PASSAGE ONE OF THE DAY: "He was working intoxicated and had at one point been forced into substance abuse treatment. Then he was allowed to return, but it turned out he foiled the tests of blood and urine by using an intoxicating drug that can't be traced in such tests."
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PASSAGE TWO OF THE DAY: "The DUI charge ultimately led to a $2.1 million review by other pathologists of Levy's 33,902 cases since 2005 that found multiple examples of bad diagnoses. All of them involved real human beings whose lives where literally in Levy's hands and in the hands of the Health Care System of the Ozarks. "The (Office of Inspector General) found a culture in which staff did not report serious concerns about Dr. Levy, in part because of the perception that others had reported or they were concerned about reprisal," the report stated. "Any one of these breakdowns could cause harmful results." U.S. Rep. Steve Womack described "an abject failure of leadership that led to the misdiagnosis and subsequent harm to hundreds of veterans." What's truly astounding are the findings that the health care system's procedures put Levy in charge of quality management within his own department. The report outlined a 12-year period in which Levy was able to influence a review process that created an "inherent conflict of interest."
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EDITORIAL: "A systemic Tragedy,' published by The NWA Democrat-Gazette on June 16, 2021.
SUB-HEADING: V.A. (Veteran's Administration) shortcomings detailed by report.
GIST: "Our fellow Americans who served in the nation's military know a little something about oftentimes cumbersome bureaucracies and their attraction to acronyms. In the armed forces, they dealt with both.
That experience continues as former soldiers, airmen, Marines, sailors and Coast Guard members rely on the U.S. Department of Veterans Affairs, the massive executive branch agency, for much if not all of their post-service health care.
A recent report from the agency described what veterans might sarcastically refer to as SNAFU, which in a family paper will be said to stand for "Situation normal: All fouled up." It's a reflection on systems from which they've come to expect complications, mistakes or nonsensical responses.
Is that the Health Care System of the Ozarks?
The report from the VA's Office of Inspector General put it this way: "Facility leaders failed to promote a culture of accountability."
That office was reviewing one of the most horrific incidents a health care system can experience -- one in which the effort to provide medical care instead does harm to the very people they're trying to help.
At the center of it all is Dr. Robert Morris Levy, a pathologist who hid his substance abuse until an arrest on a charge of driving under the influence. Further investigation found 30 cases in which Levy misdiagnosed patients to an extent his efforts had serious medical consequences. Another 562 cases involved missed diagnoses serious enough to have risked the patients' health.
Levy was found guilty of manslaughter in the death of one patient and sentenced to a 20-year federal prison term.
He was working intoxicated and had at one point been forced into substance abuse treatment. Then he was allowed to return, but it turned out he foiled the tests of blood and urine by using an intoxicating drug that can't be traced in such tests.
The DUI charge ultimately led to a $2.1 million review by other pathologists of Levy's 33,902 cases since 2005 that found multiple examples of bad diagnoses. All of them involved real human beings whose lives where literally in Levy's hands and in the hands of the Health Care System of the Ozarks.
"The (Office of Inspector General) found a culture in which staff did not report serious concerns about Dr. Levy, in part because of the perception that others had reported or they were concerned about reprisal," the report stated. "Any one of these breakdowns could cause harmful results."
U.S. Rep. Steve Womack described "an abject failure of leadership that led to the misdiagnosis and subsequent harm to hundreds of veterans."
What's truly astounding are the findings that the health care system's procedures put Levy in charge of quality management within his own department. The report outlined a 12-year period in which Levy was able to influence a review process that created an "inherent conflict of interest."
Public officials and the public are right to be angry at a system designed to care for veterans that failed seriously enough that it became an agent for harm. It's such a bureaucracy, it's hard to pinpoint needed changes, but clearly strong leadership is what's required to avoid such major failings in the future. And, if such a major case as this went on so long, it's fair if there are concerns that smaller, but perhaps no less significant, issues remain in terms of proper management.
