Cardiologist who spread heart disease

Mehmood Patel still wakes up early, just as he did when he was a popular heart specialist seeing patients who waited hours for minutes of his time.

Instead of surgical scrubs, he climbs into the khaki drabs of the Federal Correctional Complex in Oakdale, Louisiana. He leads health-conscious inmates on a morning walk, then cracks open one of the medical journals on his prison-approved reading list. Counseling fellow convicts to keep their blood pressure down is about the extent of the doctoring done by the man who once boasted he was the busiest cardiologist in the nation.

Colleagues still credit him with bringing modern heart medicine to Lafayette, in the middle of Cajun country. Three decades after he arrived, he lost his license and livelihood when he was convicted in a watershed criminal case of putting stents into the arteries of people who didn’t need them.

That was his passion: coronary stenting. The device that brought him fortune and admiration and cost him his freedom is a tiny metal-mesh tube he inserted tirelessly — hundreds of times a year — for an annual income that in 2003 reached $6 million. He said he never placed one that wasn’t warranted, and that he never hurt a patient.

At his trial, he described the stent as “a miracle thing” that could save lives and prevent heart attacks. Medical research had found before he took the witness stand that stents are no better than drug-based therapy at doing either in stable patients. He was convicted on 51 counts of billing for medically unnecessary procedures, and began a 10-year sentence in December. His stents are still taking a toll across Louisiana.

Prosecutors broke new ground with the Patel trial in 2008, using expert witnesses, patient heart scans and clinical standards to trump the defense of a doctor insisting he’d used his best medical judgment. It was followed by the convictions of two other cardiologists, in Maryland and Kentucky, and federal investigations of stenting that continue in at least six states.

The prosecutors’ tactics included equipping jurors with monitors for viewing angiograms, the high-tech coronary videos that are the chief tools for determining the extent of arterial blockages. Expert after expert testified as the angiograms played, telling jurors that the blockages Patel insisted were 70 percent or more — a key threshold for most arteries — were in reality as low as zero.

Patel, 68, declined to be interviewed. His wife Audrey provided details about his life in the low-security prison, where he earns $5 a month as the supervisor of a cleaning crew.

Some of the people he stented had heart attacks and strokes or needed remedial surgery, others required regular blood transfusions after injuries they suffered during the procedure, according to testimony and lawsuits. His stents disqualified still others from receiving or donating organs in life-or-death situations, patients said.

At least two people died because of Patel’s stenting, their relatives alleged. They were among 300 plaintiffs who sued the doctor and two of the Lafayette hospitals where he worked and shared $15.1 million in class-action settlement money.

Donna Fils was one of the plaintiffs. Patel put a stent in her right coronary artery in 2002 after saying it was 90 percent blocked. “He told me I was a candidate for a heart attack,” Fils said. “I said I don’t want a heart attack, so go do what you need to do to get me right.”

Actually, there was “no narrowing at all” of the artery and it didn’t require an intervention, John Hirshfeld, a University of Pennsylvania cardiologist, said at Patel’s trial.

New tissue formed inside the stent as the artery walls healed, and that left Fils with a true blockage, one that led to another stent, more tests and more catheters. “She was transformed from someone who did not have coronary artery disease to someone who did,” Hirshfeld said.

As the repercussions continued, Fils took a disability leave from her job as a social worker. Back at work, now 59, she said she has chest pain, difficulty sleeping and bouts of physical weakness and sees a cardiologist every six months.

“Used — betrayed,” is how she said she feels about Patel. “Because he was supposed to take care of me.”

Growing up in Bharuch, India, Patel focused on his studies and rarely joined in neighborhood cricket matches, according to his brother Ahmed Patel. His father taught English literature and mathematics in local schools and augmented his salary tutoring, and his mother stayed home to raise the nine children.

An uncle who was a doctor steered him toward medicine. At his trial, Patel said he graduated at the top of his class at Baroda Medical College, in the state of Gujarat. He left India soon after, taking a job at a hospital in Zambia.

“He escaped,” his brother said. “A lot of people were pressuring him to get married and he didn’t want to at that age. He’s a man who left Bombay with three sterling in his pocket.”

After training in New York, he took a job in 1977 as chief of cardiology at a Louisiana State University hospital in Lafayette. Two years later, at a conference in Miami, he said he heard a presentation by Andreas Gruentzig, whose new devices were transforming cardiac care.

The doctor, practicing in Zurich, had invented a catheter with an inflatable balloon tip that could be inserted into the coronary arteries. He said the balloon compressed fatty plaque buildups in the vessels like “footprints in the snow.”

For years, Patel said he and others had watched helplessly as heart attack patients died. “We put them in intensive care,” he said on the stand. “We watched them dying. We don’t do anything. Nothing.”

With Gruentzig’s balloon angioplasty, blockages causing heart attacks could be cleared, and blood could flow strongly. Patel called it the “biggest innovation” in heart care.

Soon, cardiologists around the world began to use angioplasty for stable patients who weren’t having heart attacks but felt chest pain and shortness of breath from blockages.

Still, nearly half of those with arteries unclogged by balloons ended up developing new blockages. To address this, two doctors in Europe pioneered using the catheter to deploy a tube — or stent — to keep the vessel propped open. Patel said he placed Lafayette’s first stent in 1992. “In this town, any new procedure done is done by me,” he told the court.

The advent of angioplasty and stenting fundamentally altered the business of cardiology. It increased the capacity of doctors to perform lucrative procedures and gave birth to a new kind of specialist: the interventional cardiologist, who quickly surpassed general cardiologists in income.

Before, cardiologists who weren’t open-heart surgeons were mainly limited to making money from office consultations, which bring in about $250 a patient. Patel was getting as much as $2,600 per stent. Unlike open-heart surgery, stenting can be done many times a day. Patel said he could do 10.

Hospitals built cardiac catheterization labs that allowed them to capture fees for scanning, stent procedures and overnight stays. All told, cath labs and similar facilities in the U.S. will generate about $20 billion in billings this year, according to the Advisory Board Company, a health-care consulting group.

In 2000, Patel leased an 18-wheel truck outfitted with a cath lab that would roll into the parking lot next to his office three days a week. With it, he could charge both doctor’s fees and facilities fees. Later he built a permanent lab for $1.2 million, recruiting a local doctor as an investor who referred patients and shared in the profits.

The Patel practice was like none other in the region. His business manager testified he treated half the cardiology patients in Lafayette. Patients sat for hours in his waiting room. At any one time, he had 6,000 to 7,000 under his care.

With up to 40 appointments scheduled in a two-hour block, patients said he would dispense with niceties and spend just a few minutes with them, sometimes dropping the news that they needed surgery as he was walking out the door.

Money streamed in through three channels — from cardiology consultations, from his cath lab and from stent surgeries at local hospitals. He made $4.8 million in 2001, $5.6 million in 2002 and $6 million in 2003, according to his tax returns.

At Our Lady of Lourdes Regional Medical Center, Patel at his peak was admitting more patients than any other doctor. From 2001 through 2003, he performed 7,579 procedures there, mostly stents and angiograms, about four times the number of the next-busiest cardiologist.

Lourdes dedicated as many as three operating rooms at a time to him so he could move from one to the next without taking a break. In 2003, according to hospital records, his cases brought Lourdes $9.4 million in revenue and $1.4 million in net profit — twice the amount generated by the next four cardiologists combined.

“It was an assembly line,” said Troy Chenevert, a special agent for the Federal Bureau of Investigation.

Patel was irritable when the pace slowed and if patients complained he told them to “shut up,” nurses testified. When Rosemarie Bryant questioned the necessity of a stent he was putting in, he scolded her. “I’m the doctor. You’re the nurse. Do your job,” Bryant quoted him as saying.

He could thread a stent into an artery in as little as 15 minutes. Cath lab workers said he wouldn’t always wait for anesthetic to take effect before sticking patients with a needle in the groin area where the catheter would be inserted.

In one case, Bryant said, a man was “coming off the table and lifting up his leg” when Patel put the needle in. As Bryant hurried to administer pain medicine, she said, Patel hit the patient on the leg. “It was very aggressive,” she said. “I wanted to throw up in the back of the room.”

Patel said he had simply held the patient’s leg firmly to prevent him from being injured.

Calvin Castex was stented in July 2001 — and later learned that the implant disqualified him from a kidney transplant he’d already been approved to receive, according to a lawsuit filed by his family.

Doctors at Tulane Medical Center in New Orleans had determined his daughter was a perfect donor match and were performing pre-operative testing when they discovered the device in the artery leading to his kidney, his wife Ethel said.

Castex was 64 when he died three years after the stenting, which she said hastened his decline. The stenting, according to the lawsuit, was needless.

Whether the stent or the denied transplant played a role in his death wasn’t argued in court. His family received at least $175,000 in settlements from Lourdes and Patel.

“He took a life,” Ethel Castex said of the cardiologist. “He took Calvin from me.”

A month after Castex was stented, a lab supervisor at Lourdes wrote in a memo to the head of cardiovascular services that Patel was violating medical guidelines by stenting too many people with fatty buildups of less than 50 percent in their arterial passages.

Patel performed thousands of procedures after the memo was sent, and testified nobody from Lourdes ever asked him about it. A spokesman for the hospital, Elisabeth Arnold, said officials had no comment. “We’ve reached legal closure on it and don’t feel like we can offer anything else,” she said.

In February 2002, a nurse in Patel’s mobile lab e-mailed federal investigators, saying he was exaggerating the size of blockages to justify stenting. Agents opened a case but didn’t have enough for a criminal probe. The next year, Christopher Mallavarapu, a cardiologist in Patel’s practice, said he saw signs of needless stenting, and told George Smith, the medical liaison for doctors at Lafayette General Medical Center.

Mallavarapu said Smith responded with, “Chris, grow up — everyone knows he puts a stent in every orifice he can find.”

While Smith said several physicians complained to him about Patel doing procedures he shouldn’t, he said none gave him patient names or other details he could use to start a review.

In 2004, Mallavarapu filed a whistleblower suit under the False Claims Act, alleging unnecessary stenting procedures. While Lourdes and Lafayette General settled with the government, the claims again Patel are outstanding.

David L. Callecod, president and chief executive officer of Lafayette General, said the hospital had “grown and matured” since “the actions involving Dr. Patel” and that it puts “patient safety and quality first and foremost.”

The federal investigators reopened the Patel case in May 2003 after receiving more information about inappropriate stenting from a nurse at Lourdes. Administrators there were moving at the same time.

The catalyst was Barbara Pellerin, who’d received stents in three surgeries that were among 11 procedures Patel performed on her over a nine-month period in 2002 and 2003.

Still having chest pains, she went to see Mike Mounir, a cardiologist who started practicing in Lafayette a year before Patel. He checked the video records at Lourdes, watching the angiogram taken before the stenting.

“This lady has crystal-clear arteries,” Mounir said in court. “There was zero blockage.”

Patel had inserted the initial stent after telling her the vessel was 97 percent congested. That tube created a lesion where there was none, resulting in more angiograms, exposure to radiation from more scans and then more stents. Mounir presented his findings to the hospital board in November 2003, and Patel’s privileges at Lourdes were suspended.

Pellerin, who worked as an accountant, collected $89,000 from the class-action settlement and used it to pay off the mortgage on her trailer west of Lafayette. Asked what she thought about Patel’s prison sentence, Pellerin paused. “I hope he dies there,” she answered.

Prosecutors and defense lawyers in the case said it marked the first time a cardiologist has been convicted in the U.S. of a crime based solely on charges of billing for medically unnecessary procedures — with no accompanying accusations of billing for work that wasn’t performed, or of altering test results, or of delivering sham treatments.

Kelly Uebinger, the assistant U.S. attorney who prosecuted Patel, was initially skeptical about whether the government could prove a crime. “If anything,” she said, “I thought it was a malpractice case.”

Then prosecutors realized a video was made of every artery Patel had stented. Copies of Patel’s chief diagnostic tool could be sent to experts and later shown to the jury.

“It is something we had never done,” said the FBI’s Chenevert, who likened the scans to videos of a bank robbery or “the bribe paid to the politician.”

During his 19 days on the stand, Patel went over each of the procedures behind the 91 counts of the indictment. Every patient had an artery at least 70 percent blocked, he testified, using the same angiograms as Uebinger’s experts to make his point, sometimes with views taken from alternative angles.

When Uebinger asked what the correct angle was in one instance, Patel said there was no such thing, that a cardiologist had an obligation to base his diagnosis on the “worst view” of the alternatives.

Uebinger handed Patel “Grossman’s Cardiac Catheterization, Angiography and Intervention,” an authoritative textbook that spells out precisely the best angle for viewing the artery in question. He acknowledged it wasn’t what he used.

“I absolutely disagree with the textbook in this case,” Patel said. Uebinger won a conviction on the count.

In her closing arguments, she said Patel was like the emperor with no clothes. “Underneath the layers — the skill, the knowledge, all of his education — underneath it all there was nothing there but ego and greed. That’s what was there.”

The jury found him guilty on 51 of 91 counts. In an unusual move, the judge ordered him to pay for his incarceration: $2,158.77 a month.

His conviction in December 2008, after a trial spanning three months, was followed by four years of fruitless appeals. The danger behind the government’s decision to go after him, and of its success, is that it will make doctors wary of needed procedures and put lives at risk, said Amy Adelson, a New York City attorney who handled the appeal. “I don’t think we should be criminalizing the act of a doctor’s judgment.”

Patel still has a loyal following in Lafayette, where he’d lived relatively modestly, driving a used Mercedes. Relatives in India said he shared many of the millions he made with them, and paid for nieces and nephews to attend college in the U.S. Other than an occasional game of tennis he had no hobbies, his wife said, and never vacationed with her and their son. “He didn’t have time for us. The man loved medicine.”

When he was on trial, he saw patients after court adjourned. Seven of the people named as victims in the indictment testified for the defense, not the U.S. Former patients write to him in prison, and a few visit him there.

“I still get stares and questions,” Uebinger said. “There was a time when he did a lot of good.”

Every Saturday and Sunday, Patel’s wife spends time with her husband at the prison 70 miles from Lafayette. She said he hasn’t been happy recently, having lost two weeks of computer privileges for storing fruit in his locker, a violation of prison rules. He’d been using the computer to work on his defense in the whistleblower suit.-Bloomberg