A VA ophthalmologist performed eye surgeries for two years even though the surgeon was under-qualified — and claims have been made that the ophthalmologist was only hired because the facility wanted to hire their spouse.
A VA Office of Inspector General inspection was ordered in response to complaints about an ophthalmologist working out of the Veterans Integrated Service Network 10 Medical Facility. The specific facility location was not included in the report, but VISN 10 encompasses Ohio, Indiana, and Michigan. The ophthalmologist also was not identified in the report.
Allegations about the ophthalmologist claimed they lacked training, provided substandard care, and failed to meet productivity expectations — meaning it took the surgeon up to two hours to perform cataract surgeries that take, on average within the VA system, 26 minutes. And they weren’t consistently performed well, either.
The complainant also said that numerous staff members reported the ophthalmologist's performance, but the chief of staff chose to reappoint the surgeon after the initial probationary period. The Chief of Staff (COS) acknowledged that, in considering whether or not to reappoint the ophthalmologist after the probationary period, the eye doctor’s otolaryngologist spouse was a factor.
The OIG investigation confirmed that the surgeon lacked the necessary training required by the Veterans Health Administration — the surgeon attended a foreign medical school and the credentialing coordinator had no explanation for why verification of the surgeon’s training was not obtained.
The ophthalmologist was observed by other contracted surgeons (as this ophthalmologist was the only one on staff) as part of ongoing professional practice evaluation. But the observation and resulting report didn’t address areas of concern that had been reported — and further information and elaboration were not requested.
The COS did request clinical reviews from additional VISN ophthalmologists. Those reviews came back with reported deficits in the surgeon’s performance. The COS acknowledged the comments, described them as “significant for concerns about the surgeon’s judgment, techniques and laser procedure management,” and then made no immediate efforts to make any changes.
When attempts were made to increase the ophthalmologist’s productivity, performance standards lowered and patients experienced “suboptimal outcomes” — multiple were referred to community facilities for follow-up surgeries.
Despite these reported performance issues, the COS reappointed the ophthalmologist at the end of the probationary period. This continued until the surgeon was terminated in March of 2019, roughly two years after being appointed.
The OIG team was not notified of patients that experienced permanent vision loss as a result of the surgeon’s practice, but they concluded that patients faced unnecessary risk at the hands of the ophthalmologist.
The investigation made five recommendations for the facility including that the director ensures proper credentialing processes are followed, professional references meet criteria, and technical competence is measured using VHA requirements. The OIG also recommended a further investigation to decide whether or not an interest in keeping the ophthalmologist’s surgeon spouse on staff influenced the COS’s decision to reappoint the eye surgeon. Lastly, the director is to coordinate with VISN 10 to assist and support providers with performance deficits.