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

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The beginning of the end
It had been one hell of a night in Parkland Memorial Hospital’s emergency room when Dr. Larry Gentilello finally took off his operating gown. A resident had badly botched a gall bladder surgery, and Gentilello was furious.

He headed to see his next patient, a man who had fallen off a roof. According to Gentilello, a resident read the CT scan and reported that the man had a bruise on his colon. But Gentilello was experienced enough to know that you can’t bruise an internal organ without having a bruise on the external part of the body. He ordered a scope to be placed in the patient’s abdomen.

“We saw something most doctors will never see,” Gentilello says.

The man had a tumor called pseudomyxoma peritonei — a condition so unusual that it’s listed in the National Institutes of Health Rare Tumor Index.

The patient’s abdomen was full of mucus, and Gentilello was guiding a junior resident through the procedure to remove it. But the chief resident kept putting his hands on top of the young doctor’s.

Gentilello asked the chief resident if he’d ever worked on a patient with pseudomyxoma peritonei. The resident said he’d done it a dozen times, which Gentilello doubted given the tumor’s rarity.

“It was an outright lie,” Gentilello says.

After successfully finishing the surgery, Gentilello stormed over to the office of surgery department chairman Bob Rege. As he had done so many times before, Gentilello explained his frustrations with residents’ behavior. Rege suggested that Gentilello should have better explained his point of view to the residents.

“I don’t have to gain permission to participate in surgery of my own patients,” Gentilello recalls he said angrily.

Unbeknownst to Gentilello, his behavior — not that of the residents — was under close scrutiny. A few days later, on March 6, 2007, Rege called Gentilello into his office and handed him a post-dated letter stripping him of his chairmanship. Despite doubling the size of the trauma center fellowship, gaining grants and publishing an unprecedented volume of papers in peer-reviewed journals, Gentilello was being demoted.

“The way burn, trauma and critical care was going was a model for research, recruitment and faculty development,” Gentilello says. “People were high-fiving, but when it came to straightening out patient care, that was not going to give.”

Life in exile
Although he was no longer a distinguished chair, Gentilello was still a tenured faculty member and attending surgeon. From that post, he continued to push for more resident supervision and implemented a policy that no patient would go into the operating room without his knowledge.

His dedication did not go unnoticed by his peers. Dr. Raminder Nirula, who worked under Gentilello in the trauma division, praised his boss in a 2008 sworn statement related to the whistleblower case.

“Dr. Gentilello is one of the strongest patient advocates I've ever met,” Nirula said.

As it became increasingly clear that changes in resident supervision were not going to be made, Gentilello contacted Dallas attorney Charla Aldous.

“I figured I couldn’t get them any more mad than they already were, so I’d just do the right thing anyway,” Gentilello says.

In June 2007, Gentilello filed a lawsuit on behalf of the federal government alleging Medicare and Medicaid billing fraud. He also filed a whistleblower lawsuit to be reinstated as the distinguished chair.

His action led to the federal government joining the billing fraud lawsuit, which was settled for $1.4 million in 2011. Parkland and UT Southwestern have denied any wrongdoing and have fought to get the whistleblower cases thrown out on legal grounds. The federal whistleblower case was dismissed before ever going to trial. The state whistleblower case went before the Texas Supreme Court on September 12, and a ruling is pending.

If Gentilello is successful, his case will be cleared to go before a jury. His ultimate goal is to get his job back, although he’s never been let go officially.

“I’m fully credentialed, and I’ve never had a peer review sanction or any other problem. I just don’t come out on the call schedule, for years,” says Gentilello, who is still listed on the UTSW faculty website. “In theory, they could put me on the schedule tomorrow.”

In a 2008 sworn deposition related to the whistleblower case, Rege defended stripping Gentilello of his chairmanship.

“I demoted him because of problems with interpersonal relationships, and some of those problems with interpersonal relationships were based around disagreements about involvement in cases,” Rege said.

Drs. Shahid Shafi and Raminder Nirula, who served under Gentilello in the trauma division, disagreed with that assessment.

Although Nirula did not respond to requests to be interviewed for this article, he spoke with Dallas Morning News in 2010 about the lack of resident supervision and gave a sworn statement related to the whistleblower case in 2008.

In a 2008 deposition, Shafi described Gentilello as a consensus builder who was supportive and receptive to his colleagues. Nirula also had great confidence in Gentilello as the chairman.

“I thought that he was a very strong leader with an excellent vision and the capacity to achieve the goals that he had set out,” Nirula said in his sworn statement.

A handful of former Parkland surgeons and UTSW professors who worked under Gentilello reached out to him after the federal whistleblower case was dismissed in August and offered their support and sympathy. CultureMap granted a request for anonymity from the group but has confirmed all worked with Gentilello in the division of trauma during the period in question.

Gentilello was demoted in the spring of 2007. But he continued to teach and operate at Parkland and UT Southwestern until the next summer, when he was taken off the trauma call schedule after an alleged case of “grave concern” in the ER.

After filing lawsuits against his employer, Gentilello felt like he had a target on his back every day.

“It was very nerve-wracking, because you do make mistakes in medicine, despite your best efforts,” he says. “They were really gunning for me, but I was never caught in a mistake. Meanwhile, I saw some real mistakes that I reported, and nothing would get done.”

Barred from the operating room
On the 2008 night in question, Gentilello was on call in the emergency room. His first case was a man who’d been stabbed in the neck and had a severed windpipe. As he was helping residents control the blood flow and repair the man’s trachea, four other serious patients came in to the ER: one who’d been in a car accident, another with a BB gun wound to the neck, a severely injured motorcycle crash victim, and one with a gunshot wound to the abdomen.

Parkland policy says that the attending surgeon must evaluate all serious patients. But Gentilello didn’t leave the first victim’s side.

“Protocol says to give priority to penetrating wounds to the torso, but you are also supposed to use your common sense,” Gentilello says.

After discovering that none of the residents in the ER had experience with repairing a trachea, Gentilello made the decision to see his first patient through before moving on to the others. The motorcycle crash victim who’d been brought in while Gentilello was in surgery was pronounced dead shortly after midnight.

“It was just like a thousand other nights that I’ve ever had on call in trauma,” Gentilello says.

The only difference was this night resulted in his supervisor, Bob Rege, filing a complaint of “grave concern” against Gentilello.

Two Parkland peer review boards would later find nothing wrong with Gentilello’s actions. But, no-fault finding notwithstanding, Gentilello was stripped of all responsibilities in the classroom and the operating room.

“You take someone who has for their whole life worked 80 hours a week, and they just wanted me to sit in the office and not operate,” Gentilello says. “No lectures, nothing.”

Shortly after being removed from the trauma call list, Gentilello says he was also removed from his office and reassigned to a cubicle used by part-time nurses.

Although Parkland appeared to have little use for Gentilello, he was still a sought-after speaker and presenter. A number of local and national organizations, ranging from the Salvation Army to the CDC, requested Gentilello’s presence for panels and conferences.

However, in 2009, Gentilello says he was informed that if he left the UTSW campus, his pay would be docked. In documents obtained by CultureMap, Gentilello filed an informal grievance about this practice with his supervisor.

“They would rather me just sit there, staring at the walls,” he says.

Gentilello made good use of his idle time, publishing an average of one peer-reviewed article a month as well as responding to a nomination for a senior position within the Executive Office of President Barack Obama.

For Gentilello, this nomination represented the pinnacle of his career and the near-realization of a lifelong goal to influence practice and guide medicine in a better direction.

“If you get to the point where the president is putting a big chunk of the healthcare money for the nation in your hands, you’ve done that,” Gentilello says.

Without a real office, Gentilello filled out paperwork for his presidential nomination in the school cafeteria. Ultimately, like all the other institutions that had once come calling on Gentilello, the job fell through when word of his pending litigation got out.

“The vetting process goes on for a long time, and, at the very end, I got a phone call withdrawing the nomination, just before senate confirmation hearings,” Gentilello says. “The loss of that opportunity is what hurts the most, because I could have benefited so many more people.”

The man who had risen from Spanish Harlem cab driver to world-renowned trauma surgeon thought he had hit rock bottom after that phone call, which he still keeps a recording of.

But the free fall continued. In 2010, Gentilello lost his board certification in surgery when he couldn’t produce a record of his last 100 operations.

“They’d taken me off the schedule,” he says. “I had no cases to show.”

That same year, in an act of admitted desperation, Gentilello started a blog. The idea, Gentilello says, was to get his story in the media.

He published internal documents as well as those obtained by Freedom of Information Act requests.

“Within a few days of it going online, the Dallas Morning News called,” Gentilello says.

The blog set off a firestorm of coverage in the daily paper, which dedicated an investigative team to covering Parkland.

While he was making headlines, what Gentilello really wanted to do was operate. But from the summer of 2008 to the spring of 2012, Parkland and UT Southwestern wouldn’t let Gentilello step foot in an operating room. Five members of his staff, including advocates of better resident supervision Drs. Raminder Nirula and Shahid Shafi, quit for positions elsewhere.

“I wondered how the residents would learn right versus wrong if someone who already knew wasn’t standing there to teach them,” Gentilello says.

The hammer drops
Since Gentilello filed his lawsuits in 2007, Parkland has been under near-constant scrutiny and found negligent in a variety of areas, including patient care and resident supervision. A separate Medicare/Medicaid billing fraud lawsuit against Parkland is pending.

There have been state and federal investigations, which in 2011 led to Parkland becoming one of the largest hospitals ever put on probation by the Centers for Medicare and Medicaid Services. An independent auditor, Alvarez & Marsal Healthcare Industry Group, has painted a grim picture of patient care at Parkland as a whole, citing specific examples of emergency room deficiencies.

Parkland CEO Ron Anderson, as well as surgery department chair Bob Rege, have resigned in the wake of these discoveries. Both maintain their exits were for reasons unrelated to Gentilello or his lawsuits.

In August of this year, Parkland settled claims of patient safety abuses with the Department of State Health Services to the tune of $1 million — 20 times the largest amount ever paid to this entity.

Although this payment was related to claims from 2011 to the present, when Gentilello was no longer working at Parkland, the claims echo his assessment of lax supervision and unnecessary danger to patients dating back to 2003.

“The cavalry finally did come to the rescue,” Gentilello says. “It’s a little late for me, but the consolation is that I have no doubt that Parkland is going to be reformed.”

In March of this year, Gentilello began operating again as a board-certified surgeon. Now at a private hospital in Northern California, Gentilello has no academic responsibilities — a term of his employment that pains him greatly.

“UTSW has made me into a good example of what happens when you cross them,” Gentilello says. “I think about that when I'm walking around in this tiny level 2 trauma center.”

In the end, though, Gentilello says he wouldn’t change a thing.

“Why is my life more important than the next person’s? You’re going to just let them be killed because of care that you could have changed? These are real people. These are teenagers being taken to Parkland who are going to die and leave their parents heartbroken for the rest of their lives. There are mothers losing husbands, fathers losing children. That’s real, and you’d have to be particularly cold-hearted to walk away from that.”