A Department of Veterans Affairs hospital in Richmond, Virginia, rehired a pathologist who had been previously fired for failing to diagnose or misdiagnosing cancer in at least a dozen patients, the VA Office of Inspector General reported Wednesday.
None of the incidents were reported as adverse events to patient safety officials at the facility, the Hunter Holmes McGuire VA Medical Center, including one involving a patient whose misdiagnosis caused their condition to worsen, later requiring advanced medical treatment.
The report is the second in two days from the VA OIG to expose physician failures at VA hospitals that went unchecked by administrators. On Tuesday, the VA OIG released a report finding that the department took nine months to fire an emergency room contract physician who, after deciding a patient was "malingering" and "ranting," called VA police to have the patient escorted off property and said they could go "shoot [themselves]. I do not care."
The veteran died by suicide six days later from a self-inflicted gunshot wound.
In 2017, the Government Accountability Office reported that VA medical center officials regularly failed to investigate complaints lodged against providers or waited months to look into allegations.
The report also found that when the VA revoked doctors' privileges, officials often failed to inform state licensing boards or a national database, allowing the doctors to practice elsewhere. The VA also sometimes reached settlements with physicians that allowed them to resign in exchange for not reporting their errors.
In subsequent congressional hearings on the issue, VA officials pledged to address the problems, including reporting adverse actions at the state and national levels.
But the OIG report released Wednesday indicates that hospital officials continue to engage in cover-ups.
According to the report, the hospital's Pathology and Laboratory Medicine Services chief wasn't even aware of the VA's requirement to report the misdiagnoses to higher-ups. Senior officials also weren't aware they were supposed to participate in a state licensing review board process following the incidents.
The physician was fired but appealed the termination. In March 2019, the doctor was rehired, and clinical privileges were restored. As of last September, the physician continued to work at Hunter Holmes McGuire as an investigation was ongoing into his or her ability to turn around surgical readings in a timely manner.
Likewise, at the Washington, D.C., VA Medical Center, officials failed to dismiss the physician, a contractor, who verbally abused the suicidal veteran even though other employees reported the incident and the doctor had been the subject of other reports of "verbal misconduct."
The report noted that the doctor remained as a physician at the VA because reviews found his or her care of patients to be sufficient.
The Washington, D.C., VA eventually ended the physician's contract, according to the report.
President Donald Trump frequently touts changes that his administration has made to "fix" the VA, including accountability legislation approved in 2017 that accelerated the process for firing workers for misconduct or poor performance, as well as shortening the time employees have for processing appeals.
"I signed the VA Accountability Act into law, and we've removed more than 9,000 VA workers who were not giving our veterans the care, respect, attention that they've earned. And now that we have accountability -- it's 'accountability;' a very nice word -- if an employee of the government mistreats our veterans in any way, does something wrong, isn't good for the VA, the secretary looks at them and says, "You're fired. Get out," Trump said in a speech June 17 to introduce his plan for reducing veteran suicides.
The OIG reports this week, however, indicate that the VA still struggles to hold physicians accountable and to protect veteran patients or the public, in cases of physicians who go on to practice at civilian facilities after leaving the department.
In Richmond, VA officials failed to conduct a state licensing board review and in Washington, D.C., the doctor was never reported to the state and national boards that record physician misconduct.
"Facility leaders did not report [the Washington, D.C.] physician to the State Licensing Board or National Practitioner Data Bank. Although facility leaders did not conduct a formal investigation, they removed [the physician] from the VA contract ... and therefore, facility leaders had a duty to report," the VA OIG wrote.
"Neither the former Facility Director nor the Chief of Staff completed all elements of a [VA]-required review upon discovery of the subject pathologist's 'egregious performance,'" the VA OIG wrote.