Editor’s Note: Before Parkland Memorial Hospital came under national scrutiny, before it was one of the largest hospitals ever put on probation by the Centers for Medicare and Medicaid Services, it recruited Larry Gentilello, M.D., to be the distinguished chair in surgery for trauma and critical care. This decision would irrevocably change the hospital’s standing and the course of Gentilello’s career.

In 2002, Gentilello was a world-renowned trauma surgeon and academic at Harvard Medical School and its teaching hospital, Beth Israel Deaconess Medical Center. In 2003, he left that post for a prestigious chairmanship and tenured position at UT Southwestern and a surgical appointment at Parkland.

It’s a long fall from the top, and Gentilello has taken quite a tumble. Demoted at UTSW and barred from operating at Parkland in 2008, Gentilello now works at a low-level private hospital in Northern California. Although he's been quoted as a corroborating source in a number of articles, this is the first time Gentilello is speaking publicly about his journey from the height of academic medicine to virtual obscurity after filing a slew of lawsuits against his former employer.

A spokesman for UTSW declined to be interviewed for this series, citing a policy against discussing pending litigation. However, the medical school’s voice is represented through internal documents, sworn statements and depositions obtained by CultureMap.

Chief among his complaints, Gentilello alleges UTSW committed billing fraud and endangered patients’ lives by failing to properly supervise residents in the emergency room at Parkland.

In state whistleblower litigation that went before the Texas Supreme Court on September 12, Gentilello claims UTSW retaliated against him for reporting the alleged fraud. UTSW is trying to get the case thrown out on the grounds that Gentilello had a legal burden to contact law enforcement, not his supervisor at UTSW. The case is still pending.

The federal whistleblower lawsuit was dismissed in August on legal grounds before ever going to trial. The billing fraud lawsuit, filed in July 2007 and sealed until September 2011, was settled for $1.4 million last year. For a billing fraud lawsuit, $1.4 million is rather paltry. Similar suits at other institutions have drawn upward of $30 million.

Although the monetary damage is minimal, Parkland’s standing has suffered greatly as numerous state and federal agencies have found fault with the storied medical center. In August, Parkland reached an unprecedented $1 million settlement with the Department of State Health Services for patient safety claims. The largest hospital fine previously levied by the entity was $50,000.

Parkland is in the midst of a stringent improvement agreement with the Centers for Medicare and Medicaid Services. If it fails to meet standards, the hospital could lose significant funding in April 2013 and effectively be forced to shut down. All of this can be traced back to one man: Dr. Larry Gentilello.

This is the third installment in a four-part series on the rise and fall of Larry Gentilello. Read the full series.

---

Peeking behind the curtain
It didn’t take long for Larry Gentilello to discover Parkland’s penchant for lax resident supervision. In fact, it took no time at all.

In 2003, on his first day in the operating room, Gentilello says he came face to face with Parkland’s policy of “See one, do one, teach one.” It has a nice ring to it, but according to Physicians at Teaching Hospital Laws, unattended surgery that’s billed to Medicare or Medicaid is illegal.

“I was expected to stand behind the residents, or go to the lounge, or back to the office. Do whatever,” he says. “It was amazing that the residents had that authority.”

Although it was nine years ago, Gentilello remembers the case vividly. A woman in her mid-’30s had been in a car crash with her two children. “Based on her condition, it was obvious that she was bleeding internally, massively,” he says.

The woman was taken into the operating room immediately — so quickly, in fact, that Gentilello was left in the dust. When he arrived, the patient was already on the table, and residents were blocking Gentilello’s path. He pushed his way down to get to the patient.

“This one ended up in death, even with me being there, trying to save her life,” Gentilello says. “How could I be expected not to participate, knowing that the most likely outcome in that situation was death? A young mother was going to leave two children to fend for themselves.”

Residents, no matter how experienced, can’t perform surgery that will be billed to Medicare or Medicaid without supervision from an attending doctor. As Gentilello learned at the University of Washington, violating this law can have serious consequences.

Other doctors voice concerns
Soon after joining Parkland, Gentilello began assembling his staff. Although he didn’t plan it, several of his hires had previously been at universities investigated or fined for billing fraud.

His chief of critical care, Heidi Frankel, came from Yale. Raminder Nirula, who was in charge of a new department called emergency critical care surgery, had been at the University of Wisconsin. And chief of trauma Shahid Shafi, who was in place before Gentilello arrived, hailed from the University of Pennsylvania, where the first major fine was levied in the ’90s.

Drs. Nirula and Shafi were vocally opposed to the state of resident supervision. In a 2008 sworn statement related to the whistleblower case, Nirula said patients at Parkland were routinely taken to the operating room without the attending doctor’s knowledge, and the residents thought it was unusual for him to scrub in for a surgery.

Shafi voiced similar complaints in his deposition taken the same year. He said that many times, residents would put a patient to sleep and begin surgery without notifying him.

“The residents at Parkland were far more autonomous than anywhere that I had trained and worked,” Shafi said, adding that it was part of the Parkland culture to let the residents “run the show.”

Gentilello took all of the concerns from his staff, as well as his own misgivings about resident supervision, to heart.

“Everybody was concerned that things needed to change, and they looked to me as the chairman to get it done,” Gentilello says.

But, as a newcomer to Parkland, Gentilello recognized he didn’t have much clout.

“In order to transform an institution that has such an ingrained and particular way of doing things, I knew that I had to first have some sort of credibility and to build up my reputation,” Gentilello says.

Nose to the grindstone
From 2004 to 2006, Gentilello focused on improving the trauma department by publishing papers and getting grants. In his first review from then-chairman of surgery Bob Rege, Gentilello was praised for his “pertinent observations” and “suggested changes, which would improve care and training,” as well as developing a plan to institute changes.

“We expect [Gentilello] to have a very positive influence on clinical programs, research and teaching in that division,” Rege wrote in an evaluation dated February 19, 2004.

During the next few years, Shafi said that Gentilello developed a reputation for “raising Parkland’s trauma unit from the dead.”

Gentilello continued to grow in esteem locally and nationally, and although his concerns about resident supervision created discord among faculty members and residents, Gentilello earned the second highest possible rating (very good) in his 2006 performance review.

With a good reputation firmly intact, Gentilello set out to right the ship. When Gentilello informed Rege that procedures at Parkland’s emergency room were eerily similar to those that led to a $35 million fine at the University of Washington, Gentilello says Rege was nonplussed.

“I was pretty much told, ‘This is the way we’ve always done it. We’ve been investigated before, and we’ve always passed,’” Gentilello recalls.

In a sworn deposition from May 2008, Rege denied that Gentilello had ever broached the subject of the University of Washington’s fines, let alone made a comparison to the billing practices at Parkland.

“If he brought up a complaint like that, I would have looked into it in depth through my billing office,” Rege said. “I would have asked him for specific examples. I do not believe that conversation could occur without a response.”

Gentilello’s no-nonsense approach to operating room procedures didn’t win him many friends, and his clashes with residents are well-documented in his performance evaluations.

As the distinguished chair, Gentilello felt the residents should defer to him, not the other way around. Nirula and Shafi testified that the residents were given huge latitude in the operating room and frequently made judgment calls without consulting the attending surgeon.

In an attempt to curb this autonomy, Gentilello held regular meetings with residents and surgeons on the topic of “New Trends in Critical Care.” But they were far from fruitful conversations.

In his performance reviews from 2007, Rege cited Gentilello’s inability to get along with his colleagues and subordinates.

“He is so focused he does not make an effort to understand others’ points of view,” Rege wrote. “He has developed conflicts with Parkland administration, neurological service, members of his own division and general surgery residents.”

Gentilello doesn’t deny having a strained relationship with administration and residents. The cause, however, is up for debate.

Gentilello maintains the tension was because of his dedication to following the law — and Parkland’s resistance to it. Parkland officials blame the conflict on Gentilello’s poor communication and management skills. One thing is certain, after Gentilello filed a lawsuit against Parkland alleging Medicare and Medicaid fraud, the relationship took a turn for the worse.