A Naval Surgeon in the Dock

By Jamie Murphy

Bethesda Naval is the hospital of Presidents. Ronald Reagan went there last year to have a cancerous polyp removed from his colon. Richard Nixon was treated for viral pneumonia at the 500-bed facility in 1973. Lyndon Johnson had his gall bladder excised at the hospital in 1965 then proudly displayed his scar to anyone who cared to see it. Bethesda, in the northwest outskirts of Washington, D.C., is also a jewel in the crown of the U.S. military health care system, whose 688 facilities care for the nation's wounded in time of war. But presidential patronage notwithstanding, the massive system, and Bethesda in particular, has been sorely wounded in recent weeks and may be slow to recover from the strange case of Commander Donal M. Billig, whose court-martial was still under way last week at the Washington Navy Yard.

Billig, 55, was chief of Bethesda's cardiothoracic surgery in 1983 and '84. He is charged with five counts of involuntary manslaughter resulting from technical foul-ups and poor judgment in the operating room. A five-page list detailing the charges specifies that Billig "wrongfully sewed" and tied blood vessels during bypass surgery, "improperly manipulated" heart tissue and, in one case, "tore" a woman's aorta and "improperly repaired" it. Also listed are 24 counts of dereliction of duty for performing unauthorized operations. If he is convicted on all counts, the surgeon, who was commissioned in December 1982, faces dismissal from the Navy and a maximum of 21 years in prison. Meanwhile, 15 of Billig's former patients or dependents of former patients have sued the Federal Government for $75.7 million in malpractice claims.

The beleaguered surgeon suffers from an appalling handicap: 20/400 vision in his right eye, the result of a 1978 tennis accident. Because of the damage, which is only partially correctable, the prosecution contends that Billig cannot accurately judge depth and distances. A number of his former colleagues have stated under oath that he is unable to see small blood vessels in tissues and has difficulty clamping arteries and veins. Army Colonel Russ Zajtchuk, who had worked with Billig in the operating room, described his technique as that of "a first-year resident."

Billig's substandard performance at Bethesda should have come as no surprise. Before joining the staff there, he had been fired from two previous jobs, one at Monmouth Medical Center in Long Branch, N.J., in 1980, and another with a Pittsburgh physicians' group in 1982. When he arrived at Bethesda the following year, he had not performed open-heart surgery in six years. Nonetheless, the Navy permitted him to undertake such operations after only six months of retraining. Last month Monmouth's chairman of surgery, Dr. Cyril Arvanitis, revealed that he had begun to suspect Billig after examining weekly reports of patient deaths. "Dr. Billig's cases began to appear with increasing frequency," Arvanitis testified. "We kept seeing new cases, and his explanations weren't satisfactory."

Bethesda's then vice commanding officer, Captain Leon Hodges, learned of Billig's Monmouth troubles when an unusual circumstance forced the surgeon to come forward. According to Billig, his ex-wife was demanding $5,000 in exchange for silence about the firing. Hodges began an investigation. When he inquired about Billig's competence, a junior cardiologist volunteered that the chief surgeon had "trouble clamping small vessels." Hodges then asked if the young doctor would let Billig operate on his mother or father. The answer? No.

How could such a man have found his way to the hospital of Presidents? The military health care system in general seems to be at fault. Eleven Navy officers have so far been censured or face disciplinary action in the affair, including the officer who supervised Billig's recruitment, Commander Reginald Newman. The recruiter was convicted of perjury at a court-martial in January, fined $10,000 and docked $2,000 a month in salary for ten years. His crime: withholding information from an investigating team regarding Billig's competence. Perhaps because the Navy has difficulty attracting experienced surgeons (their average pay is $70,000, vs. nearly $240,000 in private practice), it apparently had decided to overlook Billig's poor record and his poor eyesight.

Even attempts to investigate Billig were marred by incompetence and misdirection. Scarcely a week after he had begun his inquiry, Hodges was telephoned by his onetime commanding officer, Captain James Quinn, who told him to drop the Billig case. "He accused me of ruining the reputation of an outstanding physician," Hodges testified. "I was chewed out severely." Quinn, who is now retired from the Navy, has received a letter of censure. The review ultimately cleared Billig, and four of the deaths with which he is charged occurred in the following year. Outrage over the Billig case has focused attention on more widespread deficiencies in the nation's military health care system. "This is the most glaring example in recent years of the failure of the system," says Democratic Senator James Sasser of Tennessee. "It reflects a general problem with quality, including improper selection of physicians and inadequate supervision." In response to the case, the Pentagon and Congress have undertaken several studies examining the shortcomings of military medicine. An audit of 22 medical facilities conducted last year concluded that two-thirds of the practicing doctors and nurses did not have proper "qualifications and current competence." Another study revealed that 20% of military doctors do not have licenses to practice. Throughout the entire system, misdiagnoses are common, and waiting lines are so long that people give up trying to be treated.

As Billig's trial comes to a close, a number of reforms are in the works to help prevent future scandals. Beginning in April, for example, civilian doctors will be appointed to monitor the quality of care at military hospitals around the country. Though many problems remain, the Pentagon, asserts David Newhall III, principal deputy assistant secretary of defense for health affairs, "now has more extensive quality review than civilian medicine." If nothing else, Commander Billig has provided his superior officers with a painful but much needed lesson.

With reporting by Michael Duffy/Washington