Next week marks the five-year anniversary of Texas neurosurgeon Christopher Duntsch being sentenced to life in prison. Dubbed “Dr. Death,” the case gained national attention, revealing how easy it can be for dangerous doctors to transfer between hospitals. A KXAN investigation found Texas patients aren’t getting all the information they need about some doctors’ histories. Our team searched through thousands of disciplinary records, spanning more than a dozen states, to discover some physicians are coming to Texas to leave their pasts behind. After KXAN started asking questions, the Texas Medical Board promised changes.
FORT WORTH, Texas (KXAN) — In Dallas, the same city where Christopher Duntsch once operated more like a “butcher” — according to his former anesthesiologist — than a skilled surgeon, Dr. Robert Henderson is still fighting to fix the system that allowed Duntsch to keep practicing.
“It isn’t just a state problem,” said Henderson, a highly-respected spinal surgeon in the industry who reported Duntsch to the Texas Medical Board and was instrumental in stopping him. “It’s a national problem.”
Dubbed “Dr. Death” in a 2016 D Magazine article, Duntsch described himself in an email, read at trial, as someone ready to become a “cold-blooded killer.” He left more than 30 patients injured or dead while performing botched spinal surgeries before finally losing his Texas medical license in 2013. During the unprecedented trial, Dallas County Assistant District Attorney Michelle Shughart, who still holds that title, told a jury Duntsch didn’t stop “because he has no conscience.” Henderson agrees, but also puts the microscope on a system he says too often prioritizes protecting physicians — even dangerous ones — over patients.
“I think they have their priorities wrong,” Henderson said. “I think their priorities are out of line, according to my experience with the [Texas] Medical Board during this Dr. Duntsch/Dr. Death saga.”
KXAN recently visited Henderson in Fort Worth. Sitting at a table, he studied an Excel spreadsheet containing the findings of a three-month long KXAN investigation which discovered some doctors are coming to Texas to escape problems in other states.
Patients, meanwhile, are kept in the dark.
“I’ve always fought for patients,” Henderson said. “That’s why I went into medicine, was to help people. And you can’t help them if you don’t fight for them.”
“Do you think what we found suggests there could be another Dr. Death all over again?” KXAN investigator Matt Grant asked.
“Well,” Henderson said, “I think the odds of it are pretty darn high.”
Featured in the hugely successful “Dr. Death” podcast, which was heard by an estimated 60 million people, and portrayed by Alec Baldwin in a Peacock miniseries with the same title, Henderson today is now semi-retired. He still performs about 50 spinal surgeries a year in the Dallas area.
What KXAN found, he said, suggests there could be another Dr. Death all over again. It is a sentiment echoed by other patient advocates who believe it is a matter of “when” not “if.”
“Well,” said Henderson, “I think the odds of it are pretty darn high.”
Duntsch, who declined KXAN’s multiple requests for an interview, was sentenced to life in prison on Feb. 20, 2017. He is serving his sentence at the O.B. Ellis Unit in Huntsville and will be eligible for parole in 2045 when he is 74.
Gone to Texas
There is an old saying: “Gone to Texas.” Two hundred years ago, before Texas became a state, the area that was once part of Mexico was seen by Americans in the South as “a place to start over.” Outlaws running from the law — along with those trying to escape debt collectors, or other personal and legal problems — all came looking for a fresh start, according to the University of Texas at Austin. Before leaving their homes, they used chalk to scrawl a three-letter parting message on their cabin doors and fence posts to announce their sudden departure: “GTT” — for “Gone to Texas.”
Today, some physicians also see Texas as a place to leave their pasts behind.
KXAN spent three months pulling thousands of physician disciplinary records from medical boards across the country dating back to 2017. Those records were then cross-referenced with the TMB’s physician portal one name at a time. At least 49 doctors who had disciplinary actions in other states — including having their medical licenses suspended, revoked or surrendered — are still practicing (or able to) in Texas. Some of these physicians were found to be repeat offenders with actions in multiple states.
Some physicians were disciplined following criminal charges including driving drunk, domestic violence, possession of a controlled substance and operating a firearm while intoxicated, KXAN found. In total, our team discovered disciplinary actions taken against physicians licensed in Texas spread out over 30 different states — with no record on the TMB website.
“I’m surprised you found so many so fast,” said Henderson, who added he is shocked but not surprised by the findings.
A Texas patient wanting to research one of these doctors prior to treatment would have no idea about any of that prior history.
A search of the TMB’s data portal for the doctors we identified found no record of disciplinary actions or criminal histories from other states. That information is required to be reported by a state law passed in 2001.
“Now,” Henderson said, “I have little to no confidence in what’s stated on that [TMB] website.”
Disciplined Doctors Coming to Texas
ARKANSAS
An Arkansas doctor’s medical license was suspended four times, revoked for five years and he was required to participate in multiple substance abuse treatment programs. The Arkansas Medical Board reported he was a “danger to the public and himself,” and took actions against him for violations of the Medical Practice Act consisting of “gross negligence and ignorant malpractice” after he was accused of prescribing excessive amounts of controlled substances to himself, family and patients, as well as multiple violations for “habitual, intemperate, or excessive use” of narcotics and alcohol.
CALIFORNIA
A California physician was forced to surrender her medical license in California in 2019 for “repeated negligent acts” in the care of a patient suffering from a brain bleed. The doctor failed to properly assess the patient, did not detect the brain bleed and administered “potentially harmful medication with a risk of worsening the patient’s condition,” according to the Medical Board of California. The patient died.
COLORADO
A Colorado neurosurgeon was disciplined for performing surgery on the wrong spinal disc. The surgery, to alleviate chronic back pain, was supposed to be a L5-S1 discectomy. The surgeon instead performed an L4-L5 discectomy and admitted he “failed to properly confirm the correct level of surgery,” according to the Colorado Medical Board, which called the error “substandard care.”
FLORIDA
A Florida doctor was reprimanded in 2019 for prescribing “excessive quantities” of Oxycodone and other opioids without adequately assessing a patient’s complaints, symptoms and medical history. The patient died of an overdose with the cause of death listed as “oxycodone toxicity,” according to the State of Florida Board of Medicine.
INDIANA
An Indiana physician’s license was placed on “indefinite probation” after the Medical Licensing Board of Indiana revoked his clinical privileges “due to medical impairment, evidenced by documented alcohol dependence and abuse” after being intoxicated while on duty and driving under the influence, and a pattern of domestic violence, breaking a no contact order and making false official statements.
NEW MEXICO
A New Mexico doctor surrendered his license in 2019 while under investigation for drinking alcohol during a telemedicine group session for individuals in recovery. He welcomed one new member to the group by saying he “considered asking the group to ‘commit mass suicide,'” according to the New Mexico Medical Board. He was fired and failed to report it, the NMMB found, in addition to failing to maintain complete and accurate medical records for his patients.
VIRGINIA
A Virginia anesthesiologist was disciplined in 2020 after failing to document his patient’s medical record and need for continuous respiratory monitoring once transferred out of his care. As a result, the patient did not receive continuous respiratory monitoring and developed a brain disorder caused by a lack of oxygen to the brain. The patient was put on life support but died, according to the Virginia Medical Board.
WISCONSIN
A Wisconsin orthopedic surgeon’s license was suspended “indefinitely” in 2018 after operating on a patient while intoxicated early in the morning. He was previously suspected of “alcohol abuse affecting his work” and resigned after testing positive for alcohol during a random breathalyzer screen, according to the Wisconsin Department of Safety and Professional Services.
Click the states in red to learn about some of the disciplined doctors KXAN found currently licensed in Texas with a “clean” disciplinary record.
KXAN is focusing on greater accountability within the system rather than specific doctors, which is why we have not named individuals.
Texas Medical Board looking into cases further
Henderson is concerned. He says the TMB promises patients transparency but fails to deliver.
“Right now,” he said, “the public isn’t getting the information they need … to determine who they want to be treated by.”
Asked if KXAN’s findings suggest a systemic failure to protect patients, Henderson replied: “By definition, yes.”
KXAN provided the full list of physician names to the TMB prior to our interview so officials would be fully aware of our findings.
“We are always trying to find a way to do our jobs better,” said the TMB’s Executive Director Stephen Carlton in an interview by video conference. “To get information faster. And to be able to take actions quicker to protect the public.”
While Carlton said he cannot comment on the specific cases we identified, he said it is up to the board to determine if a physician is safe to practice on a “case-by-case” basis. The board, he said, is aware of the “vast, vast majority” of cases KXAN brought to its attention, noting it was only unaware of five or fewer.
“Missing one is unacceptable,” Carlton said. “Missing a handful is unacceptable. But it is something that we’re looking into right now.”
The TMB is now investigating the ones it said it missed after KXAN brought it to the board’s attention. Prior disciplinary actions do not disqualify an applicant, Carlton said.
“So, the board doesn’t have a blanket, ‘If you’ve ever had an action, you can’t get a license. If you’ve ever had a conviction, you can’t get a license,'” Carlton said. “Everything is looked at on a case-by-case basis.”
It is unclear after speaking with him why the public profiles for the physicians KXAN identified had not been updated. He would not say if any will face any disciplinary actions for not sharing issues in their pasts.
“They are supposed to disclose that information and put it into the profile,” Carlton said. “Some of them do. But, obviously, some of them don’t … Any type of previous disciplinary action, convictions, arrest, is something they would have to disclose upon initial application with us.”
“Again, we can’t get into any of the specific cases,” Carlton added. “But there are a couple cases on the list where we’re looking into further.”
Asked why the board is aware of past disciplinary actions but Texas patients are not, Carlton responded by saying, “that’s one of the things, starting this year, that we want to start doing.”
Beginning Jan. 1, the TMB says it will “more proactively” post on its website when it finds new out-of-state disciplinary actions. Those actions will include a note that it was not disclosed by the physician, but instead, by a third party like the Federation of State Medical Boards. It will not be retroactive, at least for now. However, by law, this information should already be public.
Physician profiles must contain “a description of any disciplinary action against the physician by a medical licensing board of another state,” among other things, according to the Texas Occupations Code (Sec. 154.006).
The board announced these changes after KXAN started asking questions. The new steps are the TMB’s “effort to better meet that profile information requirement,” a spokesperson later clarified.
The TMB says its honor-system approach is “historically” how the board has operated, adding it has always “relied” on physicians to self-report. The board said it had not “gone the extra step” to post information online because it would be “staff and time intensive.”
“As far as, ‘Does the [Texas] Medical Board go and review all, you know, 154,000 of our licensees to make sure that they’ve disclosed everything that’s come in?’ That’s something that’s a little more time intensive that the medical board has not in the past done,” Carlton said.
Nobody from the Texas Medical Board would give a clear and direct answer when asked, multiple times, why it is not fully following the law when it comes to publishing out-of-state disciplinary actions. It suggests there is no absolute oversight and begs the question: Does this law, and the system, have any teeth?
In Texas, doctors are required to report felony convictions within 30 days. All other criminal convictions, charges, arrests and medical disciplinary actions are only required to be self-reported when physicians apply for, or renew, their licenses every two years. That means it’s possible a physician could be disciplined in another state and the TMB would not know about it for two years.
“That’s correct,” Carlton admitted. “It’s how the statutes and rules are currently written.”
KXAN compared the TMB’s two-year reporting requirement to 10 other states including Florida, New York, California and Colorado. Unlike Texas, those states require physicians to report this information to their state’s medical boards within 30 to 60 days.
“The two-year license registration timeframe for reporting is in state law,” a TMB spokesperson said. “The TMB will continue to refine processes to meet reporting obligations and promote transparency. We also encourage the public and the media to bring any profile issues to our attention just as you did.”
Pushing for change
Most state medical boards across the country, including Texas, provide “incomplete” information about a physician’s practicing history, according to a report released last month by the Patient Safety Action Network, a national advocacy group. Few states provide information on malpractice payouts, hospital adverse actions, criminal convictions and information from other states that patients would likely want to see to make informed healthcare decisions.
“Would you want to know if your doctor has been disciplined and why? Whether they had malpractice settlements? Whether they could no longer practice at a hospital because of some safety concern by the hospital? Or, whether they had a criminal record?” asked PSAN Board Chair Lisa McGiffert. “The reality is that most states only provide a sliver of this pertinent information that may tell a doctor’s history of harming or putting patients at risk.”
“At the end of the ‘Dr. Death’ miniseries, it says ‘this will happen again.’ Do you agree with that?” KXAN investigator Matt Grant asked.
“Yeah. Absolutely,” Dr. Robert Henderson replied.
All that information is stored in the National Practitioner Data Bank, which, by law, is kept secret from the public. The TMB checks the NPDB when it is screening new applicants or when it is conducting an investigation on a physician.
“Unfortunately, there remains too much secrecy about a physician’s history,” said Informed Patient Institute Executive Director Carol Cronin, who is with the non-profit that authored the PSAN report. “As state agencies charged with public protection, medical boards should have easy-to-find physician profiles with complete information about a doctor’s ability to practice medicine safely.”
Henderson said he will take the findings of KXAN’s investigation to members of Congress. He has formed a group made up of several key players involved in the Dr. Death saga — all still pushing for change and greater protection for patients.
“It helps me to actually have a handhold on more specific cases and situations that have actually occurred and are occurring in Texas,” he said, after reviewing KXAN’s findings. “I’m really glad to have that information.”
When asked what patients need most right now, Henderson paused for a brief moment before answering: “transparency.”
“There’s something wrong,” he said of the current system. “That’s just plain easy to see.”
Director of Investigations & Innovation Josh Hinkle, Photojournalist Chris Nelson, Digital Special Projects Developer Robert Sims, Digital Director Kate Winkle and Graphic Artists Rachel Gale and Jeffrey Wright contributed to this report.
