"JAMA Medical News & Perspectives - October 28, 1998

"Only the Tip of the Iceberg"?

The number of physicians who have been convicted of crimes or disciplined for serious misconduct who are now working in correctional health care is unknown. However, those brought to light by the preventable death of inmates are probably "only the tip of the iceberg," said psychiatrist E. Fuller Torrey, MD, executive director of the Stanley Foundation Research Programs, Bethesda, Md. Based on his observations while visiting jails and prisons and following news accounts during the past decade, he said, these scandals are neither rare nor found in only one region of the country. An examination of medical licensing board records for physicians who were involved in inmate deaths recently reported in the news media shows he may be right. For example:

The suicide of a 17-year-girl in the Westchester County jail in Valhalla, NY, in May 1996 brought to light the past crime of the jail psychiatrist who had ordered the teenager to stop the antidepressant medication she was taking for more than a year. According to New York Times news reports, jail records noted that Nancy Blumenthal was depressed and suicidal when she was incarcerated on April 17, 1996, on charges of robbery and threatening her mother with a kitchen knife. The girl had a history of psychiatric treatment going back to the fourth grade, including hospitalization for depression and suicide attempts, her mother Wendy Blumenthal said. The day after Blumenthal was jailed, Harvey N. Lothringer, MD, interviewed her for about 20 minutes and ordered her medication discontinued. She told him it made her violent and that she didn't want to take it, he said. Four weeks later, she was found dead in her cell, hanging from a bedsheet.

The Westchester County health commissioner issued a report criticizing Lothringer for stopping the girl's medication without consulting her parents, physician, or psychotherapist. In June 1997, Westchester County and EMSA Correctional Care, the Fort Lauderdale, Fla-based private firm that provides medical care for Westchester county jail inmates, settled a wrongful death lawsuit by paying Blumenthal's family $1.45 million. EMSA officials declined to comment.

According to the family's attorney, Jonathan Lovett, that settlement was reached quickly because the defendants feared what a jury might award after hearing the details of Lothringer's criminal past. In 1962, the physician fled the country to avoid arrest after a plumber called in to unstop the drains of his house in Queens, NY, made a gruesome discovery. Lothringer had killed a college student in a botched illegal abortion and tried to hide the crime by cutting her body up and flushing the pieces down his toilet. Lothringer was apprehended in Europe and returned to New York where, in 1964, he pleaded guilty to second-degree manslaughter and served 4 years of an 8-year sentence. In 1973, one year after his parole ended, New York State reinstated his medical license. Lothringer did not respond to a written request for comment.

In Utah State Prison, a psychiatrist who was twice placed on probation by the state's medical licensing board was blamed for the death of a schizophrenic inmate he ordered immobilized in a restraint chair for 16 hours. Michael Valent, a 29-year-old inmate, had stopped taking his medication, and his symptoms grew worse. When he put a pillowcase over his head and refused a nurse's order to remove it, the nurse phoned the prison psychiatrist, David L. Egli, MD. Without examining the inmate, Egli ordered him confined in the prison's special restraint chair. Guards removed the inmate from his cell, stripped him naked, and strapped his arms, legs, and torso in the restraint chair, which had a hole in the seat for defecation. A condom catheter was attached to his penis. He remained in the chair for 16 hours before he was seen by the physician and released. Moments later, he collapsed and died of a pulmonary embolism resulting from blood clots that formed during his extended immobility. The death was ruled a homicide by the medical examiner, although no criminal charges were brought.

Utah State Prison halted use of the restraint chair following the public outcry over its use on mentally ill inmates, and in July, the state agreed to pay Valent's family $200,000 to settle their wrongful death suit. Nevertheless, attorneys for the state maintain that Valent had to be restrained because he was a danger to himself and that, while in the chair, he had received good care. "I believe that the preponderance of evidence shows that Michael's restraint was done in his best interest," Egli said. "Our experts do not believe that the restraint caused his fatal embolism."

At the time of the inmate's death, Egli's medical license was under probation. The psychiatrist was disciplined for having three male psychiatric patients perform what he said was a "balance test" to adjust their medication. According to Utah's Physicians Licensing Board, he regularly required these patients to stand in front of him while he sat in a chair. He told them to close their eyes and stand on one leg while stepping down on the physician's scrotum with their other foot as hard as they could for up to 30 minutes at a time. After Egli acknowledged that his conduct was "professionally inappropriate and was abusive to his patients," the board placed him on 5-year probation, which expired April 1997.

Some of that abuse occurred while Egli was still on probation for a previous offense. In 1986, he received a 5-year probation after being found guilty of providing controlled substances to an addicted friend and writing fraudulent prescriptions.

Egli declined to comment about his past misconduct. However, some of his medical colleagues, including his former boss, Robert E. Jones, MD, now with the Montana Department of Corrections, speak highly of Egli's compassionate care of inmates. Carol Gnade, executive director of the American Civil Liberties Union of Utah, Salt Lake City—which worked to halt the prison's use of the restraint chair—said that inmates she interviewed generally spoke well of the care they received from Egli. "It wasn't Egli who introduced the use of that chair," she added.

In Nevada, while still on probation for previous professional misconduct, Warren S. Gilbert, MD, medical director of the Washoe County Detention Center, ordered nurses to remove a diabetic inmate from the jail's diabetic protocol. Two days later, the woman died of diabetic ketoacidosis.

According to the Nevada State Board of Medical Examiners' findings, when Jacqueline Reich was booked into the jail on October 16, 1994, her intake form noted that she was a diabetic who took 30 units of insulin every morning along with medication for hypertension and that she wore a diabetic alert bracelet. A nurse placed her on the jail's diabetic protocol, including blood pressure checks and fasting blood sugar checks. The next day, without examining or talking with the inmate, Gilbert wrote an order on the inmate's treatment sheet to discontinue the diabetes protocol and to put her on a general diet. The nurses stopped giving her insulin and monitoring her blood glucose level.

When she began to exhibit the classic signs of uncontrolled diabetes, she was taken to the jail infirmary on October 18 and given an over-the-counter cold remedy. No blood glucose testing was done. She fell into a diabetic coma and died on the following day. According to the Nevada board's findings, Gilbert testified that he had "intended only to cancel the order for a diabetic diet and the regular insulin dosages. He did not intend to cancel the order for glucose and blood pressure tests to be performed 3 times a day for 3 days. However, it is clear from the records that the nurses construed respondent's [Gilbert's] order to mean a discontinuance of the entire diabetic protocol, including the glucose tests. Respondent was aware that no glucose tests had been performed for over 20 hours because on October 18, 1994, he signed off on the treatment sheet, which indicated that no glucose tests had been performed."

The year before, the Nevada Board of Medical Examiners had placed Gilbert on probation for 2 years for violating medical practice regulations by prescribing synthetic thyroid medication for weight control and for overprescribing and inappropriately prescribing excessive amounts of controlled substances. He was charged with 33 counts involving 32 patients and 20 individual acts of malpractice.

Following the inmate's death, the board of medical examiners charged Gilbert with gross malpractice. On January 5, 1996, the board concluded that, although Gilbert's actions were "below the applicable standard of care," they were "not done willfully or with conscious disregard [and therefore were not] gross malpractice." However, the board did find Gilbert guilty of violating regulations that protect the exclusive right of physicians to practice medicine. By allowing nurses to diagnose and treat medical conditions, the board said, Gilbert was guilty of "aiding, assisting, employing, or advising, directly or indirectly, unlicensed persons to engage in the practice of medicine."

"In the interest of improving the health care of inmates in Nevada who are under the care of the Respondent as a physician or a medical director, it is hereby ordered that Respondent's license to practice medicine in the State of Nevada is revoked; however, the revocation is stayed and respondent is placed on probation for a period of 4 years," the board wrote.

Gilbert, who is now working for Nevada Occupational Health Center in Sparks, Nev, blames the nurses for the "foul up" that resulted in the death of the diabetic inmate. He also accuses the Nevada Board of Medical Examiners of being grossly unfair and unjust and of denying him due process. "I did nothing wrong either time I was disciplined by the board," he said.

—A. A. S.

(JAMA. 1998;280:1388-1389)