Q: How did you learn about the strange case of Michael Swango?
A: He is from my hometown, Quincy, Ill., and that is a relatively small place. I specifically heard about him when Judge Dennis Cashman in Quincy called me. This was the judge who had presided at Swango's trial about 15 years before, when Swango was convicted of poisoning his co-workers. The judge had just heard that Swango had been arrested at O'Hare airport, and he was just shocked that it was still going on. He was extremely frustrated that word had not spread about Swango.
The judge seemed quite upset that none of the safeguards seemed to be working. A doctor who was a convicted felon-and not just for any kind of felony but for poisoning people-was still being hired as a physician.
My initial reaction was virtual disbelief-one, that there was a serial killer from my hometown and, two, that he was getting jobs as a doctor. How could something like this happen? I wanted to know.
Q: How many deaths do you believe can be attributed to Dr. Swango?
A: My own research links him to 35 highly suspicious deaths-some of them so suspicious that I think the circumstantial evidence is overwhelming that he has committed murder, even though he has not yet been charged or tried with that. An FBI agent told Judge Cashman that the FBI had linked him to 60 deaths, and that very well may be.
Q: Your book about Dr. Swango makes for a ghoulish spine-tingler. Do you think his case says something more significant about healthcare?
A: I don't think the point is to terrify people that the next doctor they meet is likely to be a psychopathic serial killer. That is extremely aberrational. To me what is more frightening about the story is the inadequacy of the safeguards that exist to protect the public from these highly aberrational cases and the less shocking and less dire examples of doctors who should probably not be practicing medicine, maybe because of some physical or mental impairment or simple incompetence.
Q: Your book shows that Swango is very clever, a gifted liar and a passable forger. Should the system have been able to stop him?
A: He should have been caught at a very early point in his career. He was almost expelled from medical school and was saved by one vote by one faculty member. But even putting that aside, his career should have come to an end at Ohio State during his internship there. I think that that's abundantly clear.
Q: How did he manage to escape punishment?
A: At Ohio State there was a division between hospital administrators, who for the most part were not physicians, and the M.D.s. The university vice president in charge of all the medical areas and the dean of the medical school was an M.D., and the decision was made by him that all aspects of the investigation were to be handled only by other doctors. Hospital administrators were to some extent excluded. They played supporting roles here and there, but they were not permitted to conduct any actual investigations. The acting executive director of the hospitals at Ohio State, Donald Boyanowski, had urged that the police be called in to investigate. And that recommendation was summarily rejected. Had the police been called, I think there is a good chance that Swango's career would have ended right then and there because he would have been charged.
Q: You wrote at length about the unrealized potential of the National Practitioners Data Bank. What is it exactly, and why is it significant?
A: The data bank was established by federal legislation in 1986 and went into effect in 1990. It's a national compilation of information on disciplinary actions and malpractice verdicts against physicians. That information is available to other doctors and hospital administrators. And here's the most important thing: Administrators and physicians and hospitals are required under the law to report these actions against physicians and to consult the data bank before granting hospital privileges to any doctor they hire.
Q: Why didn't this stop Swango then?
A: The idea is a good one, and it should work. But it's not working for a variety of reasons. First of all the law was subject to heavy lobbying by the American Medical Association, which, based on my research, has opposed virtually all legislative attempts to insert any nonphysicians into the issue of who does or does not practice medicine.
The AMA opposed this bill in its entirety. They failed to prevent its passage, but they did significantly dilute the provisions of the data bank. For example, the requirements of the law apply only to licensed physicians. So the irony was that Swango had been licensed in both Illinois and Ohio. But after he was convicted of poisoning his co-workers, quite understandably and appropriately, his licenses in both Ohio and Illinois were revoked. He was still a physician. He was an M.D. He was a graduate of a medical school. But he was not licensed. Therefore, anyone who hired him could take the position that they didn't need to check the data bank because only licensed physicians have to be checked. Now that's a major loophole-especially in teaching hospitals, when you think of the degree to which interns and residents, who often aren't licensed, handle patients. None of them needed to be checked in the data bank.
Secondly, the only disciplinary actions that are required to be reported to the data bank result from the peer-review process, which means bizarrely that a criminal conviction in a court of law does not have to be reported.
So it's possible that Swango was never in the data bank. I tried to find out. But the information in there is available only to hospital administrators and doctors. To this day I don't know if there was anything on Swango in that data bank.
Q: Several nurses were deeply suspicious of Dr. Swango. Why did they seem to have trouble being heard by authorities?
A: If there was any group as a whole that you could say were the heroes or heroines of the Swango story, it would be the nurses. But I think the story exposes some serious problems in the day-to-day operations of hospitals.
Nurses were isolated within the reporting structure. At Ohio State, it was so extreme that the nurses were certainly under the impression that the were not permitted to address an attending physician.
Literally, as the nurse was standing by the doctor's side at the patient's bed, she was not supposed to say anything. They felt they were treated, and they were, as second- or third-class citizens within the hospital.
It seemed there was a long history of mutual bad feeling between the nurses and the doctors, which made it very difficult when a crisis like this struck for the nurses to respond effectively and to get their message heard.
Later Ohio State went back and did an internal report about what went wrong in this case and zeroed in on the poor relations between doctors and the police. But I thought that report glossed over the equal, if not more serious, problem in relations between doctors and nurses.
Q: Did any other factors work against an effective response to Swango?
A: Potential liability was probably the main issue driving how this was handled in the hospitals. The lawyers were brought into the process immediately in every case. And I think to a potentially dangerous degree, the legal advice determined the course of various investigations and actions taken against Swango. That advice seemed always to have at its heart protecting the institution from potential liability, and it showed scant interest in the future well-being of patients. To an outsider it was almost shocking. This fear of liability dictates much of what is going on in hospitals- that's my impression anyway-even at the expense of patient well-being. And I think this is a sorry state of affairs. I don't mean to be too judgmental about it, because I understand from both sides how things could reach this juncture. There's no easy solution here. But this hostility and mistrust between doctors and hospitals on the one hand and patients and lawyers on the other is a very serious problem that needs to be addressed systematically.
Q: In Zimbabwe, a country with far fewer healthcare resources than the U.S., the investigation of Swango after a baffling wave of patient deaths seemed both speedier and more complete. Was that so?
A: I would agree with that. Certainly, the checking of his credentials by the people doing the hiring there was no better, if not worse, than in the U.S. But once it became suspected that he was actually murdering patients, the hospitals in Zimbabwe moved more quickly and more effectively. First of all, they did call in the police. That was a big difference. And they got him out of the hospital. There wasn't this overriding concern that they were going to be sued. . . . The legal system in Zimbabwe simply does not accommodate the level of medical malpractice litigation that exists in the U.S.
Q: What's the latest on Swango?
A: The investigation by the FBI continues full-throttle as best as I can tell. They're working against a deadline by the end of the year because he could and in all likelihood will be released into a halfway house in January. And I know the FBI fears that the minute he's out of jail he's gone-probably to a foreign country where he would resume his practice. The indication I've gotten is that is there is a good chance that he will face murder charges before he's released. I certainly think he should.