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Buch examined Bajadali's shattered knee for a few minutes.
"We'll take care of this in the morning," he said, sounding confident, almost arrogant. During the surgery at Medical City, he would remove shattered pieces of bone; she might need an artificial knee.
Bajadali, a telecommunications manager, and her husband, Harold Bajadali, were relieved. After falling from a ladder in 2002, 57-year-old Linda had been in excruciating pain. A doctor in the emergency room at Baylor University Medical Center said her injury was so serious she needed an orthopedic surgeon. He gave them Buch's name, which the Bajadalis took as an endorsement of sorts.
Buch reinforced the feeling, saying that four other surgeons would be observing and learning as he worked on her leg the next morning.
"The inference was he was a hotshot," Harold says.
The Bajadalis now believe the "hotshot" botched the surgery, leaving her with a huge, infected open wound that required extensive treatment and repair by two other doctors. She lost mobility and her job.
Though the Bajadalis filed a lawsuit against Buch, the case was dismissed by a judge because medical charts did not indicate Buch had done anything wrong.
Lawsuits are a fact of life for doctors, especially someone like Buch, a highly trained physician in the high-risk specialty of orthopedic oncology and surgery. Now 54, Buch is perennially on D magazine's "Top Docs" list. His waiting rooms are packed with patients in need of knee and hip replacements or reconstruction of bones and joints.
Like television's Dr. Gregory House, Buch is a scourge of hospital administrators and underlings.
"The guy is one of the most brilliant surgeons that I've ever worked with in 25 years," says one former colleague, a nurse who asked not to be identified. "The guy can do things that most mortal doctors can't even dream of. He's also one of the most self-destructive, obnoxious, vicious people I've ever met."
Buch's medical license was suspended for unprofessional behavior in 2001. In a dozen medical malpractice lawsuits filed against him in Dallas County, his skills, ethics and personal behavior have been questioned. Some lawsuits have been dismissed; a few have been settled by his insurance companies. In the handful of cases that have gone to trial, Buch has won.
Lawsuits, even unsuccessful ones, can increase a doctor's malpractice insurance premiums, but far more damaging to Buch's career has been the controversy over his privileges at four of the largest hospitals in the Dallas area. As the result of negative peer reviews at St. Paul Medical Center, Buch was banned from performing surgery there. He resigned his "courtesy privileges" at Presbyterian Hospital and Medical Center of Plano under pressure. And Medical City suspended his privileges for 45 days pending an investigation
The doctor filed lawsuits against St. Paul and Medical City, claiming he was harmed by their revocation or suspension of his privileges and the hospitals' subsequent reports to the National Practitioner Data Bank.
Created in 1986 by the federal Health Care Quality Improvement Act, the NPDB is a central database that tracks health care professionals by "adverse action" reports. Its purpose is to solve the problem of doctors who go from state to state to avoid having their licenses revoked. The act also provides immunity from liability for doctors who participate on medical peer review committees, panels of doctors who evaluate other physicians' performance.
Suspensions of more than 30 days or lost hospital privileges trigger a negative report to the NPDB, as do lawsuits and investigations by health care agencies such as the Texas Medical Board.
The data collected is not available to the public. Reports of peer reviews by doctors at hospitals where Buch has practiced are secret. Hearings by the Texas Medical Board are secret. Reports to the NPDB are secret.
So, consumers have no way of knowing if their physician has zero "adverse action reports" or 20. Nor are they told a doctor has lost privileges as a result of negative peer reviews.
Such revocation—especially for an orthopedic surgeon who generates substantial revenue—is uncommon. "Hospitals now are less politically motivated and more quality-oriented when they dissociate themselves from a physician," says a board member of the nonprofit American Medical Foundation for Peer Review who asked not to be named. The foundation does independent peer reviews; since 1986, it has conducted reviews for 4,200 hospitals.
"Hospitals are reluctant to revoke privileges," the board member says. "It's usually either the mortality or infection rate, but it's something that's a serious quality issue."
According to statements in court documents by Dr. Kevin Gill, a spine surgeon and then-head of orthopedics at St. Paul, the peer reviews of Buch at St. Paul did not focus on patient care, but his behavior.
"The guy is brilliant," says one malpractice attorney, who asked not to be named, "but he's also an asshole."
Buch admits he's demanding when it comes to patient care, but he contends that the medical peer review process has been unfair, allowing his enemies to blackball him in the NPDB. Some call it being "databanked."