The more I look at the circumstances that lead up to the criminal prosecution of a nurse in Texas for informing the State Medical Board of her concerns with a local physician, the more I wind up wondering just how things wound up where they are. It's easy - and far from inaccurate - to view this as a case of the good ol' boy network gone bad, or as an example of a quack doctor twisting the system to turn the accusers into the accused. The more I think about it, though, the more I'm starting to think that we've really been looking at part of the picture. We've been missing something that's probably just as important - the role played by the totally screwed up medical care delivery system in this country.
Let's start by taking another look at Dr. Rolando Arafiles. He graduated from medical school in the Phillipines in 1977. In 1994, he did an internship at Harbor Hospital in Baltimore. Two years later, he finished a residency in Family Medicine at SUNY Buffalo - but I can find no indication that he has ever been board certified in FP or any other specialty. In 2007, the Texas Medical Board restricted him from supervising physician's assistants because he had failed to properly supervise (pdf) a PA at a weight-loss clinic he worked for, and had failed to ensure that the clinic protocols met standards of care.
At the trial yesterday, Arafiles reportedly had difficulty even defining "standard of care". He said that diabetics heal as easily as anyone else. He was questioned about a number of medical errors he's made, and he explained that contrary to reports, he had not in fact intentionally sewn part of a suture kit to a patients finger, but had instead done so accidentally. According to the hospital administrator, Arafiles has been reprimanded for mistakes a number of times since he was hired in 2008, which was confirmed by a surprise state inspection.
On top of all that, Dr. Arafiles does not seem to have ever seen a non-traditional remedy that he didn't like. He's been selling alkalized water and colloidal silver on his website. He testified yesterday that he - and his buddy the sheriff - have been selling the Chopra Center-endorsed supplement beverage Zrii - a 25 ounce energy drink that seems to mostly consist of grape juice, and which retails on Amazon at a little over $50 per bottle. According to woo-megasite educate-yourself.org, Arafiles was offering IV Hydrogen Peroxide and Bioluminescence Therapy in 2002. More recently - as in Christmas, 2009 - Arafiles posted something on the "no-forced-vaccination" Yahoo! group asking when he would receive materials for a homeopathy class he was interested in.
At this point, the picture is fairly clear. Arafiles looks to be a minimally qualified medical doctor, with conventional clinical skills that are, at best, barely adequate. He also has an enormous interest in non-conventional therapies. This does not surprise me. It's easy to become an expert in a field that doesn't really exist.
With that picture of Arafiles in mind, let's look at Winkler County, Texas.
As of the 2000 census, the county had a population of under 8,000. Only 60% of the adults in the county had finished high school; only one in ten had finished a Bachelor's degree. The median family income was about $34,000 (well under the national average), and the median home price was slightly under $30,000. The major highways are all State roads - not US highways, and not Interstates.
In a word, rural.
And that brings us to the health care delivery problem.
In an ideal world, you want to have extremely competent and extremely qualified primary care doctors working in rural areas. When specialists are hard to get to, when there's no teaching hospital anywhere nearby, when trauma patients need to be airlifted to distant trauma centers (preferably after being stabilized locally), and when you have a very small number of doctors out there, you want to be damn sure that they're all very good at what they do.
In the United States, what you get is what you can pay for. A county with a tax base like Winkler County's is not going to be able to pay much, and the area doesn't have all that many features that would make up for low pay. That's why, as the hospital administrator admitted to the New York Times, it's hard for them to attract good physicians. So they take what they could get, and what they could get was Arafiles.
So now you have Dr. Arafiles, his substandard clinical skills, and his snake oil. He's in an environment where 40% of the adults don't have a high school education, and 90% don't have a college degree. He's in a place where he can be a big fish - play golf with the sheriff, appear on local cable programs - and where many people simply don't have the education needed to easily detect the difference between real medicine and "alternative therapies".
Fortunately for Winkler County, they had good nurses. People who had been in the area, and at the hospital, for a very long time. People who know the community, care about the community, and are willing to do what they think is needed to ensure the welfare of their patients.
Unfortunately for Winkler County, they've got the doctor's business partner/golfing buddy the sheriff, his pal the prosecutor, and the rest of the local good ol' boy network. So now they've got two fewer good nurses, and they've still got Dr. Arafiles practicing what he calls medicine.
What an absolute tragedy.
Agreed, Isis. Not surprisingly, AAPS feels some ways about this.
wow, interesting reading. you did a very good job on developing this, and of course, on interpreting human behavior. best of luck to the nurses!
Thanks for writing about this angle. I have been following Orac's blogs on the case, and I too have been deeply puzzled that it could actually have reached trial stage. No matter what happens here, with appeals this nurse will undoubtedly emerge vindicated eventually. But what a waste of state resources and money, and a harrowing ordeal for a woman who has done nothing wrong, while the person who should really be censured goes free.
When specialists are hard to get to, when there's no teaching hospital anywhere nearby,
Define "nearby"? Lubbock is 3 hrs away. Admittedly, it seems far, but for West Texas, three hours isn't that big of a deal (we used to say that Lubbock was "6 hours from everywhere").
I have wondered why they don't try to recruit more doctors out of TTU? A lot of the students there are west texas natives.
We have the same sort of recruitment problems in this area. Even though my city has a family practice residency, the surrounding very rural counties have a major shortage of physicians. Lots of the residents finish the program heavily in debt and say they can't afford to go to rural areas with no supplemental income opportunities. IF there is a hospital in the county, it can't afford to pay a physician to be on staff full time. If the physician sets up a practice on her own, most patients will have to pay cash because only a small percentage have insurance (no large employers with health care benefits). And because they have low incomes they put off health care until it is urgently needed, complicated, and expensive. Yes, a very dysfunctional health care delivery system indeed.
Consider the fact that it's healthcare. Three hours could be the equivalent of weeks away for some conditions. Three rather serious things in my family just in the last few years include a grandparent with an aneurysm (six BLOCKS from the nearest teaching hospital and still barely made it), a cousin with a blood pressure high enough to cause several unstoppable nosebleeds that required cauterization and two transfusions, and a cluster of congenitally malformed veins in my father's head that started to bleed into his brain (thanks to DC/Maryland traffic, nearly 45 minutes to the hospital they chose) that resulted in weeks of intensive care, two neurosurgeries and a short-term medically-induced coma.
Three hours is a very long drive, when it comes to emergency medicine or difficult to treat conditions.
I'll just second what was noted above in response to Pablo #5:
For regular health care 3 hours might not be a big deal, for emergency care it might as well be Mars if the first contact personnel isn't stellar, and even then it might not be enough.
She was acquitted!! Nice to see the jury system providing a bit of sanity.
Looks like she's also suing over a trampling of her 1st Amendment rights, hope she destroys them and sets a precedent against a witchhunt like this ever happening again. It's crazy how similar this was to an actual witchhunt, in fact, I'm having trouble figuring how how they'd be different.
Regardless, I can be sympathetic to false accusations against good doctors being used as harassment. I'm sure this case probably provokes reactions based on personal histories and the inevitable stereotypes that result, rather than the facts in this particular case. Because the facts are insane, that prosecutor and sheriff need to get counter-sued into oblivion.
The point about distance being relative is significant, particularly in the west. Its only about 50 mi to Midland Odessa which is big enough to have significant medical facilities and as noted about 150 mi to Lubbock and a medical school. Actually the rural town is IMHO an ideal candidate for the nurse practitioner, supervised by a physician back in say Lubbock. (note that nurse practicioners apparently are a prime source of care from the article) In this area everyone has to have a car practically speaking, or they won't survive.