Copyright © 2009, 2010 Tom Harbin, M.D. and reprinted here with his permission
PROLOGUE
September 1983
"Genevieve, block that eye." The surgeon, gowned and gloved, pointed to the patient's left eye. Genevieve Switz hesitated, and as she later recalled, looked around for the operative permit. As the physician's assistant, she always checked the op permit one last time before an operation began. She had barely stepped into the room; everything was rush-rush. It was 6:00 PM, and this was the thirteenth operation of another long, hard day.
"Come on. Let's go." Genevieve heard the stress in his voice. She proceeded to block the eye without looking at the permit.
The patient lay sedated and oblivious while Genevieve pierced his left lower lid with the 26-gauge needle-a needle quite sharp, thin, and long-and maneuvered the tip to a position behind the eye. Five cubic centimeters of Xylocaine filled the space, paralyzing the muscles that move the eye and numbing the pain nerves.
The surgeon, H. Dwight Cavanagh-M.D., PhD, professor of ophthalmology and department chairman at Emory University School of Medicine in Atlanta-prepared to perform a corneal transplant with removal of cataract and insertion of lens implant.
First he sewed a ring to the sclera, the "white" of the eye, to prevent collapse later in the operation when the eye was open and vulnerable. Cavanagh had almost finished attaching the ring when Dr. Philip Newman, the senior cornea fellow who was Cavanagh's first assistant, entered. Newman would remember Cavanagh's icy look and reprimand for the patient's poorly dilated pupil. In cataract surgery, the pupil should be dilated before the patient enters the room. Newman mumbled an apology and busied himself with the donor cornea. Newman turned the tissue upside down and picked up a circular cutting tool to punch out a dime-sized button from the center of the cornea.
Meanwhile, Cavanagh twirled a slightly smaller instrument through the center of the patient's own cornea until only a tiny barrier kept the circular blade from penetrating the eye. Using scissors to cut into the eye, he removed the smaller button, leaving the eye open and exposed. This is a critical moment. If the patient coughs or moves, the contents of the eye could spill out, leaving the eye forever blind. Speed counted now, while the cataract was removed and replaced.
Still grumbling about the insufficiently dilated pupil, Cavanagh demonstrated what must be done to the cataract when pupils are not dilated. Pushing the iris aside to gain room, the surgeon removed the cloudy lens and placed a plastic lens exactly where the old one had resided for seventy-four years. Coaxing the button of clear donor cornea into the slightly smaller ring of remaining host cornea, he swiftly placed a silk suture at 3:00, 6:00, 9:00, and 12:00. With the graft in place, the eye had a barrier-a clearer barrier-to the outside world. Everyone began breathing again. Another success, and with an operation not easily performed.
Dr. Cavanagh turned to Dr. Newman and instructed him to finish the case and left to dictate the operative reports. Newman must have appreciated Cavanagh's dictating his own notes, especially since Cavanagh required two reports for each operation, where other surgeons only required one. Most surgeons assigned this tedious work to assistants, so Dr. Newman was lucky.
It took Newman thirty minutes and twenty-four bites of the needle to run a suture smaller than a human hair, a suture that provided continuous closure to supplement the four silk sutures placed by Dr. Cavanagh. Then Newman sewed the patient's eyelids partially shut to protect the surface of the new graft.
Meanwhile, Cavanagh dictated two separate notes about the operation. He first described the intraocular portion of the surgery-the removal of the lens and placement of the corneal transplant. The second note detailed the extraocular portion of the surgery, the part where the lids were sewed partially shut. During the thirty minutes it took Newman to complete the surgery, Cavanagh also dictated the notes for his other twelve cases. All the cases had gone well. He was one of the busiest corneal surgeons in the nation and justly proud of it.
Dictation finished, Cavanagh had barely settled into the lounge when Philip Newman burst into the room. "We need to operate on the other eye as soon as we can," blurted Dr. Newman, then turned and fled. A few minutes later, the anesthesiologist came in. "Dwight, we have a problem, a big problem. You operated on the left eye, his good eye. You were supposed to do the right."
The next day, the patient woke up blind.
CHAPTER ONE
BEGINNINGS
1976
Dr. Dwight Cavanagh had top credentials and honors. He had earned not only a medical degree from Johns Hopkins, where only a tiny percent of applicants were admitted, but a PhD in biochemistry from Harvard, where he worked in the laboratory of Harvard's Nobel laureate George Wald. After his internship, he took a residency at the Wilmer Institute, the eye department of Johns Hopkins. After his residency, Cavanagh took a cornea fellowship, the final year of specialty training, at Harvard's Massachusetts Eye and Ear Infirmary. Another fellow at the time remembered that Cavanagh stood out for his brilliance and lucid discussions even at that early stage of his career. The faculty and attending staff led the world of ophthalmology, and few people could impress Harvard in this way.
Cavanagh came to Emory in the fall of 1976 as an assistant professor, eager to pursue his dream of success at a university medical center. He peered at the world through thick, wire-rimmed glasses. Thirty-six years old, tall, erect, white lab coat always buttoned and crisp, he commanded attention. With a rapid pigeon-toed gait, he would charge through the halls, residents and fellows trailing behind. When he walked, his body tilted forward, head leading shoulders and hips. He always appeared to be in a hurry.
Articulate, charming, and sincere, he particularly impressed patients. He held their hands, looked intensely into their eyes, pattered on for a minute or so, all the while leading them toward the exit door since he knew other patients were waiting. They would leave in love.
I first met Cavanagh when I arrived on the Johns Hopkins campus in the summer of 1971. I was a first-year resident in ophthalmology at the Wilmer Institute of Johns Hopkins, twenty-six years old, a rookie; Cavanagh was a second-year resident, one of five who, along with the third-year residents and the chief resident, would teach us newcomers the ropes. He manifested his management talent to me early in that first year, when I was in the Wilmer emergency room at 2:00 in the morning wrestling with my first case of an attack of glaucoma. Cavanagh was my backup, so I called for advice. He heard my description, told me what to do, and he was definitely right. The treatment broke the attack, and all was well by morning rounds.
Two short years after his arrival at Emory and one year before the scheduled retirement of the current chairman, the university appointed Cavanagh chairman of the Department of Ophthalmology. Week after week Cavanagh mesmerized students and staff at teaching conferences with his brilliant synthesis of research and clinical data pertaining to particular patients' problems. When he spoke extemporaneously about the cases presented, he would often cite numerous journal references. He knew personal information about most of the researchers whose papers he quoted, and he always recited their credentials. Cavanagh was well acquainted with everyone on the cutting edge of eye research. Credentials mattered to Cavanagh.
I had come to Atlanta to practice in 1975, joining a group in downtown Atlanta. I attended these teaching conferences for years and was continually awed by Dwight's fund of knowledge, both clinical and scientific. Few could touch him when it came to case discussions.
Cavanagh had a wonderful vision for his department. He would build for himself one of the world's biggest practices in corneal-disease treatment. As chairman, he would lead his department to the top ranks of teaching and research institutions, rivaling Hopkins and the Ivy Leagues. He would build the new eye center promised to Emory faculty since the 1960s. He would raise the funds and ensure the eye center's mission to bring together patient care, surgery, research, and collegiality among young, outstanding, energetic doctors in one building. It would be world class.
But in the years that followed, it became apparent that Cavanagh's dreams did not end with the building of the eye center. He wanted research and academic renown as well. He would direct research fellows and PhDs, and together they would write papers that would be published in leading journals and read worldwide. His faculty would do the same in their subspecialties. Born in Atlanta's Piedmont Hospital, Cavanagh had returned to the city of his birth to a department and university ripe for growth and direction.
Our chairman at Johns Hopkins was a world power in ophthalmology. If the events of this book had not taken place, Cavanagh might have exceeded him. Starting with Emory's chairmanship, he might have progressed to the chairmanship at Harvard or head of the National Eye Institute.
He set to work. From 1978 to 1980, Cavanagh attracted specialists from academic centers across the United States and vastly increased the research funding and capability of the department. He began raising the $10 million ($22 million in 2008) necessary for construction of the new eye center while fending off opposition from other Emory faculty, who viewed the eye as a minor appendage of the body and not deserving of a building of its own. He oversaw many of the details for construction of the eye center. His own surgical practice expanded, and he took on responsibilities with national organizations.
One of the technicians marveled that within a few minutes of meeting someone, and after only a few questions, Dr. Cavanagh could tell that person what to do with the rest of his or her life and would be correct. He had great insight. He was one of the hardest-working people she had seen, paying close attention to detail. She said he noticed everything. Every Saturday, Cavanagh went to Grady Hospital, the downtown Atlanta hospital where the residents performed much of their work, to teach the doctors in training. He wanted to make good ophthalmologists of the doctors he admitted to his training program. He grew busier and busier, and his duties pulled him in many directions.
During these early years, Dwight Cavanagh grew close socially and professionally with two faculty members who came to Emory about the same time as he did-doctors David Campbell and Frank Bell. They and their wives got together on weekends, and Cavanagh dubbed them the "Three Musketeers."
David Campbell had a bright future. After Yale Medical School, Dr. Campbell had gone to Harvard for his eye residency, glaucoma training and, early on, a faculty appointment. The Campbells spent summers in Woods Hole on Cape Cod and were used to the cold northeastern winters. Six feet tall and blond-haired, the conservatively dressed Campbell impressed people as straitlaced, but in reality he was a man with a lively, if quiet, sense of humor.
Encouraged by Dwight Cavanagh even before he became chairman, David Campbell joined the Emory faculty in 1977. All Saints Episcopal Church attracted the Campbell family, and the kids were enrolled in good private schools. All the Campbells loved Atlanta, with its mild winters and long springs, and David had negotiated a month each summer for them to return to Woods Hole. Here at Emory, family settled, Dr. Campbell set out to meet his goals-to do valuable eye research, treat glaucoma patients and, most importantly, put down deep roots for his family. David Campbell never suspected that Dwight Cavanagh's dazzling energy and enthusiasm would irreparably damage his family's life, reputation, and career.
In David Campbell's first three years at Emory, he built a busy clinical practice but always gave time for teaching and research. He made weekly trips to Grady Hospital, the downtown public hospital staffed by Emory's faculty, residents, fellows, and medical students. He expanded the glaucoma clinic at Grady, affording more specialized care to Atlanta's poorest citizens as well as more focused teaching for the residents.
At Emory, Campbell continued the research he began at Harvard, studying two types of glaucoma, pigmentary glaucoma and a syndrome dubbed ICE (iridocorneal endothelial syndrome). In 1979 a prominent national organization, Research to Prevent Blindness, named Campbell the Robert McCormick Scholar, a coveted award recognizing him as an outstanding young researcher. Even more significant, the National Eye Institute awarded him a grant in September 1979 to study pigmentary glaucoma. This grant named Campbell the principal investigator and extended funding over six years, allowing him to expand his lab and hire other scientists.
David Campbell's activities didn't stop with research and teaching. Residents and fellows sought his advice. They trusted him. His honesty and conservatism shone through every encounter. A few described him as puritanical, but only a few. And all members of the department regarded him as their conscience. Consequently, residents sought his counsel between patients, in the halls, and after hours. Where could they go into practice? Which was better, academics or private practice? What should they do with their lives?
After two years of Dr. Cavanagh's hard work, cracks in the foundation of his well-constructed department began to appear. Cavanagh grew frantically busy, so busy that his activities generated concern not only from colleagues within his department but also from the highest levels of Emory's administration.
As 1980 began, the tenor of David Campbell's discussions with the young doctors shifted and reflected these cracks. Activities on campus dominated the conversations, especially the patterns of Dwight Cavanagh's practice. They insisted on talking with Campbell behind closed doors. The discussions-hesitant and with lowered voices-centered on Campbell's chairman, friend, and fellow musketeer, Dwight Cavanagh.
***
October 1980
Dr. James Glenn came to Emory as dean of the medical school from Duke University. Soon after Dean Glenn arrived at Emory in early 1980, he began to hear complaints about Dwight Cavanagh. Years later, in preparation for his testimony in one of the lawsuits precipitated by the events of this book, he told a lawyer, I began receiving numerous phone calls from patients on a regular basis, some of whom had driven in from out of town for appointments with Cavanagh and been required to wait as long as five or six hours past the time of their scheduled appointment. And when they finally got in, Cavanagh spent all of two or three minutes with them because he still had a long line of other patients waiting outside the door. Cavanagh was not spending enough time with the patients to perform any kind of meaningful examination or establish a proper rapport with the patients.... On several occasions, I was performing surgery myself in one of the operating rooms close to the operating rooms Cavanagh was using, and I observed that this surgery schedule listed more major surgeries than anyone could properly perform in one day...
Glenn continued his story to the lawyer, relating the details of a meeting in his office with Cavanagh in late 1980. I told him it was clearly unfair to the patients to see that many in one day.... I told him no doctor could hope to complete that many surgeries in a day without taking a substantial risk of a mistake.... I told him that as dean of the medical school, I was instructing him to reduce the volume of his practice to a level commensurate with his ability to render good-quality patient care.
After ordering Cavanagh to change, Glenn headed home in the dark, hoping his direct order would produce results. A dean's direct orders should produce results, but though he ran the medical school and faculty, Glenn did not have full authority on campus. It was complicated. The several hundred Emory University doctors, when seeing patients, did not do so as university employees, as it is in many medical schools. These doctors actually practiced in the Emory Clinic, a group practice independent of the medical school and Dean Glenn. The clinic was run by Dr. Charles Hatcher, an outstanding heart surgeon. Most of the Emory doctors' incomes flowed through the clinic. Money generates power, and Glenn had not yet fully realized the extent of Dr. Hatcher's influence and the consequent limitations imposed on Glenn's own power and his ability to make changes in the activity of his faculty.
* * *
January 1981
Dr. David Campbell remembers Dwight Cavanagh dropping down to the third floor of the clinic, the location of director Charles Hatcher's office, on a regular basis. Each had something to teach the other, and they enjoyed each other's company. Hatcher knew about department and practice finances; Cavanagh knew about the funds to be gained from research grants.
Dr. Charles Hatcher, born in 1930, grew up in Attapulgus, a town in southwest Georgia near the Florida line. After a residency in heart surgery at Johns Hopkins, he turned down a position there to come to his first choice, Emory. He pioneered heart surgery at Emory and in the state of Georgia, performing a number of firsts-the first successful blue-baby surgery, the first heart-valve replacements, and the first coronary bypass, among others. His obvious administrative talents led to his election as head of the Emory Clinic in 1976. Over the five years of his directorship, Hatcher had gradually reduced his clinical load of heart surgeries in order to make room for his increasing administrative responsibilities. Yet he kept his administrative office on the third floor, the cardiovascular floor, the source of his income. He made financial decisions for his cardiovascular partners and the clinic. No one doubted that Hatcher, a born leader, ran things. Strong and charming, he had a commanding personality. A member of Atlanta's social elite, he had gained membership in the leading social club and the downtown Rotary Club, where Atlanta's business leaders met weekly.
CHAPTER TWO
PROBLEMS: 1982
February 1982
In 1982 most of the Emory Clinic doctors were crammed into one building, the Scarborough building, with ophthalmology and four other specialties sharing the fifth floor. Patients coming to the eye department turned to the right off the elevator and headed down the hallway to check in. Dwight Cavanagh, in practice now for six years, had so many patients on Tuesdays and Wednesdays that the waiting rooms overflowed. The space could not accommodate a hundred or so patients plus family members spending the day as they waited their turns. Thirty or more patients filled extra chairs lining the hall, wherever they could fit amongst patients in wheelchairs or standing or using walkers. White-coated faculty, residents, fellows, and technicians threaded their way through this obstacle course.
Across from Cavanagh's office, down the hall jutting off to Psychiatry, sat three bins of charts for the patients of the day. First an assistant took the relevant history from the patient, reviewed the tests, did an examination, and placed the chart in a pile near Cavanagh's secretary. She decided who would be seen next and would place that patient near Cavanagh's door.
Into this scene, and not for the first time, came two patients: Gladys Wilson and her mother. Her 1986 deposition revealed the following. Wilson, born in Alton Park, Tennessee, on April 13, 1911, had lived in Decatur, Georgia, for twenty-four years. She had taken early retirement from Delta Airlines in 1962. Wilson's mother, now in her nineties and under Wilson's care, had worked on the eye floor at Emory years before and had even had several eye operations there. By 1982 Gladys Wilson found it difficult to care for her mother. She no longer trusted herself driving. She began to miss street signs, occasionally getting lost in her own town, and couldn't tell whether a traffic signal was green or red. Her husband had a part-time job that he didn't want to give up in order to drive Gladys around and aid in caring for her mother.
Wilson and her mother were both Dr. Cavanagh's patients and were accustomed to the three-to-four-hour wait. Wilson knew the routine: no trips to the bathroom after the secretary had the charts. If she called while they were in there, it would be another two hours.
When at last their turn came, Cavanagh, charts in hand, helped them down the hall to his office, charming them with small talk. Mother in the exam chair, light from the scope on each eye; out of the chair, time for the daughter. One minute for the mother, one minute for Gladys, and then time to discuss the treatment plan.
Gladys Wilson had referred herself to Dwight Cavanagh for problems with cataracts. Cataract surgery in the 1980s had improved significantly over the previous ten years. A cataract is a clouding of the normally clear lens that occupies the front third of the eye. When haziness occurs, the term cataract applies. Heretofore, cataract surgery consisted of removing the entire cloudy lens, forcing the patient to wear thick glasses or uncomfortable contact lenses. Surgeons could now implant an artificial lens. Intraocular lens (IOL) implantation rapidly became the gold standard for cataract surgery.
But Dr. Cavanagh told Wilson that, in addition to a cataract, she had a disease of her cornea. The cornea is the thin, transparent tissue that covers the front of the eye, analogous to the crystal of a watch. It acts as a lens and begins the process of focusing light on the back of the eye. The cornea is about as thin as a credit card and slightly bigger than a nickel.
Cavanagh's diagnosis surprised Wilson. Her previous ophthalmologist had never mentioned corneal problems, only the cataracts, but Cavanagh was the expert, and she accepted his opinion.
Cavanagh then gave Wilson's mother to the technician for instructions and prescriptions. He turned to Wilson and told her she needed a "triple" (a corneal transplant, cataract extraction, and lens implantation). Wilson knew that Cavanagh had done this same operation on her mother's eyes. She knew that, despite Cavanagh's assurance that the operation was successful, her mother had remained blind. But unlike Wilson, her mother also had glaucoma. So, notwithstanding the inevitable doubts that arise when we are faced with surgery that has not gone well for someone we know, Wilson agreed and scheduled the surgery. She did request that she have no further contact with Dr. Cavanagh's fellow at the time, Dr. Leaper (not his real name). She felt he had treated her rudely and wanted no more of him. Gladys Wilson wanted to be treated only by Dr. Cavanagh himself.
***
According to his tech, Dr. Cavanagh often joked as he entered the operating room, "These hands have been touched by God." But as Cavanagh proceeded through Gladys Wilson's operation, he must have muttered the words his technicians had come to dread, the words Cavanagh would always and only say when he had problems in surgery: "Perfect, perfect."
As soon as the tech heard the sarcastic "Perfect, perfect," he knew the eye was in trouble, and indeed it was. The lens sac, or capsule-a membrane that surgeons strive to keep intact-had ruptured. Worse, swelling of the tissues from the back of the eye threatened to extrude and ruin the eye completely.
With a crisis like this, the words would flow from the surgeon: "Come on, where's the button? Get that blood pressure down. That's where this fluid is coming from. Hold this here. Suture, suture. Perfect, perfect. Hurry, hurry, and give me another suture."
With sticky, vitreous gel from behind the lens sac all over the place, Cavanagh placed as many sutures as he could. He was unable to put in a lens implant but did transplant her cornea, averting the disaster of a lost eye. Without an intraocular lens, she would be able to see, but only if she could tolerate a contact lens.
The operation brought only misery to Wilson. In the days after her operation, her eye flashed and flickered, and she never saw well. Her eye hurt most of the day, every day. It also drained fluid and felt like something was in it. She was puzzled. Cavanagh had told her that her eye was too small for a lens implant and that she would eventually need a contact lens. He emphasized that "the eye is fine," so Wilson wasn't too concerned. Then he left town, leaving her in the care of his cornea fellow, whom she did not like and whom she had requested not be involved in her care.
Now home after a week in the hospital, she had her husband Arthur call Cavanagh's office every day, only to learn that the cornea fellow was still taking calls for his chief. She would have none of that.
After three weeks, Gladys Wilson called the secretary. She had to see somebody, she said, anybody but that cornea fellow. Her eye had developed a shade that blocked part of her vision. The next day she saw Dr. Doyle Stulting, another cornea fellow. He found trouble.
Dr. Henry Kaplan, the senior retina specialist, confirmed Stulting's diagnosis of retinal detachment. The retina is the thin tissue that lines the back of the eye. Light rays bent by the cornea and lens are focused on the retina, which sends nerve impulses that the brain translates into vision. When fluid accumulates behind the retina, it balloons forward and detaches. Untreated, a detached retina causes blindness. Surgery is the only treatment.
Kaplan's words shocked Wilson. Emergency surgery on an eye that Dr. Cavanagh said was "fine," retinal detachment related to complications at the first surgery, complications never disclosed to her. Her worst nightmare, all in a rush.
Dr. Hank Kaplan had arrived on campus in 1978, a Cavanagh recruit from the University of Wisconsin with great research potential. Kaplan had a PhD in immunology in addition to a retinal fellowship. He could not only develop a retinal practice but also get government money for retinal research. Kaplan produced results in both his clinical practice and research.
Gladys Wilson had her first retinal-detachment operation in March, a month after Cavanagh had operated. Throughout the procedure, Kaplan worked hard, both hands and both feet busy. One hand controlled the main instrument, a long, thin pipe that cut and extracted bands of scar tissue. The other hand controlled the light pipe that illuminated the inside of the eye. The left foot worked the pedal of the operating microscope while the right regulated the pace of the cutting.
Looking through the microscope for almost transparent bands of scarring, Kaplan noted, as detailed in his operative report, a lot of vitreous on the back of the graft. When the lens sac ruptures in surgery, the vitreous gel needs to be removed or it will stick to the structures of the eye, contract, and pull the retina loose, detaching it. The amount of vitreous stuck to Wilson's graft indicated an inadequate cleanup at the first surgery.
Typically when a surgeon cleans up a colleague's mess, it's not easy. When the colleague has not mentioned complications to the patient or prepared the patient for problems, and the surgeon has to endure the shocked anger of the patient as well as undo the damage, it's even harder. Fortunately for Gladys Wilson, she was unconscious and blessedly unaware of the future of her eye.
***
March 1982
Dean Jim Glenn paced the length of Dr. Charles Hatcher's office and back. After two frustrating years and three formal meetings with Dr. Cavanagh, Glenn had seen no change in Cavanagh's office or surgical schedule. Glenn took the problem to Hatcher. Glenn had recently heard of another aberration in Cavanagh's practice, that of using residents in corneal-transplant surgery but submitting bills as if another type of doctor, a fellow, had assisted.
A fellow is a doctor in the last phase of medical training. You become a fellow after four years of medical school, one year of internship, and three years of residency. Instead of going into practice as a general ophthalmologist, a fellow serves one or two more years to become a subspecialist in one of several areas-glaucoma, cornea, retina, pediatrics, or plastic surgery, to name a few. Because fellows have completed residency training, Medicare and other insurance companies allow training programs to bill for their services in certain situations. Residents, on the other hand, are doctors still in training and not yet fully fledged ophthalmologists. The federal government pays universities to train residents, so Medicare does not allow a program to bill for them. When a training program has both residents and fellows, Medicare assumes that residents are available to help in surgery and thus doesn't allow separate billing for fellows. Cavanagh was billing Medicare and insurance companies for fellows' services when only residents were in the room. A fellow could bill $600 ($1300 in 2008) for assisting on a triple, a significant amount for a training program always looking for dollars.
Glenn had seen the following letter of justification that Cavanagh sent to the insurance companies when they challenged Cavanagh's practice of billing for fellows as assistants in some of Cavanagh's operations.
Dear Sir:
Emory University School of Medicine, Department of Ophthalmology, is the leading referral center for corneal transplantation work in the United States.... It should be clearly understood that corneal transplantation operation is a highly complex technical operative procedure which requires...
Residents have never been allowed to assist at this surgery at Emory University School of Medicine, Department of Ophthalmology; nor are they taught this procedure as an undergraduate in eye surgery training....
To entrust this to the level of a beginner would not only not be in the patient's best interest but in my opinion would constitute malpractice...
From this information, it should be rapidly and easily seen that an assistant's fee to a senior physician is not only justified in this case but depriving the patient of such skilled assistance could be construed as acting against their best interest directly.
With warmest personal wishes and thanks for your consideration...
H. Dwight Cavanagh, M.D., Ph.D.
Professor and Chairman
Department of Ophthalmology
In the later trial preparation, Glenn told the attorney: "At some point, it came to my attention that Cavanagh was billing for assistant surgeons used in cornea transplants. I told him I didn't know how he could justify doing that, that no other teaching hospital I'd ever been affiliated with had done that, and that it was clearly illegal to bill for assistant surgeons in a teaching hospital if a qualified person on the staff of the hospital, such as a resident or intern, was available to provide such services."
When the attorney asked Glenn's opinion of the above letter, he replied, "This is preposterous. Most of the cornea surgeons I know in private practice routinely perform cornea transplants without any assistant surgeon. It is basically a one-man operation."
Glenn then told the attorney Hatcher's response to Glenn's concerns about Cavanagh, "I know all of that, but I can control him." A frustrated Dean Glenn left, determined to pursue the matter in other ways.
* * *
The resident assigned to ocular pathology was bent over his microscope. He had a question for Dr. John Wright, the faculty member who doubled as a pediatric ophthalmologist and ocular pathologist. The slide under the microscope had a tissue reading from Gladys Wilson's cornea.
Dr. Cavanagh's diagnosis of Gladys Wilson's disease was Fuchs' dystrophy, but the resident could not see the signs of this disease as he looked at the tissue.
Pathologists at all hospitals examine tissue removed at surgery and make a diagnosis, a pathological diagnosis. They compare their diagnosis to the clinical diagnosis sent by the surgeon submitting the tissue sample. Mismatches between the diagnoses of the pathologist and the surgeon are rare. When they occur, the surgeon has some explaining to do. In fact, in some departments such as general surgery, entire monthly conferences center on these unusual occurrences. No such monthly conferences were held in the eye department.
Dr. Wright had been on campus for seven months. By now he was not surprised at the resident's problem, but Wright would look himself to be sure. The findings of this disease can be subtle or alternately obvious on different slices of the patient's tissue. But in the case of Gladys Wilson, both the resident and Dr. Wright confirmed that her cornea was healthy. Fuchs' dystrophy is easy to spot in patients with significant vision loss. It's easy to see in the office, and it's easy to see in the pathology lab. When a patient with a healthy cornea is subjected to surgery unnecessarily, the pathologist can tell by the lack of significant findings under the microscope.
Dr. John Wright later testified that he had seen a number of totally normal corneal specimens from Cavanagh's surgery in his seven months. Dr. Cavanagh had diagnosed a disease and operated, but Wright had found no sign of any abnormality. So he had a dilemma and a big responsibility. He had accurately reported his findings on each patient, including, as revealed in her later lawsuit, placing a report in Wilson's chart noting the absence of Fuchs' dystrophy. He hoped that a report of a normal cornea would elicit concern from Dr. Cavanagh. No query came.
John Wright crossed the street looking for the head of general pathology. He found him amidst the usual chaos-phones ringing from surgeons asking where their frozen section reading was, techs cutting tissue, organs being delivered fresh from surgery in large metal pans.
As soon as the department chairman looked up, John Wright unloaded his burden. Wright had a problem, needed help. Corneal transplants with no disease, cases with minimal disease, what was Wright to do when they came from the chairman, the boss? Dr. Cavanagh doesn't comment on the reports.
He testified that the normal tissue came from only one of the three corneal surgeons, Dwight Cavanagh. Dr. Wright told him there were too many to count if you include the minimal cases, five to ten of totally normal corneas. No, talking to him wouldn't help. So Wright wanted advice on what to do.
The chief said to put a label on the normal ones, Code 3, and send them over to him. Code 3 means the pathology doesn't match the surgeon's diagnosis. A special committee of pathologists, the Tissue Committee, reviewed all such cases from throughout the hospital and would summon the surgeon for an explanation. A relieved Wright discharged his responsibility by sending over his Code 3 cases. In his experience, Cavanagh would not question him about the path reports on the chart, but he trusted the system to rectify his growing problem.
* * *
James T. Laney, PhD, president of Emory University, must have sighed when he saw Dean Jim Glenn on his schedule. Jim Glenn, not again, always complaining, never happy. Dr. Laney, a graduate of Yale Divinity School and an ordained Methodist minister, had studied and written on ethics and the moral life. Harvard Magazine had published his article "The Education of the Heart," and it was widely quoted. He struck you as the perfect university president. Solid in body, with a reassuring, pastoral voice, he exuded calmness, solemnity, and the ability to solve the gravest of problems.
Laney spent most of his time developing the nonmedical areas of the university, thinking perhaps that the medical center was already dominant. But he did monitor health affairs. Dean Glenn told his attorney that he knew that one of the highlights of President Laney's week was the trip from campus to downtown Atlanta with Charles Hatcher and Garland Herndon, the vice president for health affairs, to the Atlanta Rotary Club. There they mixed with Atlanta's business leaders, some of whom, including my uncle, were on Emory's board. On the return trip, the three would decide issues and weekly jobs for their subordinates, including Jim Glenn. Dr. Herndon was Dean Glenn's superior, yet, despite the protocols of hierarchy, sometimes Glenn would insist on talking to the president.
If Laney hoped he would get good news, he was wrong. Jim Glenn had come to warn Laney about Dwight Cavanagh. Glenn's attempts at solving the matter lower in the chain of command with Charles Hatcher had failed; he had a duty to talk to the ultimate boss. Glenn recalls that he laid out the familiar story-patient volume too large, too many complaints, headed for trouble, "that unless something could be done about him, patients would be injured and the reputation of the medical school would be damaged."
Then Dean Glenn, unaware of the close friendship between Laney and Hatcher, says he warned Laney about Hatcher, whom Glenn had come to distrust. Dean Glenn told President Laney that Dr. Hatcher was a liability to the university, in large part because Hatcher had failed to rein in Dwight Cavanagh. Laney, Glenn recalls, said he would get back to him.
Dean Glenn told his lawyer he got the word from his boss, the vice president, a few weeks later: "Get off Cavanagh's back...Cavanagh was too valuable and was bringing in too much money and they didn't want to interfere with him."
* * *
Dwight Cavanagh beamed as he approached his patient's bedside. Cavanagh had operated on Mattie Brown, giving her a new cornea and a lens implant. The diagnoses: Fuchs' dystrophy and cataract. He was optimistic on this visit and all future ones. Brown recalled the litany in a 1987 deposition: "You're going to get a good eye, Mattie. Hang in there." Then off he ran. She said she never saw him walk.
Mattie Sue Brown, almost seventy-five years old, had come from Calhoun, Georgia, a small town sixty miles north of Atlanta. She liked to garden and do handwork. Her local doctor had diagnosed cataracts and changed her glasses until new ones no longer helped. She had four land lots to care for and plant flowers in, and she couldn't see to garden anymore. She could not do her beloved handwork. Sunlight blinded her, and driving was more and more a problem. A lively, talkative lady, Mattie Brown wanted her independence. She needed help.
When Mattie Sue Brown said that sunlight "kindly blinds you," she referred to glare problems common to some cataracts. As the normally clear human lens becomes opaque and cataractous, patients experience vision difficulties in different ways. Less light reaches the back of the eye, so everything appears dimmer. "Turn up the lights" is a common request even when, to unaffected family members, room lights seem too bright already. The ability to discern contrast between an object and its background diminishes, making small bumps in a walkway invisible. Walking becomes more uncertain; golf balls disappear. Wrinkles disappear in the mirror, as do crumbs on the floor or dust on the furniture. When some patients finally get a clear view of their wrinkles for the first time in years, they jokingly wish for their cataracts back.
Some cataracts scatter light, producing glare. In this case, driving with the sun behind you is easy. But driving into the sun nearly blinds you. Headlights at night flare, making night driving particularly difficult.
Mattie Brown knew that the Calhoun Lions Club sold brooms and mops, donating the proceeds to Emory's eye bank. After a good experience with an Emory internist, she solicited his recommendation for an Emory ophthalmologist and, from the two names given her, chose Dwight Cavanagh. She had seen many eye doctors in her past, but Cavanagh particularly impressed her. She wanted the best for her eyes and willingly trekked back and forth between home and Emory. On every visit after the surgery, even though she was seeing poorly, Cavanagh would tell her she had a good eye and pat her shoulder as they walked to the side door. In her 1987 deposition, Brown's daughter Lois recalled the stock phrase Cavanagh would say to the family: "Take her home and keep her happy."
After looking at Mattie Brown's corneal button, seeing no sign of Fuchs' dystrophy and duly noting it in the chart, Dr. John Wright must have wondered how many more normal corneas he was going to see. He forwarded yet another Code 3 case to the General Pathology Department's tissue committee and wondered when he would get feedback from his previous cases.
***
Meanwhile, the eye department continued to grow. Dr. Doyle Stulting, who had diagnosed Gladys Wilson's retinal detachment when he was a fellow, joined the faculty, in part to relieve Dr. Cavanagh of some of his patient load.
The Atlanta community of ophthalmologists viewed Emory's growth with mixed feelings. We knew that an outstanding academic program helped the city and indeed the state. Yet new faculty members meant more competition for patients. As fellowships across the country pumped out graduates, more and more subspecialists came to Atlanta, some in individual practices, some to my group, Eye Consultants of Atlanta, at Piedmont Hospital. Our group collaborated with Emory on clinical studies while competing for referrals from individual general ophthalmologists. We spent considerable time discussing the threat Emory posed to us. Yet, while group-to-group interactions were occasionally strained, most of us remained friends on a personal level. My friendship with David Campbell grew; I attended most of the eye department's social occasions, including parties at Dwight Cavanagh's home. We had been friends at Johns Hopkins, and our wives regarded each other warmly. He and I rarely saw each other one-on-one, but we regarded our common Hopkins experience as a bond. The Cavanaghs lived distant from the Emory campus in the beautiful and exclusive Buckhead area, nearer Atlanta's leading private schools.
* * *
July 1982
Gladys Wilson, now dismissed by Dr. Kaplan, was back in Cavanagh's office. Her later deposition revealed the details. Wilson's eye was blind. Three retina operations had failed. Worse, the eye still hurt. Her husband had quit his part-time job to drive Gladys and her mother around and care for them. Now they had only retirement income to make ends meet.
Gladys recounted his words in her deposition: "Well, you know God did this to you. Your family must have a curse on it." He switched to the right eye, declaring that it had the same diseases as the left, cataract and Fuchs', and would soon need a triple.
Around this time, a surprising incident caught everyone's attention. The fire marshal was on the eye floor of the clinic. He had come at the order of the DeKalb county commissioner, Manuel Maloof. The husband of Cavanagh's main technologist, Mary Gemmill, tired of her complaints about the overcrowding, stress, and twelve-hour days, had tipped Maloof off about the crowding of the hallways.
Cavanagh came out of his office to find the DeKalb County fire marshal demanding to speak with him. One day earlier, the marshal's deputy had instructed Cavanagh to clear the hall of the extra chairs. Had a fire erupted, no one could have made it out through the maze and obstruction posed by the clutter. Cavanagh had shaken hands with the deputy, ignored his orders, and Ollie, Gemmill's husband, had called the county commissioner again.
This time the message was emphatic: "Clear the chairs within the hour or I will shut you down." The chairs disappeared, never to jam the halls again. Mary Gemmill's husband had hoped to reduce the volume of patients in Cavanagh's practice by denying them close places to sit, but he hoped in vain. The patients kept coming and had to pack themselves into even more crowded waiting rooms.
The incident amazed the entire faculty. The typical visit from the fire department was invisible, and a doctor's clinic day had never been threatened with cancellation before.
***
The fire-marshal story added to David Campbell's worry about Dwight Cavanagh's practice. Campbell was busy, very busy. He had built such a large practice that a second faculty member in glaucoma, Dr. Robert Allen, had just arrived. Yet the secretive visits from worried residents and fellows had continued, even escalating since 1980. The growing concern about Cavanagh remained Campbell's only source of discontent at Emory. Campbell was worried about Cavanagh himself, since he knew about a gastric ulcer that Cavanagh had developed, and about the patients. Dr. Campbell felt that he should try to work with Dr. Cavanagh personally and privately, so he made an appointment for a meeting.
David Campbell didn't know it, but he was not alone in hearing about problems in the department. Dr. George Waring also had become aware. Waring, the first cornea subspecialist recruited by Cavanagh, had joined the Emory eye department in 1979. A rising star himself in national ophthalmology, he had moved from Sacramento, despite warnings from mutual colleagues. The doctors in American cornea circles who knew both Cavanagh and Waring had predicted that the two would never last in the same department. Tall, adventurous, and athletic, Waring wore glasses almost as thick as Cavanagh's. He had settled into an office on the other side of the elevator from Cavanagh, but "settled" did not define Waring, with his numerous projects and frequent travels. When he was in residence, he usually had a phone glued to his ear.
Residents and fellows repeatedly complained to Dr. Waring that Dr. Cavanagh operated on eyes that seemed to have only mild signs of disease. They noticed other senior corneal physicians rejecting surgery on such eyes, feeling they would not need surgery for many years, if ever. So many comments came that Waring had concocted a stock answer. In a 1984 letter to Cavanagh, Waring revealed the words he used: One of the advantages of being at Emory is that we have a diverse faculty with different approaches to ophthalmic problems; this is part of the richness of the department. That's what he said, and that was it. Then he would change the subject. George Waring didn't convey his concern to Dwight Cavanagh, but he was paying attention.
***
August 1982
David Campbell found Cavanagh cleaning off the top of his expansive, six-foot-wide desk before leaving for his summer vacation. Visitors in Cavanagh's office sat either in a chair to the side, with no direct view of Cavanagh, or on a low sofa directly facing him. Photographs of Cavanagh with chairmen from other eye departments and bookshelves lined the walls.
The Cavanagh family spent August on the coast of South Carolina in their beach condominium on Hilton Head Island, and Campbell wanted to reach him before he left. The two had worked closely the last five years, and Campbell was sure he could sway his friend and chief.
Campbell later testified that he told Cavanagh that Cavanagh was far too busy and needed to slow down, needed to give something up. Cavanagh needed to pass patients to his cornea colleagues, to lighten his load, to get his ulcer healed.
But Cavanagh said he couldn't cut back. He could handle it. At Hopkins they learned to work hard. If he kept going, this would be a great department. The department would get a good ranking. Campbell needed to support him.
Cavanagh moved quickly on to fund-raising and then questions about Campbell's research, touching on anything and everything except the very subject Campbell wanted to pursue.
He went on and on, until he finally wished Campbell a great time on Cape Cod. Campbell watched Cavanagh head for his month off and wondered how long this could continue.
CHAPTER 3
COMING CRISIS
October 1982
Dr. Allen Gammon hated Cavanagh's clinic days. Every Tuesday and Wednesday he heard the patients complaining as they passed his office and disappeared into Cavanagh's, just next door.
Gammon had joined the Ophthalmology Department in April 1980. He was a pediatric ophthalmologist, trained in both pediatrics and ophthalmology after graduating from the University of Kansas medical school. All pediatric ophthalmologists train an extra year after their eye residency; Gammon had gone the extra years of a pediatric residency before his eye training. He had arranged that his pediatric fellowship would involve training in Washington, D.C., New York City, and London, assuring exposure to the top names in the field. He had passed the board examinations in both disciplines. Now well into his thirties, he had begun to show a few gray hairs amidst the black ones. He was intense and to the point. He gave no quarter in a dispute and would not rest until he had won. Call him the bulldog.
In a later Emory Ethics Committee investigation, Gammon recalled the problems he encountered early on. The cornea fellows would often ask Gammon to examine Cavanagh's pediatric patients so the young patients and families wouldn't have to wait the typical four to six hours. To Gammon's dismay, Cavanagh would keep the eyes of infants patched for weeks and weeks, robbing the brain and the eye of the opportunity to interact so that vision could develop. Gammon wondered why you would operate at all if you patched the eyes this long. Finally, he could take it no longer.
Gammon later testified that he made an appointment with Dwight Cavanagh. He told Dr. Cavanagh of the multiple complaints heard on each clinic day, how Gammon lightened the load by seeing some of Cavanagh's babies. Cavanagh needed to slow down.
Cavanagh told him that's how he developed a busy practice-he saw all comers. If he started turning patients away, he would start to lose it. They could wait.
Gammon kept at it. Waiting was just part of the problem. Keeping the babies patched so long kept them from developing vision. Cavanagh's staff was too stressed, no lunch, no break, and sometimes no dinner.
Cavanagh told him that he wanted support from Gammon, not criticism. Cavanagh was working hard and would continue to do so, and Gammon was to find a way to help.
Frustrated, Gammon knew he would keep seeing the babies, not for the chief but for the babies' sakes. He would find a way to fix the other problems, too. It might just take a while.
***
March 1983
President Jim Laney gave Dean James Glenn the news personally. Dr. Garland Herndon was too ill to continue as vice president of Health Affairs; Laney had no choice but to accept Herndon's resignation and relieve him of his duty. Laney had appointed two people as co-vice presidents-John Palms, the current vice president of the university, and Dr. Charles Hatcher.
Since Dr. Hatcher was more active in health affairs, Hatcher would become his boss. Dean Glenn had no intention of reporting to Dr. Hatcher or becoming subordinate to him in any way. He decided to resign. In his words, "You can quote me on this, money mattered more than anything in those days at Emory; more than quality, ethics, and honesty."
Glenn began looking for another job. A few months later, he became president of Mt. Sinai Medical Center at Mt. Sinai Hospital in New York City.
***
Dr. Alan Kozarsky had a problem. He had been a cornea fellow since July 1982, first working with Dr. George Waring and later with Dr. Cavanagh. Dr. Kozarsky saw that Dwight Cavanagh was altering patient records, so he took his concerns to George Waring. Dr. Kozarsky had observed that Cavanagh crossed out eye-pressure readings recorded on the chart by Dr. Kozarsky. Dr. Cavanagh wrote in lower numbers. High numbers mean glaucoma. A change to lower numbers makes it appear that glaucoma, a blinding disease, never existed. Kozarsky was fully trained. He and the experienced technicians knew how to measure pressure accurately. In some patients, Cavanagh wrote "FT normal." "FT" meant "finger tension," indicating that Cavanagh didn't use an instrument but would quickly touch the eye with his finger to estimate its degree of firmness, a method of pressure measurement that had been abandoned in ophthalmology decades earlier.
A second chart alteration involved vision measurement. Dr. Kozarsky worked with the patient to obtain a measurement of the vision, a difficult task with some of these patients. Cavanagh would strike through the vision recorded and substitute his own. Kozarsky noted that, if the patient was potentially facing surgery, Cavanagh would substitute a worse vision, thus making the patient appear more in need of surgery. If the patient had already had surgery, Cavanagh's substitution would indicate better vision, thus making his surgical result look better on paper. Dr. David Campbell later testified that Alan Kozarsky told him there were between 500 and 1000 such chart alterations.
In medical practice, the chart reigns. Many people enter data on charts, especially on hospital charts. Everyone assumes honesty holds and that the chart notes are accurate. From early in training, junior doctors hear, "Is the chart right? Is the chart right?" The question means, does the hospital chart accurately reflect all the lab values, the original condition of the patient, the progress of the patient, and the final disposition? Or does the office chart accurately reflect the history, vision, pressure, other measurements, and the doctor's thoughts on the patient's condition? Documentation is everything. If you didn't record it, you didn't do it.
Ideally chart entries are never changed. In the real world, people occasionally write the wrong thing and need to make alterations. The correct way to make a change is to line through the incorrect entry in a manner that allows a reader to see what had been written originally, albeit incorrectly. Then you initial and date your entry so a reader knows who made the change.
A good way to ruin a malpractice defense is to change the chart, to try to hide the truth. Opposing attorneys chew up the hapless person who makes these changes, and juries reward plaintiffs accordingly. Every malpractice seminar stresses the correct way to change a chart. If you change the chart in desperation, get out your wallet and settle the case.
When lawsuits occur, everyone scrutinizes the chart and makes decisions more on chart findings than on plaintiffs' complaints or defendants' explanations. Few doctors cheat, but those who do learn very early to keep good charts.
As a result of their meeting, Waring's awareness was building. Kozarsky kept watching.
***
May 1983
His creased brown fedora planted to his balding head, Sargus Houston shuffled down the long hall of Emory's fifth floor and sat in Mary Gemmill's exam chair. He shuffled because his seventy-four-year-old knees didn't work too well, not because he couldn't see. He had one good eye and one bad eye but got through his days pretty well. He was here to see the big doctor.
Mary Gemmill was Cavanagh's number-one technologist, responsible for working up Cavanagh's new patients. Rushed and harried as usual, she wrote in the chart, "Can't see out of OD very well, has had poor V OD for two years." This meant the right eye-Oculus Dexter (OD)-had poor vision (V) for two years. His ophthalmologist in Macon, Georgia, Dr. J.O. Martin, had referred Houston to Cavanagh.
Sargus Houston had lived a simple life. Born in middle Georgia to a poor African-American family, he had worked either construction or farming after leaving the army in the late 1940s. His army duties took him to Cherbourg, France, where he served in the 711 Medical Unit handling dead bodies. He hadn't known it, but this unit was known as the "Emory Unit." He did remember that most of the doctors were from Georgia.
He spent eleven years working construction in Ohio, where he married and fathered a daughter. Sargus Houston left Ohio alone, without divorcing his wife, and returned to Georgia. In the late 1960s, his mind "got bad," and he had several short admissions to Georgia's public mental hospital in Milledgeville. These problems cleared, but he never worked again, subsisting on disability payments and living with one sister or another in Macon. His nephew, Dophus Davidson, had driven him the ninety miles from Macon to a niece's house, and he had spent a week with her awaiting his visit with Cavanagh.
Why did he come if he could see pretty well? He came because his doctor told him to. When you were old, poor, and African-American in middle Georgia in the 1980s, you grew up in a culture that discouraged questioning your doctor.
Gemmill further noted that Houston's vision was 20/300 in the right eye and 20/25 in the left eye. Roughly speaking, visual acuity of 20/300 means that his right eye could see at twenty feet what a normal eye could see at 300 feet. Vision at this level constitutes legal blindness. 20/25, the vision of the left eye, is essentially normal.
Hat in hand, he moved with Cavanagh from the hall to the private office.
The patter began. Sargus was having trouble with that right eye. Dr. Martin had said it may need some fixing up. Houston readily acknowledged that the right eye had poor vision.
Cavanagh noted that he had "lattice dystrophy 8+ OD, ½+ OS, cat OD." Lattice dystrophy is one of several corneal diseases that produce visually disabling opacities. "Cat OD" is shorthand for the presence of a cataract of the right eye.
Cavanagh told Sargus Houston that he had a cataract and a bad cornea and needed surgery. Houston agreed. Dr. Martin, his Macon doctor, had told him he could trust Dr. Cavanagh, that he would do right by him. Houston had faith.
Cavanagh further wrote "Plan-PK+ECCE+PC IOL OD, elective," meaning he planned to do his triple. He walked Houston to the side office, where his secretary scheduled the surgery for September, the soonest date available.
***
June 1983
Every June, the eye faculty looked forward to their annual retreat. This year they would meet at Callaway Gardens. Only a ninety-minute drive from Atlanta, the facility provided a peaceful setting with activities for young families. The past few retreats had allowed the department to review its considerable accomplishments and plan for more. The department was cohesive and proud.
For David Campbell, however, doubts, worries, and anxieties had eroded his sense of well-being and pride. He had talked to Cavanagh, written a letter, and had seen no results, no lessening of patient volume. Dr. Campbell didn't know that Allen Gammon had spoken with Cavanagh; Campbell had his own worries and knew that rumors were beginning to circulate in the community. George Waring, aware of problems, did not talk with Cavanagh and, in a later letter, he frankly admitted being afraid of Dr. Cavanagh.
Why should Waring, or any of the faculty, be afraid? The eye department had all witnessed the retaliation Cavanagh attempted to visit upon Dr. Frank Bell, the third of the Three Musketeers, when he left the faculty to practice in town. In my interview with him, Frank Bell related that he had decided to practice at St. Josephs Hospital to develop a retinal practice complete with a surgical team. One day, as Bell was at the hospital checking on preparations for his arrival, he saw another Emory retinal surgeon leaving the hospital administrator's office. Bell learned that Dwight Cavanagh had sent this doctor to pursue setting up a retina service run by Emory, thus thwarting Bell's plans. Bell went to Charles Hatcher, and the idea was cancelled.
An academic chairman, like any boss, wields power. The chair awards salaries, academic rank, grant endorsements, secretarial and other support, lab space-in short, all the necessities in a teaching center. Dwight Cavanagh was already known as of one of the most powerful chairmen on the Emory campus. For whatever reasons, with the exception of Campbell and Gammon, each individual faculty member had been silent on the subject of Dwight Cavanagh's overextended practice.
But the Cavanagh problem festered in Campbell. He felt he could not keep his self-respect if he did not act, no matter the consequence. He and Cavanagh had remained friends in the early 1980s. Even though Campbell's warning in August had yielded no result, Campbell thought another, more public warning should not greatly strain their relationship.
In these times, my relationship with David Campbell had grown. I had continued to teach at the Emory glaucoma clinic at Grady every other week, attended the weekly grand rounds (teaching conference attended by faculty, residents, fellows and local ophthalmologists), and held a clinical appointment on the Emory faculty. Dr. Campbell and I consulted on difficult patients with each other and participated in clinical research studies together. Even though we were not at Grady together, our friendship had increased over the years.
About this time, I had called David Campbell about a patient, a seven-year-old child, whom Cavanagh had scheduled for corneal transplantation even though the eye was perfectly normal. This child was a patient of one of my partners in my practice group. My partner had referred the child to Dr. Cavanagh and had received the usual written report. Cavanagh's letter confirmed that the eye had recovered as expected from a self-limited condition. But Dr. Cavanagh had scheduled the child for a corneal transplant and, contrary to custom, had not reported this to my partner. When my partner accidentally heard about the scheduled surgery from the mother, he re-examined the child, found a normal cornea, and told the family to cancel the surgery. It would be unconscionable to put a child through such an unneeded operation.
Corneal transplantation in the early 1980s was a far-from-perfect operation. The suturing techniques caused large amounts of astigmatism, and many eyes never regained normal vision. Add to this the many postoperative visits, the need for prolonged eye-drop treatments, the lifelong risk of graft rejection, and you had an operation that should be done only when necessary, when a patient's vision was greatly reduced. This was especially true for children who were more difficult to follow after transplant surgery.
Several weeks before the retreat, Campbell invited Gammon into his office. Allen Gammon and David Campbell, very different in personalities and styles, had not been close. They respected each other professionally but had different friends and social lives. As Gammon sank into the chair, David Campbell launched right in, and they began to discuss the problems each of them had observed.
Gammon described a two-year-old child with a previously transplanted cornea, who had been operated on by Cavanagh. The child had reported back to Gammon with a corneal ulcer, an eye emergency and a sight-threatening condition without prompt treatment. Gammon arranged for a visit with Cavanagh and went about his business. A few weeks later, the child reappeared in Gammon's office. The eye was blind, and Cavanagh had never carried out any treatment. Gammon was greatly upset.
The two then discussed the rumors circulating amongst the fellows and residents about aggressive surgery and chart alterations. Gammon didn't tell David Campbell, but Gammon had decided to take his concerns to Charles Hatcher. David Campbell continued his plans to speak up at the retreat.
During the retreat, Dr. Campbell addressed his partners, now numbering at least ten, who were assembled in the meeting room. Their chairman was too busy-too busy on his clinic days and too busy in the operating room. Now the community was beginning to know about it and express concern. Their reputations were at stake.
As Campbell continued, everyone heard his concerns, including Dwight Cavanagh. As frequently happens in a public meeting, the culture of politeness prevailed. Campbell did not mention the specific, damning details, just his general concerns of long patient waits and the potential for mistakes. The message was delivered but in a diluted manner. Not surprisingly, no one else spoke a word, and nothing changed. The train kept going, seemingly still on the tracks.
***
June 1983
Genevieve Switz had been Cavanagh's physician assistant for three weeks. She had recently finished Emory's Physician Associate Program, graduating with a degree of Bachelor of Medical Science in December 1982. This was her first job after a lot of schooling, and she was anxious to do well.
Cavanagh had hired her to assist him with patient care. She was to perform admission histories and physicals and help with medical management and preoperative education on his patients. In addition, she assisted him at some of his surgery and helped with the postoperative care of his patients.
Switz had enjoyed the first few weeks of her new job, but she had noticed a practice pattern that puzzled her. She took her concern to Dr. Alan Kozarsky, still a cornea fellow, who would shortly complete his training and become a faculty member in the eye department. She had noted that African-American patients were all operated on at the end of the day. Was her observation accurate?
Kozarsky told her that it wasn't just the African-American patients; it was the poor white ones as well. That was the type of patient Cavanagh let fellows operate on while he assisted and taught them surgical technique.
But fellows only got to operate at the end of the day, so they just learned to put them last. Dr. Cavanagh had the last word on the schedule anyway, and he would put them at the end if the fellow didn't. They all wanted to operate, too, so that was how they got it done.
Switz had already seen that doctors in training, whether residents or fellows, wanted to do surgery themselves, and getting their own cases consumed them. Most patients who come to an academic medical center know that they will spend a certain amount of their time seeing students, residents, or fellows. Many fewer realize that these young doctors perform part and sometimes all of their procedures, both diagnostic and surgical, under supervision of the full-time faculty. In the case of Cavanagh's service, as Dr. Kozarsky would later testify, the custom was to put the "poor, unconnected" patients last, and the reward was that the fellow got the surgical experience. In Georgia in the 1980s this meant many of these patients were African-American, although the differentiation was economic, not racial.
Kozarsky's answer did not placate Switz. She began keeping copies of the daily surgical schedules, noting which patients were African-American and where in the rotation their surgery was performed. She kept these records at home. She also kept records and portions of the charts of patients with untoward outcomes. She could not know how important these records would become or the eventual cost to her for keeping them.
***
Late June 1983
Allen Gammon, frustrated by his unproductive meeting with Dr. Cavanagh a few months earlier, had taken his worries to Dr. Charles Hatcher. He and Dr. Hatcher had met right before the retreat, and Hatcher had listened intently, occasionally commenting. In his deposition, Gammon related that he told Hatcher about the infant's eye lost to the corneal ulcer. And Hatcher responded, "You win some and you lose some." Then Gammon had complained about the lack of support from Cavanagh, and Hatcher had responded, "That's an issue you have to fight on your own. I can't help you." Gammon had questioned Cavanagh's mental status as he had laid out his concerns.
Allen Gammon never dreamed how quickly the word would reach his chairman. Late one afternoon after the retreat, Dr. Gammon was discussing a mutual patient with Dwight Cavanagh. To Gammon's surprise, Cavanagh brought up the meeting with Hatcher. According to Gammon's later deposition, Dr. Cavanagh said that Gammon had made a big mistake, talking to Charlie Hatcher, criticizing his practice and even questioning Cavanagh's sanity. That was dumb, plain old dumb. Gammon had better hear this loud and clear: Cavanagh's support for him was finished.
Nothing that Gammon said could mollify Cavanagh. The fact that Gammon was the first ever to go above Cavanagh's head especially angered him. During the coming months he would face payback and the consequences of losing his chairman's support. As Hatcher had told him, he was on his own. But Gammon wasn't a quitter. Giving up was simply not in his nature.
***
July 1983
Dr. Philip Newman, Dwight Cavanagh's cornea fellow for the next three months, began learning the details of Cavanagh's service even before his starting date of July 1. Newman thought he knew something about Emory and being a fellow. He had already served a valuable year in Emory's research lab after completing a prestigious fellowship in medical diseases of the cornea in San Francisco. He blinked frequently behind thick glasses. His blinking, combined with a furrowed brow, gave him a bewildered look and caused some people to underestimate his abilities.
Newman discovered that Cavanagh, unlike the other cornea doctors, handled the assignment of corneal tissue to the transplant patients for the day himself. Corneal tissue comes from the Eye Bank, whose technicians "harvest" corneas from recently deceased patients. The younger the patient and the fresher the tissue, the better the recipient eye does. An important advance in corneal-transplant surgery was the invention of a solution that kept corneal tissue fresh for days. With that invention, corneal transplantation was changed from an emergency surgery performed at odd hours to a scheduled procedure during normal daily times. Still, the younger and fresher, the better, and the Eye Bank technicians graded tissue on appearance and other factors.
Some corneal surgeons took only the best tissue and would cancel surgery if a certain grade was unavailable. Others, including Cavanagh, would use all grades allowable, all but the clearly unusable tissue. After all, if tissue was below a certain grade, it could not be used. Switz would later testify that Cavanagh handled the grading issue by using the best first. Thus, all factors being equal, those receiving operations early in the day had the best statistical chance of retaining their grafts and seeing clearly. Switz remembered a day when Cavanagh moved a Coca-Cola executive from number six on the schedule to first.
Another unusual feature of Cavanagh's service involved chart dictation. Cavanagh insisted on dictating operative reports himself, a practice highly unusual in academic medicine. Almost every doctor who has a physician as an assistant assigns the task of dictation to the helper. Dictating takes time, and time becomes more precious the more senior the physician is. The fellows and Cavanagh's fellow faculty marveled at the sight of him hunched over the charts, not only dictating but also filling out billing slips. Many faculty have no clue about medical-practice finances; Cavanagh made sure every charge was entered correctly.
Dr. Newman had conferred with Switz, now the most experienced member of the Cavanagh team with all of five weeks behind her. She relayed what she had learned from Alan Kozarsky: Keep things moving; speed counts. Have the patients ready for surgery, all testing done, all clearances from internal medicine and anesthesia accomplished, no delays. Dr. Cavanagh handled the assignment of tissue and would rearrange the order of patients if Newman didn't get it right. Cavanagh dictated, but Newman would do the handwritten note in the chart. And he didn't like to see fellows mention complications in that written note, not even the big ones. Just do it his way. Again, speed counts. Dr. Cavanagh, no prima donna, had actually mopped the floor between cases himself to move things along. So don't slow things down.
***
August 1983
Dr. Bob Allen, David Campbell's new glaucoma partner, had never seen a patient this angry. He had just told this man, a Cavanagh patient referred to Allen for glaucoma evaluation, that his left eye was 70% blind. The patient was forty-three years old, an executive with Georgia Power, intense and compulsive about everything. Allen's stool moved farther and farther away as the words blistered him.
The man, unlike many of Cavanagh's patients, had picked up on things right away. He took in that the tests performed by Bob Allen had never been done before, that the diagnosis of glaucoma mentioned by Dr. Allen was a new one, that the discovery of significant vision loss was made today, not previously, despite years of appointments with Cavanagh. He was not happy. Why hadn't tests been done before? Treatment started? Treatment could have prevented permanent loss of his vision.
Allen sighed, sliding his stool to the desk, and picked up the chart. But he didn't need to look in the chart; he had seen too many of them already. It was always the same-high pressures measured by the technicians or residents crossed out by Cavanagh and lower pressures written in or the notation "FT soft," or "finger tension soft," meaning the eye's pressure felt normal when Cavanagh pressed his index finger on the eye. No mention of the optic nerve or the peripheral vision, no tests done, no treatment. No hint from the chart that anything was amiss. Yet these patients had lost vision frequently, a lot of vision. And they obviously had advanced glaucoma damage when Allen saw them, damage that took months or years to develop.
So what do you say to the patient? My chairman blew it; he missed your disease; sorry you're blind, but it's too late now. Instead of paying attention to the pressure recorded by his assistants and giving you some drops to keep you from going blind, he crossed out the numbers he didn't like, put his fingers on your eye, even though they quit doing that years and years ago, and wrote that the pressure was normal. So now your eye is blind and it didn't need to be. And I've seen so many like you already, I'm sick and half crazy. But, he couldn't express these thoughts to a patient.
So the story would go something like this: Mr. Wade, your eye pressure is high and you have some nerve damage. Part of your side vision is lost, but you have a good bit left. Glaucoma sometimes occurs after a corneal transplant, and it can be very sneaky and very tricky to detect in the early stages. Pressure fluctuates and can be up and down in the same day. But then it gets more obvious and can be diagnosed. And we do have treatment, usually eye drops, and drops are all most people need. There is also laser treatment and, as a last resort, surgery.
Allen couldn't tell the patient that he had gone to Cavanagh several times and written memos, begging Cavanagh to do more visual field testing and to send him the patients sooner, before damage occurred. Allen had even gotten Mary Gemmill, Cavanagh's main technologist, to go ahead and order testing based on her suspicions. He had done all he could do as junior faculty to remedy the situation. But the patients kept coming, and Cavanagh's neglect festered in Allen's conscience.
CHAPTER 4
THE OPERATION
September 1983
Sargus Houston felt fine, but his doctors didn't. They worried about him. Houston had entered the hospital on Sunday, September 11. The preoperative evaluation revealed that he had several medical problems. His blood pressure was too high and his blood potassium too low, making it dangerous in case he needed to be put to sleep. His blood count was low, and his heart had an irregular beat.
On Monday, the day of Houston's planned surgery, the anesthesiologist confronted Dr. Phil Newman between cases. He wanted to cancel Houston's surgery, postpone it while the medical team evaluated Houston further. It was their job to make sure patients lived through surgery, especially elective surgery. A few days' delay couldn't make much difference to Houston's sight, and surgery today could be dangerous.
Philip Newman felt stuck. He knew the right thing to do was cancel the case, but that would anger Cavanagh. They were doing thirteen cases that day, a huge caseload, but every case was crucial to the chief. Newman knew he couldn't make that decision; he had to check with the boss.
Dr. Cavanagh was not happy, but he devised a simple solution. They had good donor tissue; they weren't going to cancel. Call the case an emergency and move it to the last of the day. That would give them hours to fix his medical condition. If a case is an emergency, there is more leeway to operate on a marginally stable patient.
The day progressed uneventfully until after the twelfth case, when Charles Hatcher summoned Cavanagh to an emergency meeting. Dressed in scrub clothes, hat on with mask dangling, Cavanagh leaned forward at an especially acute angle as he sped into Hatcher's office.
What was going on? Dr. Cavanagh had done twelve cases that day and wasn't through. The operating room was waiting. Everyone wanted to go home. As Hatcher began, Cavanagh slumped in his chair, stunned. Hatcher wanted Cavanagh to fire Robert Wayne (pseudonym), Cavanagh's chief fund-raiser. Wayne had to go.
Cavanagh tried to take in this news. It was a bombshell. Robert Wayne was his mainstay for raising money. The new eye center was well on its way, and Cavanagh had almost reached the goal of raising $10 million dollars (equivalent to $22 million in 2008). Now they wanted to take away the man Cavanagh relied on to make it happen. After arguing and discussing with Hatcher, Cavanagh realized he had lost this round. His reaction, as he later related, was, "Now, without Mr. Wayne, no money; without money, no department."
Cavanagh sped back to the OR. He replaced his shoe covers, hat, and mask, and after scrubbing his hands and arms, he sat at the head of the bed, the anesthesiologist to his right. He always had the anesthesiologist sitting by the eye to be operated on. Thus the fellow could position himself on the other side, and Cavanagh would have plenty of room to work.
The physician's assistant entered the room. "Genevieve, block that eye," commanded Cavanagh as soon as he saw her. Still upset over his new financial problem, he motioned to the left eye. Switz, now a veteran of several months, later testified that she had learned never to cross or question Cavanagh. She, like the fellows and residents, had experienced his quiet but withering disapproval following any departure from his instructions.
She testified that she wanted to follow her routine and check the operative permit one last time, but he motioned to the left eye again. "Come on. Let's go." Assuming the surgeon knew his business, she complied.
A few minutes later, Dr. Newman entered the room, noted that Cavanagh was operating on the left eye despite the room's arrangement for a right-eye operation, and, despite some discomfort, began his part of the operation. Newman later testified that he wondered if the correct eye was being operated on, but it was late, he was tired, and he assumed that Dr. Cavanagh was correct and that he, Newman, was wrong. He flipped over the cornea and punched out the donor button, only mumbling as Cavanagh complained about the poor dilation of the left eye. "Why isn't the damn pupil dilated?"
As Cavanagh turned over the last part of the case to Dr. Newman, he told his fellow to partially sew the lids together as well. Protecting the surface of a fresh corneal graft is vital to long-term success, and some eyes need the extra step of partial lid closure. Cavanagh did more lid surgery than most corneal surgeons, and he always dictated a separate op note. Newman complied, despite the fact that the chart said nothing about a lid problem and that Cavanagh's initial plan was to operate only on the right eye, not the lids. Cavanagh retreated to the surgeons' lounge to dictate the day's thirteen cases.
Phil Newman finished the lids on Sargus Houston at 7:00 PM, about the time Cavanagh completed his dictation. The evening nurse came to Dr. Newman, puzzled. She didn't do many eye cases and wanted to know the difference between "OD" and "OS," the abbreviations of the Latin for "right eye" and "left eye." She had noted that the operating schedule was for Houston's "OD"-his right eye-but they had all written "OS" (left eye) in writing up the actual surgery.
Dr. Newman blanched, reading and rereading the chart and the schedule. He sat down, staring at the chart, desperate to find some explanation. After a few minutes, he couldn't deny it. The nurse was correct. Houston had been scheduled for his OD, the right eye, but they had operated on the OS, the left eye, the good eye, the eye with minimal corneal disease and a vision of 20/25. They had committed the ultimate surgical blunder, operating on the wrong organ.
Newman panicked and ran to Switz. An explosion of emotion filled the room. Fear permeated everything-fear of telling Cavanagh, fear of being blamed.
Switz would later testify that she called her husband at home and told him, "It finally happened," referring to previous conversations with him where she had predicted, "Things were so rushed and hectic that it wasn't inconceivable that such a thing would happen."
Philip Newman knew he was one of those mechanisms. His eyes were blinking so fast it was amazing he could see. He and Switz were concerned about themselves and their careers at this point also. What do they do now? Who would tell Dr. Cavanagh? Who would tell the patient, and what would they say to him?
Switz shot right back. He and Dr. Cavanagh were the doctors. Newman had better let anesthesia know and one of them let Cavanagh know. Then decide who tells the patient.
As she was instructing Newman, she noted that he was changing the hospital chart, crossing out "right eye" and inserting "left eye." She asked him what he was doing. Newman looked up, still blinking. He was getting the chart right. Switz told him to stop. The page Newman was working on already had another doctor's note on it, not to mention that changing a chart in this way defied all malpractice seminars and was illegal.
Newman stopped and then reversed himself. He identified all the changes he made in the correct manner so that anyone reviewing the chart could see his changes. He did make necessary changes, those that told the nurses to put the postoperative drops in the correct eye. Newman also wrote a reminder that the unpatched eye had very poor vision and that Houston would need more help in getting around than the typical patient.
Next came the hard job, something he dreaded in the worst way. The anesthesiologist refused to go first. After a few moments to summon his courage, Newman went looking for Cavanagh. It was his job to tell the surgeon.
Newman found Cavanagh in the lounge. He thrust the chart into Cavanagh's hands, said "We need to operate on the other eye as soon as possible," turned, and fled into the dressing room.
Minutes later, the anesthesiologist confronted a mystified Cavanagh.
"Dwight," he said, "we have a problem, a big problem. You operated on the left eye. His good eye. You were supposed to do the right."
Dwight Cavanagh would relate the following to one of the committees investigating this incident:
There are about eighteen things in an operating room that makes that [operating on the wrong eye] not happen. One, you come in, the nurse asks you which eye you are there for. The second thing, if the block [local anesthetic] occurs in the [operating] room, which it sometimes does, or if it occurs in the waiting area, the nurse, Anesthesia, and everyone always asks the patient which eye you are there for.
Bear in mind, this man is awake. It's local. And bear in mind the nurse came in and the one who started the case stopped and left and then another one came in and picked up and she didn't know. The P.A. and Anesthesia stood there without looking at the chart. I mean, it's my responsibility not to have picked it up, but I would say that every fail-safe mechanism in an operating room that exists failed.
Cavanagh's deposition testimony related the following, after Phil Newman returned to the room:
And I turned to Dr. Newman, and I said, "What in the world happened?"
And he said, "At that time, I thought we were in the wrong place [wrong eye]."
And I said, "Why in the world didn't you tell me that you thought we were in the wrong place?"
And he said, "Well, I wasn't completely sure," or words to that effect...
Well, my response to that [was] I was fairly upset. I didn't berate anyone or, you know, I have the attitude that the person in charge bears the responsibility. And I was in charge and it was my responsibility. And at that point in time, an error having been committed, it didn't do any good to start blaming people. That's not my style.
As both Dr. Newman and Switz would later testify, he reassured them that he would handle things, that the main job was to take care of the patient, keep his eye in good shape. He made sure they knew to keep this quiet. Word would get out, but the less said by them the better.
The next morning Ms. Switz and Dr. Newman met on the eye floor of Emory University Hospital, floor 6D, to make rounds on the patients. Not a single nurse or assistant said anything about Houston. They could see the word was out: no talking about this.
After cleaning Sargus Houston's eye, Dr. Newman told him that they "had decided" to operate on his left eye instead of his right one. Houston had no questions; he trusted them.
As soon as they left Houston, Switz turned on Newman. She didn't like what she had heard. Dr. Newman, as she would later testify, told her that Dr. Cavanagh had called him at home the night before, had told Newman what to say, had given him specific instructions: "Tell him we decided to operate on the left eye." Dr. Newman was following orders and, in his later testimony, he confirmed Cavanagh had told him just what to say to Sargus Houston.
After all, Houston was Cavanagh's patient, not theirs. During this argument, they looked at the two charts, the hospital chart and Cavanagh's clinic chart. Switz remembered that Houston's left eye was healthy, making Dr. Newman's statement to the patient about needing to do the left eye even more troubling. She had looked at this man's chart yesterday. There was no mention of anything significantly wrong with that left eye.
After looking at both charts, she looked even harder at Newman. She thought they had agreed not to change the chart. Newman nodded his agreement. She showed him a note added to the hospital chart, which said "Cat OS, rough surface, consider canthoplasty."
She then looked at Houston's clinic chart, in which the diagnosis was changed from "Cat OD" to "Cat OS," with "OD" obliterated, not lined through, and "OS" substituted.
When Cavanagh finished his clinic chart for a surgical patient, it was copied twice. The original stayed in Cavanagh's office, one copy went to the hospital, and the second went to pathology. Someone in addition to Newman had made changes in each of the hospital and clinic charts, but different changes had been made in each one, and they were different from those Dr. Newman had made and reversed the night before. That mystery person had neglected to make them jibe with the corresponding copies. Dr. Newman and Genevieve Switz looked at each other, and Switz spoke first. She didn't like anything about this. Nothing good could come from this, and pretty soon the blame would be spread around.
Switz and Newman knew who was low on the totem pole at Emory and who might one day be blamed, despite Cavanagh's reassurances. They both made copies of the hospital and clinic charts, each of which had the alterations made by someone other than them, and took the copies home with them to store in safe places.
Switz took another step. She testified that, "I objected privately to Newman, to Dr. Newman, and I decided not to-you know, I decided to avoid the patient and family so as not to have to answer any questions. And I decided that I needed to consult an attorney...because I didn't have the impression that what was happening represented the facts, and I didn't want to be a party to dishonesty."
Dr. Dwight Cavanagh told the story in the following way. He said that, on the night of the surgery, he called Houston's sister in Macon, Carrie M. Davison:
I told her that Mr. Houston's-I told her we had a problem. I reassured her and I said, "I think Mr. Houston's eye is going to be all right. However, we didn't operate on the eye we intended to."
I told her the same thing that I later told him [Sargus Houston], that I thought this would be all right. That there was no complication during his surgery, but that I was concerned about his general medical health and condition, that there were serious health questions on the horizon, that we were perhaps fortunate enough to have been able to do the surgery.... I also told her it was not our custom to operate on the better of the two eyes because when we operated on the better of two eyes, when one had a complication, a hemorrhage or infection, that one would, obviously, one didn't want to have that in the better eye.
When Carrie Mae Davison gave her testimony regarding the phone notification from Dr. Cavanagh, she said, "He called me. He didn't tell me what he was calling for. He told me that the operation went well and he-Sargus-was back in the room."
When asked if Cavanagh told her they had operated on the left eye instead of the right, she stated, "He didn't say anything about [the] eye. He said the operation went well. He didn't tell me nothing about no eye."
And Sargus Houston, when asked by the attorney, testified to the following:
Q: Do you remember talking to a doctor that night, September the 12th, the night of your surgery, about the wrong eye having been operated on?
A: I don't know whether it was that night or not, but he told me they operated on the wrong eye.... He said they wouldn't let him operate on the other one.
Q: Do you know who said that?
A: No. One of the doctors.
Q: When is the first time after your surgery that you remember talking to Dr. Cavanagh?
Q: When I told him that he operated on the wrong eye.
Q: That was Dr. Cavanagh you told that to.
A: That's who I remember it to be.
Q: Dr. Cavanagh was the first doctor you told that they had operated on the wrong eye.
A: Yes, sir. I took it to be him.
Q: You took it to be him?
A: Yes, sir.
Q: And it was Dr. Cavanagh that told you they wouldn't let him operate on the other eye.
A: Yes, sir.
Sargus Houston, with a patched left eye, now viewed the world through a blurred right eye.
The news of Cavanagh's blunder ripped through the department, into every office, every lab, every examining room. By noon the day after, everyone knew, but no one talked publicly. Whispers ghosted behind closed doors, penetrating everywhere. The news was too juicy, too unprecedented, and too sensational to be kept from everyone's ears.
David Campbell had a hard time believing it. Since his plea at the previous summer's retreat for Cavanagh to slow down-a plea totally ignored by Cavanagh both at the meeting and later-several of the faculty had been distinctly cool to Campbell.
Three camps were slowly emerging in the eye department. The first camp, which Campbell later called the "club," was made up of Cavanagh and the two retinal surgeons-Henry Kaplan and Travis Meredith-both of whom supported Cavanagh unequivocally and unreservedly. The second camp agreed with Campbell, privately and publicly. Allen Gammon and Campbell comprised this camp. The third, the other seven, agreed with Campbell in private but feared Cavanagh's wrath and kept quiet in public.
Travis Meredith met up with Campbell in the hall to see if Campbell had heard the news. Dr. Meredith, the more junior of the retinal specialists, had arrived at Emory in 1979. He and Cavanagh had begun their residency at Johns Hopkins together, but military service had intervened for Meredith, and he fell two years behind. Tall, about 6'2", with closely cut black hair and erect posture, Meredith had kept the military appearance. He also kept a military attitude and respected his chief.
Campbell motioned Dr. Meredith into his office, asking if this meant that Cavanagh would have to go. Meredith said certainly not, not until they had heard all the facts, all sides of the story, and most important, heard what Cavanagh had to say. The two half discussed and half argued about the next steps. The positions taken would change slightly over the coming months, but only slightly.
Meredith's position: Dwight's the chairman. He needs and deserves our support. He is putting us on the map, creating a great department. Give him a chance. Support him.
Campbell's counter: Dwight's too busy and won't slow down, no matter what they say or how they try. He won't listen. This disaster was predictable. His poor reputation in town affects all of us in the department, and it won't be long before it spreads outside Atlanta. Campbell could support Dwight only if he made drastic changes in the way he practiced.
Finally, they arrived at a plan. At the upcoming faculty meeting, Dr. Campbell would move for a faculty investigation. Travis Meredith would second and support it. Dr. Cavanagh wouldn't like it, but David Campbell would stand by the results of the faculty study.
***
Sargus Houston stayed in the hospital for eleven days, far longer than needed to recover from eye surgery. Houston's niece in Atlanta, Dorothy Fuller, visited him almost daily. When she first saw him, she exclaimed over the bandage on the left eye and wondered why they did the left eye.
Houston didn't know, only that they had "decided" to do it. He assured his niece that Cavanagh was optimistic and happy with the progress of the left eye.
***
The eye faculty met three days after Houston's surgery. They wondered how Dr. Cavanagh would handle the discussion. Cavanagh meandered through the prepared agenda and said nothing about Sargus Houston until Gammon prodded him. After a sharp exchange, Cavanagh discussed the evening of Houston's surgery.
Cavanagh noted that all measures usually taken to avoid disaster had failed. He was let down at every step along the way. It was 6:00, and there was a new team of nurses and techs. They all knew how it was with the evening shift. These nurses knew nothing about eyes. It would have been nice if the fellow, Dr. Newman, had everything properly arranged so that when he walked into the room the correct eye was ready. And Newman had caused him other kinds of trouble. And he wasn't happy with Genevieve Switz either; it was her job to check the operative permit. It was a terrible day in other ways. But the surgeon was captain of the ship, so he had to take responsibility.
Cavanagh continued on, in theory accepting responsibility but, in fact, blaming others who he felt had let him down. Finally, David Campbell spoke up and moved that a committee investigate the whole issue-how it happened and how something like this could be prevented in the future.
The room was silent. No one moved. David Campbell, expecting the agreed-upon second, eyed Travis Meredith, who was looking toward Cavanagh, avoiding Campbell's gaze.
After another moment, Dr. Allen Gammon seconded the motion. Travis Meredith objected. He wanted support for the chairman, not a potentially divisive investigation.
Cavanagh, losing control of the meeting, appointed George Waring chairman of a quality-review committee.
Campbell had another question: was Cavanagh going to charge the patient for the surgery? Yes, the patient, or more accurately, Medicare, would be charged. Cavanagh had talked to the clinic's attorney, Hunter Allen, and he had advised charging. He had also strongly advised that no one talk about this case. The potential for publicity and lawsuits was real. Everyone was to keep quiet.
David Campbell was not mollified. He felt the patient should not be charged and wanted to know other details. Travis Meredith pointed out that patients are charged for heart surgery even if they die. Cavanagh, instead of answering, adjourned the meeting.
***
As George Waring headed home, he pondered Cavanagh's choosing him to be chairman of the quality-review committee, a dubious honor, especially since Dr. Waring was already overburdened with tasks. Waring and Cavanagh were cordial colleagues but not close socially or personally. Perhaps the reason was the joke Waring had played on Cavanagh when Waring was to be introduced to the ophthalmologists of Georgia. In my interview with him, Waring recounted how he had a friend place a call pretending to be an Atlanta police detective, telling Cavanagh that Waring had been arrested. After a number of frantic and frustrating phone calls to police headquarters by Cavanagh, Waring appeared at his door, infuriating his chairman. Perhaps it was the stripper dressed as a gorilla in the clinic on Waring's fortieth birthday, a gorilla that chased a terrified Cavanagh into his office. Whatever the reason, they were not close.
In my interview, Waring's thoughts hearkened back a few years to one of the few occasions he and Cavanagh had spent time together alone. They were sitting on the porch of Cavanagh's beautiful home, smoking cigars and talking. Between puffs, Cavanagh said, "George, I am the most powerful ophthalmologist in the country" and listed the reasons. He was chairman of the National Eye Institute Council, which made final decisions about research grants to academic ophthalmologists across the country. He was secretary-treasurer of ARVO, the Association for Research in Vision and Ophthalmology, the premier research organization in ophthalmology. He had a leadership position in the American Academy of Ophthalmology. And the Emory Eye Center, one of the few such centers in the country at that time, was well on the way to completion, with all the necessary funds raised.
Now, with this new committee assignment, Dr. Waring was under the gun. Perhaps Cavanagh thought he could control him, especially since Cavanagh had persuaded Emory University to defend Waring in a lawsuit that was still under way. Waring and others had been sued over a restraint-of-trade issue involving a new type of eye surgery, radial keratotomy. He remembered telling himself that night on his way home, "Look out."
***
As Dr. Bob Allen, the second glaucoma specialist, left the faculty meeting, he ran into Phil Newman. Ignoring Cavanagh's warning, he pulled Dr. Newman into his office. He told Newman a few details of the faculty meeting, most importantly that Cavanagh had implied that Phil Newman had started the operation.
Newman recoiled in horror. No, no. He wasn't even in the operating room when the case started. When he came in, Cavanagh was already cutting out the button. Newman figured that Cavanagh had somehow changed his mind without letting Newman know, so Newman just set about doing his part of the surgery.
Newman wanted to know exactly what Cavanagh had said, but Bob Allen couldn't recall each word. Dr. Allen just knew the clear implication: Newman was to blame.
Newman trembled all the way to the parking lot. He barely found his car. Genevieve Switz was right. Cavanagh would shovel blame all around. And as the cliché goes, the bad stuff flows downhill. Newman was at the bottom of the hill, the lowest doctor around.
, published in 1951, has long been a staple of college and, later, high school literature courses. The scandalous teen angst of main character Holden Caulfield electrified generations of teen readers adrift in a world of grown ups who did not understand them.
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