Of all the medical specialties, surgery is the most regimented. It is also the clubbiest, and once you understand that, you can begin to fathom how two plastic surgery trainees at Columbia-Presbyterian Medical Center could brazenly conduct a thriving unauthorized surgery business for almost a year, with no intervention from hospital staff.
What Dr. James Brady and Dr. Jeffrey Yager did was this: They diverted patients from the Columbia-Presbyterian plastic surgery clinic into a clandestine side practice. They printed official-looking business cards, with the hospital’s logo, that read “Jeffrey S. Yager, M.D., James A. Brady, M.D., Post-Doctoral Residency Fellows, Plastic and Reconstructive Surgery” and listed an office phone number that in fact rang at Dr. Yager’s East Side home. According to a patient who received the card, the number led to a voice-mail message that told callers they had reached the “offices of Drs. Yager and Brady.”
They performed procedures at discounted rates, after hours, on weekends in a senior physician’s private office.
The Observer has identified four patients who received unauthorized surgeries, two of whom were given the business cards. The two who agreed to be interviewed said they underwent the procedures on a weekend in the office of a supervising plastic surgeon, Dr. Ted Chaglassian, located in the Atchley Pavilion on the hospital’s grounds. Dr. Chaglassian was not present during those surgeries. (He did not return calls.)
The unauthorized practice lasted for nearly a year and appears to have begun soon after the two doctors became co-chief residents of the program in July 1996. Telephone records obtained by The Observer show that little more than a month after he became co-chief resident, Dr. Yager set up another home phone line-the number that was listed on the residents’ business card.
All of this was against hospital regulations: The two were still in training, were not board-certified in plastic surgery and were not entitled to operate on patients without supervision, let alone be in private practice. Under several state laws, the residents may have been practicing outside the terms of their residencies, conducting a negligent practice and committing fraudulent medical practice by possibly deceiving patients. What really rankled one senior Columbia-Presbyterian surgeon familiar with the residents’ actions, however, was that their business “was stealing assets from the hospital. The patients belonged to Columbia-Presbyterian, and they were being diverted from the clinic.”
In dozens of interviews conducted by The Observer since it broke the story of how Dr. Brady performed an unauthorized liposuction on a Staten Island hairdresser, a picture emerges of a side business that the residents maintained with the acknowledgment, and maybe even the help, of employees at the hospital. One of the residents’ patients, a Columbia University employee, said that at the hospital’s legitimate plastic surgery clinic, both a desk clerk and a nurse told her that cosmetic procedures were also performed off site, and that fees were set by the residents-a highly irregular setup, according to current staff and former residents. The Columbia employee said she wound up in Dr. Chaglassian’s office on a Sunday, writing a $100 check made out to cash, at Dr. Brady’s request, for a procedure akin to a collagen injection.
System Breakdown Or Willful Ignorance?
Were hospital employees involved in steering patients away from the clinic and into the off-hours body shop? In a three-hour interview with The Observer , the Columbia University employee, who requested anonymity, said, “My full belief is that [the clinic staff] knew procedures were done in Atchley, and if that was irregular, they must have known. I don’t know if they knew the residents were being paid in cash, but they knew that the procedures weren’t being performed during clinic hours.”
When another patient was unable to pay the $14,000 fee that the senior Columbia-Presbyterian surgeon would normally charge, the surgeon referred the patient to the hospital’s clinic. According to the senior surgeon, when the patient got to the clinic, she was told that cosmetic procedures were performed in “Dr. Yager’s office.” This struck the patient as strange; she called the senior surgeon to complain. It was only later, when news of the Staten Island hairdresser broke, that the senior surgeon realized something inappropriate was happening.
“Apparently,” he said, “all the other residents on the other services knew this was going on. Residents have made that claim to me.” He also said that the department’s senior attending physicians, who are ultimately responsible for residents’ actions, have claimed ignorance of the scheme. He found this hard to believe. “There was definitely a trail,” he said, and Columbia-Presbyterian’s senior physicians chose not to follow it.
Although the residents maintained no medical records for their covert procedures, a prominent plastic surgeon who practices at another Manhattan hospital told The Observer , “It is hard to imagine they did not have the knowledge or approval of the division. Surgery requires a whole armament of preparation, staffing and ordering of medical supplies, that for a resident to do alone is almost impossible.”
Why did the basic mechanisms of oversight, which are fundamental to a teaching hospital, fail so spectacularly at Columbia-Presbyterian? Dr. Brady was only investigated by the hospital when his Staten Island patient, who contracted a liposuction-related infection that the resident could not remedy after several desperate house calls, went to see Dr. Lloyd Gayle, a physician at New York Hospital-Cornell Medical Center. Dr. Gayle quickly reported the circumstances of her surgery to his supervisor, who in turn called Columbia-Presbyterian.
Last June, one week before Dr. Brady was to graduate, Columbia-Presbyterian fired him, claiming that he was a renegade resident who had performed an isolated procedure. The chief of the plastic surgery division, Dr. David Chiu, was demoted. Dr. Yager, whose involvement is only now coming to light, graduated and opened his private practice, the Plastic Surgery Center, directly across the street from Presbyterian Hospital. Dr. Brady had intended to go into practice with Dr. Yager-the two are even listed as partners in the Manhattan White Pages.
Either there was a stunning procedural breakdown at Columbia-Presbyterian-that lasted for almost a year-or the two residents’ supervisors gave their tacit consent until it was impossible to continue doing so. “This brings up the worst nightmares any director [of a residency program] ever has: that residents begin practicing outside of the department,” said the prominent plastic surgeon.
The State Health Department is actively investigating the residents’ conduct and the hospital’s failure to properly supervise them. A department spokesman would only say, “The department is aware of the allegations about the surreptitious surgery, and our investigation remains open. At this time I cannot comment about the scope of our investigation or provide any details.” Furthermore, the plastic surgery program’s accreditation hangs in the balance. The Accreditation Counsel for Graduate Education’s residency review committee, which accredits training programs, is scheduled to re-evaluate the program’s status on Oct. 23. An administrator there said the committee was considering the recent allegations in its review.
Through his lawyer, Dr. Brady has declined to be interviewed by The Observer , as have officials at Columbia-Presbyterian, and Dr. Yager did not return phone calls.
A Climate of Lax Supervision
Former and current hospital staff have described a climate of lax supervision, and a habit of unsupervised cosmetic procedures within the plastic surgery division, which trains only four residents at a time. “At Columbia, residents really run the show,” said Dr. Alexandra Pinz, a former anesthesiology resident who added that Presbyterian Hospital was designed, specifically, as a training ground for medical residents at Columbia University’s College of Physicians & Surgeons.
A desk clerk in the admitting department said that one past chief resident routinely operated, without supervision, on hospital staff, only requiring payment to his supervisor in the admitting department to cover the cost of supplies and office time. “It wasn’t something done as a secret. I don’t think it was something hidden,” she said. From the way Dr. Brady and Dr. Yager handled the Columbia University employee, it seems they had little fear of getting caught.
In mid-February, the patient went to the plastic surgery clinic in the Vanderbilt building, which is known as VC-5, expecting to receive a high-quality, low-cost cosmetic surgery procedure on her eyelids that would be performed by a resident and supervised by a senior physician.
Instead, she said, Dr. Yager took her into an examining room. He then said, “Let me get my colleague,” she recalled, and Dr. Brady came into the room. Dr. Brady examined her eyelids and proposed a brow lift, an intensive procedure in which the forehead is raised. The woman recalls Dr. Yager reassuring her, “We work with a couple of good anesthesiologists.” ( The Observer was unable to learn whether any anesthesiology residents or attending physicians assisted the duo.) The residents urged her to schedule her procedure soon, saying they were booked through March and were graduating in June.
Dr. Brady also offered another procedure: decreasing wrinkles around the mouth by injecting body fat into them. Dr. Brady and Dr. Yager gave her their business card and told her to call if she wanted an appointment.
It is rare for medical trainees to have a business card and, if they do, the office number is almost always the department’s general number, or that of the chairman.
Past residents and other senior fellows of the Columbia program said they were never given business cards. And even though the employee had never been presented with anything like it in prior experiences at Columbia-Presbyterian clinics, the card itself seemed authoritative to her.
Like many university employees, she received much of her health care through the clinic system. In an earlier, by-the-book experience at the dermatology clinic, she was quoted a fee over the phone; when she went in for the procedure, the desk clerk gave her an invoice, which she took to the medical center cashier. She then wrote out a check to Columbia-Presbyterian, obtained a receipt and presented it at the clinic as proof of payment before being treated by a supervised resident. The deposited check had a Columbia-Presbyterian stamp on the back.
None of this happened when she saw Dr. Brady and Dr. Yager in mid-February. Two days after her consultation, the Columbia employee called the residents’ “office” number and left a voice-mail message for an appointment. Dr. Brady called back and offered her a range of weekday times, saying, “We also work evenings or weekends,” the woman recalled. She made an appointment to see him on a Friday at 10:30 A.M., and he told her to meet him in Room 607 of the Atchley Pavilion-Dr. Chaglassian’s office. The morning of her appointment, he canceled, telling her that he was in the middle of a major operation. In fact, he was caught in a conflict between the demands of his hospital duties and the demands of his private practice.
He then proposed to meet her in the late afternoon after the clinic let out, or in the evening after rounds. They agreed to meet at 4 P.M., but again he called to cancel, leaving an apologetic and revealing message on her answering machine, which the woman saved and played for The Observer . On the tape, Dr. Brady said, “This doesn’t often happen because usually me or Dr. Yager is free. But he’s away.” She paged him, and they settled on a time: noon on Sunday in Dr. Chaglassian’s office.
The Atchley Pavilion is locked on Sundays, so Dr. Brady met her outside and escorted her to Dr. Chaglassian’s office, which was empty. There were no medical records of the procedure. The employee recalls that as Dr. Brady performed the procedure, he described a thriving practice with Dr. Yager. He said that the residents had performed numerous procedures, even back-to-back surgeries. The employee said that Dr. Brady mused that their practice of off-hours cosmetic surgery might die down after he and Dr. Yager graduated.
When Dr. Brady finished the procedure, the patient took out a checkbook and asked him who she should make out the check to. “He paused, and said, ‘Make it out to cash,'” she recalled. The $100 check, which The Observer obtained a copy of, was cashed eight days later and was processed by Chase Manhattan Bank. (Though Dr. Brady told an attorney that he turned over his earnings from the procedures to an educational fund for residents, there is no evidence on the check that it was processed through any official hospital account.)
A Scheme Unraveling
The residents’ scheme was apparently operational within three months of setting up their office number. In November 1996, the Staten Island hairdresser first learned about the residents’ work from an acquaintance who works as a Carnival Airlines flight attendant. According to the hairdresser, the flight attendant told her that she’d received an eyelid procedure from the residents, and recommended them: “She gave me a telephone number and said, ‘Either Dr. Brady or Dr. Yager will get back to you.'” The flight attendant said that she had paid them with a check made out to cash, and that the duo had worked on her colleagues at Carnival Airlines, the hairdresser recalled.
In May, Dr. Brady gave the hairdresser local anesthesia and Valium, a controlled substance that he obtained by falsely writing out a prescription for a legitimate patient. His diversion of the Valium, a felony under New York State law, points up the difficulties and dangers of administering anesthesia without supervision. Dr. Herman Turndorf, chairman of anesthesiology at New York University Medical Center, said that patients sometimes panic during surgery and require narcotic sedation. But because narcotics are a tightly controlled substance and not easily available, doctors sometimes try to compensate by administering more local anesthesia, which can be toxic in large quantities.
In mid-May, the Columbia University employee called the residents’ voice-mail to make an appointment for another injection. Two weeks later, Dr. Yager returned the call, apologizing that they had been busy, and scheduled a procedure for her with Dr. Brady, again in Dr. Chaglassian’s office. By then, the residents’ business had begun to unravel: On May 11, Dr. Brady operated on the hairdresser, and soon after, she contracted the fateful infection.
Of course, the Columbia University employee knew nothing of this. Again, Dr. Brady canceled her procedure and rescheduled it for 5:15 P.M. on Tuesday, June 10, three days before he was scheduled to graduate. When the employee showed up, Dr. Yager was seated at the receptionist’s desk in Dr. Chaglassian’s empty office. He then paged Dr. Brady for the employee, and after a brief discussion told her that Dr. Brady was being delayed. The employee told Dr. Yager that she was unwilling to wait, and the procedure was canceled.
The next day, on a bizarre directive from Dr. Chiu, Dr. Brady went to the offices of the personal injury lawyer the Staten Island hairdresser had hired. His goal: to obtain a letter saying that the patient had consented to the liposuction, was satisfied with it and knew he was a resident. Apparently, Dr. Chiu had told Dr. Brady to “follow your conscience” in getting the letter. The implication was that if the Staten Island woman signed and the matter ended there, Dr. Brady would be able to graduate.
Dr. Chiu’s advice simultaneously encouraged Dr. Brady to be dishonest and abandoned him to structure his own defense, said a prominent plastic surgeon. “I would be ashamed to give a resident any kind of advice like that. It’s absolutely mind-boggling.”
Yet Dr. David Halprin, a reconstructive surgeon who was trained by Dr. Chiu in Columbia-Presbyterian’s program, said, “A lot of people would have fired Dr. Brady on the spot. But Dr. Chiu didn’t do that, did he? He could have cut his head off, but he wanted Jim to start telling the truth. I don’t think he was asking him to be dishonest. I think he was asking him to be a man.”