Texas’ public information act.

Dr. Keroack also stated the obvious: �“It is important to keep a single tragic event in perspective.�” TheNovember 14th story failed to do so, resulting in a misleading and unbalanced report.


The News’ perspective: We believe our reporting, which included both broad statistical benchmarking and deep case studies, did keep Parkland’s performance in perspective. We believe our reporting was far more balanced than the information offered by Parkland and UTSW. For instance, Parkland’s Web site says it is “considered the premier public hospital in the United States.” Our reports described it, compared with its UHC peer group, as a middle-of-the-road performer. Dr. Keroack said, in an e-mail exchange with The News, that Parkland’s overall performance as of December had improved from “middle of the pack” to the top third – but not, for instance, the top quarter. The UHC annual benchmarking data for March, which were all we had at the time we wrote the series, described Parkland’s orthopedic surgery department (which operated upon Ms. Ned) as performing substantially below target level, with a “quality alert warning.” In his letter, Dr. Keroack cited several areas where Parkland was performing well. We asked for an update of the full UHC report. Dr. Keroack said he would need Parkland’s permission to provide it. Then he said he could not provide it. Consequently, he offered no perspective whatsoever on the department that had performed Ms. Ned’s surgery. For the sake of clarification, we should note that the allegation in UTSW’s comments about our report being “misleading and unbalanced” came not from Dr. Keroack, but from UTSW’s public relations office.

C. Quality measures were used selectively, and positive data on quality and safety was omittedfrom The News�’ coverage.

Health care quality analysis is still a relatively new field. In assessing quality and safety performance, it isparticularly important to look at a broad range of data, in the context of an institution�’smission and patientprofile. The News selectively used mortality and infection rates and orthopedic clinical outcomes to buttressits story line that inadequate resident supervision was compromising patient care at Parkland. In doing so, itdenied readers a meaningful overview of the hospital�’s performance. It also dismissed data that paints avery different picture of Parkland�’s safety and quality record than the one The News presented.

UTSW had provided The News in July with CMS data, which was publicly available on the HospitalCompare website, showing that mortality rates for Parkland patients with acute myocardialinfarctions (i.e. heart attacks) and congestive heart failure were at or below national rates.

The News’ perspective: We printed a full report of exactly this sort of risk-adjusted mortality data on Page 4A of our Aug. 2 edition, beneath the headline, "Mortality rates." We used state data, because we believed that they covered a larger share of the total patient population than do Medicare data. The tables we printed showed Parkland better than state performance averages for treatment of pneumonia and heart attack, and trailing the average hospital for gastrointestinal hemorrhage, congestive heart failure, and acute stroke. The chart also put Parkland's performance in context with other hospitals in the Dallas-Fort Worth area.

In his December 10, 2010 letter to The News, Dr. Keroack of the UHC stated that the series�“overlooked the broad based superior performance of Parkland in standard measures of quality andsafety, as well as their significant accomplishments in innovating to improve quality and safety.�”

The News’ perspective: Dr. Keroack, in an e-mail exchange, made it clear that he could release only the information that UTSW and/or Parkland allowed him to release. He also made it clear that he would be releasing only information that reflected well on Parkland and UTSW. A copy of his letter, which was posted on our Web site, will verify the nature of his presentation to us. See: http://res.dallasnews.com/localnews/keroackoped.pdf In effect, UTSW is complaining that we failed to more prominently feature a deliberately one-sided public relations effort that it and/or Parkland controlled. We had already printed a full tally of Parkland’s annual UHC benchmarking results (as of March 31, 2010). This full UHC report did not reflect “broad-based superior performance.” It rated Parkland against its peers on 25 “product lines.” Of those, Parkland performed: “Substantially better than target range” in three categories. “Within target range” in eight categories. “Worse than target range” in eleven categories. “Substantially worse than target range” in three categories.


Put another way, Parkland showed superior performance in three areas and inferior performance in 14. That full UHC report also included ratings for eight “patient groupings.” Parkland performed substantially above target range in one of them, within target ranges on three, and below target range on four. If UHC’s latest reports show Parkland performing at substantially higher levels, we would be delighted to print a story to that effect. UTSW and Parkland, however, refuse to release any such reports.

In his letter, Dr. Keroack stated that �“*In a comprehensive annual ranking of quality and safety acrossall patient types, including measures of safety, mortality, effectiveness, patient centeredness anddisparities of care, Parkland ranked in the top third of 98 university hospitals across the country in2010 and was the second highest performing safety net hospital. Amongmore than 100 hospitalssubmitting data to UHC from across the country, including the majority of those on the US NewsHonor roll, Parkland ranks at or above the top quartile in outcomes related to cardiology, cardiacsurgery, medical and surgical oncology, neurosurgery, trauma care and overall surgical care.�”

The News’ perspective: Our series dealt with quality of care and patient outcomes. The measure cited here by UHC and by UTSW is something else again. It includes “measures of…patient centeredness and disparities of care.” UHC does not say how it weights those factors. UHC says its latest data show Parkland at or above the top quartile in six of its product lines. That leaves at least 19 product lines unaccounted for. In an e-mail exchange, Dr. Keroack said he would need to consult with Parkland before sharing additional details about Parkland’s performance. He then declined to do so.

The News�’ second ranking editor attempted to downplay the data and suggested it wascompromised because the UHC is supported financially by the hospitals that report data to theconsortium. He also dismissed the letter as a public relations effort because Parkland shared it withits supporters. His comments did not appear in a news story as part of the paper�’s ongoing coverage,but in the �“Ask the Editor�” column on the paper�’s website, where he reproduced portions of theletter, followed by often lengthy arguments seeking to qualify UHC�’s data and defend The News�’reporting.

The News’ perspective: “Ask the Editor” is a regularly appearing column that addresses reader questions and concerns. The column did not suggest that the data were compromised. It pointed out that the data were incomplete, at the request of Parkland and/or UTSW, and it noted the existence of the entanglements between UHC and the hospitals it serves. It did not dismiss the letter. It dealt with its contents in great detail. It did not reproduce only part of the letter. The first line of the column included a prominent link to a full copy of the letter. The column explored every significant point Dr. Keroack made, and acknowledged in several places that Dr. Keroack’s numbers seemed to reflect genuine progress by Parkland. The full column can be reviewed here: http://www.dallasnews.com/opinion/ask-the-editor/20101229-ask-the-editor-managing-editor-george-rodrigue.ece

This approach avoided a full and fair airing in the newspaper of UHC�’s quality data concerningParkland. The �“Ask the Editor�” column was hardly a sufficient substitute. It required readers to visitthe paper�’s website, click on a column with no headline alerting them to the topic of discussion, andwade though a long post filled with comments from the editor that attempted to neutralize thefavorable Parkland data.

The News’ perspective: We made it clear to Dr. Keroack that we would pursue a news story for our print editions if UHC or Parkland would provide a full accounting of Parkland’s overall performance. We had already done so once, based on UHC’s March 2010 data. Instead, Parkland and/or UTSW forbade UHC from providing complete data. That left us with only one-sided information, and put us in the position of explaining to our readers why we had not printed a news story. The column is always headlined, “Ask the Editor,” but the Web teaser and the first line of the column alerted readers to the fact that this particular column dealt with new numbers about Parkland’s performance.


Readers did not have to wade through anyone’s comments in order to read the full text of UHC’s letter. They needed only to click on the link to that letter in the first line of the column.

II. The News�’ series made assertions that were not supported by the paper�’s reporting.

In several instances, The News, in an attempt to stretch its findings and imply that the residency trainingprogram at Parkland was putting patients at risk, made unsupported assertions or ignored important contextthat would have seriously weakened its assertions. For example:

In the Aug. 2nd story examining a single gallbladder surgery case, The News asserted it had also �“foundevidence that residents had botched other abdominal surgeries,�” leading the reader to believe that thegallbladder case was part of a pattern of similar medical outcomes. No such evidence is presented in thestory. The only reporting remotely connected to The News�’ assertion is a passing reference to a 2007appendectomy cited by one of the doctors critical of the training program. The Newsmade this sweepingassertion without quantitative or even anecdotal support.

The News’ perspective: The botched appendectomy cited by the unhappy surgeon was in fact a relevant case. It was among the instances, cited in interviews and records, by faculty members who believed UTSW was not adequately supervising resident physicians at Parkland. In addition, we have seen hospital records and other documents indicating there were other surgical problems in this area. Also, UHC’s March 2010 report showed that Parkland was performing below target range in both gastroenterology and general surgery.

The lead paragraph of a sidebar to the November 14th story asserted that �“*debate has raged behind thescene for decades over how UT Southwestern physicians supervise doctors in residency training atParklandMemorial Hospital.�” The story then purports to show how a 17 year old hip replacement casefits into this alleged debate. Nowhere in its series does The Newsmake the case for a �“raging debate�”over Parkland�’s residency training program. Not even the few doctors whom The News quotedanonymously or on the record as critical of the program made such a claim; nor did the story include anyreporting from the UTSW campus to support this assertion.

The News’ perspective: The series noted that approximately half the surgeons in the Burn, Trauma, and Critical Care unit resigned after the supervision dispute arose. It noted that internal audits have raised questions about lack of supervision since the 1990s. It cited a whistleblower lawsuit by UTSW’s former billing compliance director, who said he’d never been able to reform billing practices regarding faculty supervision of residents, and was “consistently obstructed” by senior officials. He recalled being told by one supervisor that if UTSW followed the rules on supervision and billing, “it would destroy our department [revenue].” The series also cited faculty meetings at which the question of supervision was debated. The reference to lack of reporting from the UTSW campus is intriguing since UTSW’s leadership would not allow its staff to communicate with us. We received many e-mail messages from people thanking us for our work, including some who said they were warned by superiors that they’d be fired if they were caught communicating with us.

In addition �– and somewhat ironically �– the series began with a May 30th article unfairly suggesting fraud inUTSW billing practices for medical services performed by resident physicians at Parkland, and it concludedwith a December 19th article giving a national perspective on issues of resident training that included a list of26 institutions that had settled billing claims cases with the federal government between 1995 and 2005. UTSouthwesternwas not on that list, though, not surprisingly, its absence was not noted in The News�’ article,even as it essentially belied the first article of the series in its entirety.

The News’ perspective: Our series began with a March 25 story about a federal investigation into uninformed patient consent at Parkland. A May 27 story noted that a local jury had awarded $3.6 million to a doctor who claimed that he faced discrimination and retaliation after resisting orders to commit billing fraud. On May 30, we quoted from internal Parkland and UTSW documents from 2008 and 2009 that referred to “investigations and allegations concerning possible violations of fraud and abuse statutes” and warnings that “certain Medicare and Medicaid billings by UT Southwestern


are the subject of pending reviews by government agencies.” The May 30 story was one of the very few times in our series that we quoted anonymous sources: People in a position to know, who said that millions of dollars of potential billing fraud had already been identified. At least eight UTSW doctors said billing records do not accurately reflect the level of faculty supervision of residents. For instance, Dr. Shahid Shafi testified in a civil case that he had reason to believe that Medicare billing rules were being violated. On Aug. 29, we reported that back in 2005 Parkland officials had estimated its liabilities for Medicare billing fraud could be as much as $50 million, that the hospital had reserved $7.2 million in 2008, and that the hospital had paid $1.4 million to Medicare in October of 2009.

III. Website articles by senior News editors promoting the series and responding to UTSW�’s andParkland�’s concerns did not meet journalistic standards of fairness and accuracy.

The four website posts by senior News editors in connection with the UTSW Parkland series were oftenmisleading and self serving, and, in promoting the series, made broad claims that did not appear in the stories.For example:

In a lengthy piece on the NiemanWatchdogwebsite, Maude Beelman, the editor who led the team thatreported the series, claimed that the paper had uncovered a system that �“for decades had deceivedvirtually all its patients�” and �“put many at risk.�” In fact, the series makes no such claims or presents anyevidence to support such conclusions.

The News’ perspective: UT Southwestern is complaining about an article that is not part of our Pulitzer submission, but we are happy to address its concerns. The Nieman Watchdog reference to deception is amply supported by original source documents we included in our stories that highlight the fact that Parkland had to change its surgical consent forms multiple times in recent years, at least once at the government’s insistence. For many years, those forms did not tell patients that they would be operated on by resident doctors in training, rather than by faculty physicians. The extent of that deception is illustrated by the extent of the revisions. After years of leaving patients to believe that their faculty doctor would be performing surgery on them, Parkland changed its form in 2008 to say that the supervising faculty doctor “may not be physically present in the operating room.” The reference to putting patients at risk reflected the conclusions of respected organizations like the national Institute of Medicine, as well as research showing that a lack of resident supervision is linked to patient harm. For more on that question, see our Dec. 19 story, “Dying on the learning curve.” Our statement also reflected the specific cases cited by concerned UTSW faculty members, in which Parkland patients were harmed by unsupervised residents.

Ms. Beelman claims the series documented �“instances of a cowboy mentality among loosely supervisedresidents�” and �“a class based culture of care.�” The News�’ reporting did not support these claims. A singledoctor quoted anonymously deep in the August 1st story is the sole support for the �“cowboy mentality�”claim. The August 2nd story falls far short of making the case for two standards based on class, and, asnoted above, the doctors The News quotes do not allege that Parkland patients receive lesser care.

The News’ perspective: We quoted a single doctor as saying there was “more of a cowboy approach” among UT Southwestern residents at Parkland than at other teaching hospitals where he had worked. But many people, sometimes doctors speaking under oath or within the context of an internal investigation, cited examples of questionable behavior by unsupervised residents. Dr. Raminder Nirula called it “an inmates running the asylum kind of thing.” Chief among those behaviors was the allegedly common practice of residents operating on patients without even alerting the supervising faculty member. We also reported allegations of residents taking cell phone photos of certain patients, sometimes for sport, and posting them online. The practice ended, we were told, only after an internal complaint by a Parkland patient who also happened to be an employee. As for the reference to “class-based care,” doctors who later left UT Southwestern (e.g., Nirula and Dr. Terence O’Keeffe) complained that residents referred to work at Parkland as “pus service,” or “junk service.” This was a reference to the infections that afflict many of Parkland’s uninsured patients. The terms surfaced publicly first in depositions. Dr. Nirula said, “It speaks to the fact that they don’t


view these people as people. They just view them as clinical fodder.” Unless UT Southwestern is arguing that Dr. Nirula also thought private, insured patients at the medical center’s private hospitals were viewed as “clinical fodder,” it is hard to avoid the conclusion that he was saying Parkland patients got lesser care. Indeed, Dr. Nirula told us in a portion of an interview that we did not publish, that it should go without saying that his concern was about lesser care.

Ms. Beelman also describes a dozen major findings from the series, in addition to making broadstatements about its impact and The News�’ interactions with UTSW and Parkland. These assertions arehighly misleading and one sided, and raise serious questions about The News�’ adherence to standards offairness and accuracy.

The News’ perspective: UTSW does not offer any specific complaints or criticisms here, so it is difficult to respond. We can offer some background. Ms. Beelman wrote her article at the request of the editor of the Nieman Watchdog, a publication of the Nieman Foundation for Journalism at Harvard. She was asked to summarize a year-long investigation for a single article. She was asked to tell “the story behind the story,” including a discussion of whatever roadblocks the team encountered. In other words, her article was not intended to convey the full findings of the investigation to a general audience, but rather to detail, for an audience of journalists, the aspects of the story that mattered most to reporters and editors. Naturally, Ms. Beelman had to summarize some portions of the 23 stories in this series. We believe that she did so fairly and accurately.

In three �“Ask the Editor�” columns, an online feature on The News�’website, managing editor GeorgeRodrigue responded to letters from the heads of UTSW and Parkland, as well as to the UHC letterreporting that Parkland had performedwell on quality and safety measurements. His treatment of theUHC letter is discussed above at section I. C.

The Parkland letter was written for employees, and a courtesy copy was sent to The News. A portion ofthe UTSW letter was published as a Letter to the Editor. Both letters expressed broad concerns about TheNews�’ reporting and were not intended as detailed rebuttals. (The News enforced strict length limitationsof 300 words for the Letter to the Editor.) In his columns, Mr. Rodriguewent far beyond addressing theseconcerns, however. He divided the letters by sentences or paragraphs, following each segment with anextensive response. In effect, the responses were summaries of the series with additional editorialcomments. Mr. Rodrigue included only a few lines describing Parkland�’s and UTSW�’s positions, and whenhe did, he rebutted them.

This treatment of the letters was fundamentally unfair. The News has claimed that online features like �“Askthe Editor�” promote transparency and a full discussion of issues. But that is only so when there is a fairrepresentation of views and information that challenge stories.

The News’ perspective: All Ask the Editor columns quoted directly and extensively from complaint letters. Some also included a prominent link to the full text of whichever message had recently been received from Parkland or UTSW. The columns sought to address each complaint point by point. We believed this was best done, from a reader’s perspective, by breaking the debate into pieces. When appropriate, the columns included links to primary documents, to help readers judge the validity of our work and of the complaints from Parkland or UTSW. We note that the medical center does not allege that the columns contained inaccuracies or unfair statements. UTSW’s complaint seems to be that The News did not simply post or publish its statements, without analyzing or discussing them. We believe the columns speak for themselves. They can be found at: http://www.dallasnews.com/opinion/ask-the-editor/20110114-ask-the-editor-managing-editor-

george-rodrigue-responds-to-readers.ece and http://www.dallasnews.com/opinion/ask-the-editor/20101229-ask-the-editor-managing-editor-

george-rodrigue.ece and http://www.dallasnews.com/opinion/ask-the-editor/20101120-ask-the-editor-managing-editor-

george-rodrigue.ece and http://www.dallasnews.com/opinion/ask-the-editor/20100812-ask-the-editor-managing-editor-

george-rodrigue-responds-to-criticism-about-dmn_s-parkland-investigation.ece

http://www.dallasnews.com/opinion/ask-the-editor/20100812-ask-the-editor-managing-editor-george-rodrigue-responds-to-criticism-about-dmn_s-parkland-investigation.ece


We respectfully submit that the items included in this Summary of Concerns and in the related attachments raiseserious issues about the overall fairness and accuracy of The Dallas Morning News�’ series, and, ultimately, beardirectly on whether �“First, Do No Harm�” satisfies the criteria for a Pulitzer Prize.

The News’ perspective: Please see our cover letter for our summary thoughts about UTSW’s allegations.

note: for ease of use, utsw''s statements are reprinted here in dark

Documents