Earlier this year I had the extraordinary experience of spending several hours on the phone with Mark Midei, the poster-boy (or scapegoat, depending on whom you ask) for all that’s wrong with interventional cardiology in the US. I approached the conversation with some trepidation and discomfort. I’d followed his story closely– but not obsessively– and had written harshly about him. I wasn’t sure why he wanted to speak with me.
It turns out he wanted to get his side of the story across to cardiologists and others interested in the case. I listened to Midei with interest and astonishment, and over the course of our two long phone conversations I found it hard not to feel a certain amount of sympathy for the man. In his absolute fall from a position of enormous success to the disgrace and humiliation of a widely reviled public figure, I saw the elements of a tragic figure. Once a highly successful and admired physician, he was now, in his own words, a man who couldn’t get a job taking blood pressures at a Walmart. On the other hand, it was clear that Midei still refused to accept responsibility for his own role in his downfall. He painted a portrait of himself as a victim, but no matter what you ultimately think of his case, he was always much more than a passive victim of circumstances.
In the first part of this post I will try to summarize Midei’s story from his perspective, as he told it to me. Along the way I will inject some additional information and commentary as seems necessary and appropriate. In the second part I will offer my thoughts on his story.
PART ONE: Midei’s Story
Midei began by talking about his long career at MidAtlantic Cardiovascular Associates, which for many years had been the dominant cardiology group in Maryland, and where he had achieved a position as the premiere interventional cardiologist in the state.
The extraordinarily successful MidAtlantic was formed in 1995. The seeds of the current case, Midei claims, were planted when the MidAtlantic cardiologists and the cardiac surgery group at St. Joseph’s Hospital, where Midei mostly worked, had a bitter falling out after a failed merger attempt. Midei says that he played no significant role in this episode. “I wasn’t involved– I was a junior partner at that time,” he told me. (It should be noted here, however, that Midei was one of the four founding partners of MidAtlantic, and was always considered the dominant figure in the group.)
“So we shook hands and walked away from them and we hired four surgeons who joined our group,” said Midei. “And if you could point to one thing that led to all this, this is it.” Midei’s view is that the embittered surgeons then complained to federal investigators about illegal ties between MidAtlantic and St. Joseph’s, thereby initiating the federal probe that ultimately led to his spectacular fall.
(In his comments to me Midei glossed over the extraordinarily bitter turf war sparked by MidAtlantic’s effort to achieve dominance in the cardiovascular marketplace in the Baltimore region. By all accounts, MidAtlantic engaged in a highly aggressive campaign to take business from the surgeons, and in 2010 St. Joseph’s agreed to pay $22 million to resolve a Federal investigation, based on the surgeons’ complaints, that the hospital had provided kickbacks to MidAtlantic.)
But before those allegations surfaced, MidAtlantic “became disaffected with St Joe for various reasons,” according to Midei. In 2006 MidAtlantic began to develop closer relations with a rival hospital, Union Memorial. Midei was disappointed by this development. “I had a big emotional attachment” to St. Joseph’s and “had moved my family” to be near the hospital, he explained.
Although he was the dominant figure in this group, he told me: “I didn’t really have a great deal of influence, and the group began a much closer affiliation with Union Memorial.” The CEO of MidAtlantic had a close relationship with Union Memorial and in 2008 Union Memorial started negotiations to purchase MidAtlantic. According to Midei, the negotiations were completely in the hands of the two CEOs, and he felt left out. “In late 2008 I became almost despondent” about the deal.
Midei then learned that the “whole deal was contingent on my moving from St Joe to Union Memorial. That was made clear to me: if this [deal] happened I was going to have to go” to Union Memorial. “I didn’t feel like I had an option. Although I was despondent, I was more or less resigned, I didn’t take any action to prevent it, other than tell my partners that I wasn’t happy about it.”
(One important piece of background information here is that all the MidAtlantic partners were paid equally. According to a reliable source, MidAtlantic partners received $600,000 per year at the time of these events. This is at the high end for most cardiologists, but clearly Midei could have commanded a far greater salary on his own.)
In late November 2008 Midei said he was approached by St Joseph leadership for “a private conversation.” They outlined a plan to hire Midei because “they really wanted me to stay at St Joe’s.” To Midei “it was like a gift from God, they offered to triple my salary… and I could stay at St Joe.”
Midei soon reached an agreement with St. Joseph, and this effectively scuttled the midAtlantic deal with Union Memorial. In court records, the MidAtlantic CEO was quoted as saying at that time that he would “make it my mission to destroy him [Midei] personally and professionally.”
Midei claims that he “didn’t realize it at the time how disturbing it was to members of my group. Others had left and nobody batted an eye, but when I did it it was like Armageddon.” (I have much more to say about this episode in the second part of this post.)
Six months after Midei moved, St. Joseph received a subpoena from the federal government for records of the hospital’s contracts with MidAtlantic physicians. Midei says he was not concerned at the time by the subpoena. “I was certain that this was a whistleblower suit filed by the disgruntled surgeons who were not having any luck with St Joe’s.” (But another plausible scenario is that it might have been an embittered cardiologist or administrator at MidAtlantic. The Baltimore Sun reported that the investigation began when “a MidAtlantic cardiologist informs one of Midei’s patients — an St. Joseph’s employee — that his stent was unnecessary. The man reports the concern to hospital staff.”)
In February 2009 things changed again for Midei when, in response to the government investigation, the administrators who had hired Midei were all fired and replaced by an administration desperately seeking to resolve the government’s investigation. Initially Midei was just told to keep a low profile: “Keep doing what you’re doing,” is what they told him, he said. Then, shortly before he was fired a hospital consultant told him that there had been a complaint from a patient who said he had received a stent unnecessarily. “I had no idea what he was talking about,” Midei told me.
A few days later Midei was told that the hospital “had done a cursory evaluation and said I had to go home.” He said it felt like “somebody hit me over the head with a baseball bat.” They told him to ignore the patients who were scheduled to see him.
Midei’s view is that St. Joseph’s was doing “anything in its power to appease the Federal investigator.” The investigation didn’t begin because of concerns about his work, he said. Instead, they were looking at St. Joseph because of “alleged kickbacks to mid-Atlantic.” “Our allegation is that once they came in they were looking for a scapegoat or decoy.”
Midei was stunned: “It was unimaginable that there was anything wrong. I had never been sued– 40,000 cases and never been sued. It was just unimaginable.” It took a long time for the new reality of his situation to sink in. “I had done virtually nothing else since 1984,” he told me. He felt sure he would return to his job soon. “It was so far from reality that I would not return. I would do anything that they asked me to do in order to return.”
“They were paying me like a fricking baseball player.”
Midei claims he didn’t care about the money. When he joined St. Joseph his salary had tripled, but he claims that this had not been an important motivation for him. “They were paying me like a fricking baseball player. I didn’t need all that money… but they were the ones offering it to me.” Midei told me he “offered to let them rewrite the contract just to let me work.” But, he now realizes, “in retrospect, they were intent on getting rid of me.”
Midei defends himself from charges that he implanted unnecessary stents out of greed: “the first thing I want you to understand is that I was a salaried employee, I made the same amount of money if I did one case or 4000 cases. I was not compensated by fee-for-service. I was not incentivized to turn a normal patient into a diseased patient.” (In the second part of this post I have much more to say about his salary.)
We talked about peer review at St. Joseph’s. “In 1991 when I came there, there was no peer review, and I argued for peer review.” Finally, when he became the lab director a few years later, “they relented and allowed me to develop a weekly conference” at which “any doc, technologist, or nurse could submit any case for review, no questions asked.” Midei himself had hundreds of cases selected for review, he said, and he “hosted a little less than half of those conferences.” Midei denies later accusations that he “cherry picked cases for review,” since “those cases were selected by numerous sources.” Furthermore,” he explained, “there was a quarterly conference presented by the chief of cardiology, and I didn’t have any role in that.” (But Midei neglected to mention to me that the chief of cardiology was also a MidAtlantic cardiologist.)
I asked Midei about stories I had heard from a cardiologist who had attended the conferences who said “he could never see the lesions before a stent went down the coronary artery.” Midei responded that it was “regrettable that that comment wasn’t raised at the conference, that’s what the conference is for. There were many times when controversial issues were raised.”
I asked Midei about the issue in another way, if he understood that it may have been extremely difficult, given Midei’s power and position, for colleagues to criticize his work. ”I get it and I know how you get around it, which is randomized, blinded review.” But, he pointed out, prior to his case this type of review was never performed. “Nobody else did it at the time.” He added: “they all do it now.”
The Pig Roast
I asked Midei about the notorious pig roast at his house that was sponsored by Abbott, maker of the best-selling Xience stent. This prompted a long discussion about the relationship of interventional cardiologists and hospitals with industry. He acknowledged that interventional cardiologists use “a lot of stuff” but explained that “historically” he “had used everybody’s products, but I’ve always selected the devices that I think are best for my patients.” He talked about his heavy use of Guidant products in the balloon era and then switching to the Cypher stent when it came out, followed by the Taxus stent when it came out because “I thought at the time it was superior. Then the data came out and I switched back to Cypher, and when Xience came out I knew it to be better and we saw improvements in mortality and I pretty much used it exclusively.”
According to Midei, the pig roast was not an anomaly. He said the cath lab directors at all three hospitals in Baltimore had had a picnic every year, and that they were usually sponsored by device companies: “I understand that that leaves a bad taste in people’s mouths.” Now, he said, “I wouldn’t do it again, knowing what I know now.”
We talked about the ubiquitous presence of device salespeople in the cath lab. He believes, now, that “they shouldn’t be in the lab, it’s too cozy.” He has a new perspective on their role: “they’re around because it pays for them to be around. The companies see a benefit to having a representative around when we put in devices.”
Hospitals clearly share some of the blame here, he said. “Hospitals commonly set rules about industry representative access to the cath lab but they rarely police those rules. It should not be the physician’s job to police” these rules, he argues.
They may have paid for the pig roast, but Midei was not in the habit of eating free lunches, he said. “I don’t see a reason for them to be around. I never asked for them to be around. I don’t typically eat lunch, but there’s pressure applied by the staff. The staff wants them around because they like being fed.”
Midei talked extensively about the “really rough road” he’s travelled the last few years. “For the first six months I was catatonic. It was incredibly psychologically disturbing.”
He talked about his desperate search for work after he was fired. For a while he consulted for Abbott, but as the notoriety of his case increased the consulting agreement wasn’t renewed. He worked in Saudi Arabia for a few months but he and his wife found it very hard to live there. “Since then I haven’t done much of anything,” he told me. He does some “ghostwriting” for “think tanks” that have hired him to write “white papers for congresses.”
With three children in college, he had to sell his house, and he’s concerned that he will not be able to continue paying for their education. 2010 was the first year his children qualified for financial aid.
“I always wanted to be a doctor and I would love to be a doctor again,” he said. But “I couldn’t get a job checking blood pressure in Walmart right now.” It’s hard to argue with his assertion the “the attack on me has been thorough and complete.”
Midei said he is now the defendant in about 150 lawsuits, not a single one of which has gone to trial. He’s being sued by his own former secretary and neighbors, and been deposed more than a dozen times. Even in cases where expert reviews have been favorable to him, “the hospital is inclined to settle” because, he says, “the same company that owns the insurance company owns the hospital and they are looking to sell the hospital and want the cloud caused by the case removed.”
“It’s possible that things look different today than they did then.”
I asked Midei whether, in response to the overwhelming amount of positive feedback he had received over many years, from his colleagues, the hospital, and the medical community, it was possible that he might have developed the feeling that, godlike, he could do no wrong, and that almost anyone could benefit from his procedures. But, he said, “they’re not accusing me of pushing the bounds of intervention, they’re accusing me of exploitation of patients. But that’s not me, that’s just not in my DNA.”
With this answer I’m not sure Midei really responded to my question, but he did answer it somewhat obliquely a moment later, agreeing that the standard of practice had changed over time: “I know what the standard is now, and it’s different from what it was then. Even in 2009 after the appropriateness criteria were published my practice had changed.”
At this point he made an important concession: “so it’s impossible for me to look back at some of these cases and say” that they would all be justified today. “It’s possible that things look different today than they did then.”
But Midei insists on a key point: he is very confident that his standards were “no different” than the standards at St. Joseph’s and other hospitals.
“The study that screwed me was COURAGE,” Midei said. “If you listen to Chacko’s testimony [the state’s expert witness in the case where Midei lost his Maryland medical license] he basically thought no one should get a stent if they weren’t having a MI.”
When Midei’s Maryland medical license was revoked, William O’Neill, a prominent interventional cardiologist and expert witness for Midei, told Heartwire: ”I think it’s a tragedy that a fine doctor’s reputation and livelihood are ruined when there was never a single shred of proof that he harmed any patient.” My initial response to O’Neill’s remark was that his sympathy was misplaced. Where was O’Neill’s concern for the patients who had received letters stating that they might well have undergone an invasive procedure without good medical reason to have foreign devices permanently implanted in their bodies?
Now, after speaking with Midei for several hours, and spending a few months thinking about our conversation, I’ve moved a little bit closer to O’Neill’s position. I still think the Maryland patients deserve sympathy, and I still think in all likelihood something went terribly wrong under Midei’s watch and that he bears some significant responsibility for it all, but I feel a lot more sympathy for Midei, and I can’t help but feel that the price he’s paid for his mistakes has been excessive.
But I didn’t exactly drink the Midei Kool Aid. Let me first spell out where I think Midei went wrong.
I was particularly disturbed during several portions of our conversation by Midei’s use of the passive voice, and his tendency to talk about events as if they just happened to him, as if he were simply a victim, without his influence or control. In our conversations he consistently failed to take full responsibility for his actions. After he was fired Midei did in fact lose control of his destiny, but for most of the period under discussion Midei was a prince of the Maryland medical establishment, and his portrayal of his role in the events leading up to the scandal should be critically examined.
In Midei’s telling, he had no role or influence in the negotiations between MidAtlantic and St. Joseph’s. He made a point of talking about the fact that all MidAtlantic partners received the same salary, and then, when St. Joseph’s persuaded him to leave the group, “it was like a gift from God, they offered to triple my salary.” I suppose it’s possible that Midei wasn’t motivated by money, or not primarily motivated by money, but salaries don’t come like manna from heaven. As the most productive interventional cardiologist in the state, Midei simply had to have known that his “free market” value was much higher than what he was receiving from MidAtlantic, and he had to understand why St. Joseph’s was offering to triple his salary. He is correct in saying that he wasn’t directly paid based on his volume, but there had to be unstated but very clear expectations about his role. For instance, it is unlikely that St. Joseph’s would have continued his high salary for very long if Midei had chosen to switch to a career of pure research.
I am also unconvinced by the central contention of his legal defense that he was thrown under the bus by St. Joseph’s to divert the attention of the federal prosecutor away from the whistleblower lawsuit. Federal prosecutors aren’t bulls, easily distracted by anyone waving a red flag. And it’s hard to see how St. Joseph’s benefited by opening itself up to lawsuits totaling hundreds of millions of dollars and by creating an enormous public scandal. Of course, we’re in extremely murky ground here, but at this point I think the burden of proof is on Midei to demonstrate that this is a plausible scenario.
Finally, I still think Mark Midei is almost certainly guilty of poor medical judgments and decisions. There’s no reason to doubt the conclusions of the Maryland Medical Board. Certainly no persuasive evidence has been shown suggesting that the hearings were unfair or biased. I have heard nothing but praise from outside observers about the integrity and credibility of the state’s expert witness, Matthews Chacko.
Nevertheless, I think Midei deserves sympathy and, even more, forgiveness. Midei’s case should not be compared to recent cases where cardiologists have been sent to jail (see this report, for instance, about another Maryland cardiologist). Midei’s judgment may not have been perfect, but I don’t believe he ever intentionally delivered substandard care, or performed procedures solely for the sake of money, or engaged in fraud. Rather, he listened too carefully and for too long to the outpouring of praise, and he came to believe that with his golden hands he could help almost anyone who came across his path. And, until the time of his downfall, no one ever suggested that this view of him was wrong.
Ultimately, responsibility for what happened to Mark Midei must be shared by many others: his fellow workers, the hospital administrators, and, more broadly, the entire medical establishment that didn’t want to look too closely at too good a thing. Everyone benefited, there was no motive for anyone to approach it with a critical eye.
Midei acknowledges that many of his cases, when viewed today, in the post-COURAGE, post-Midei era, would not be favorably viewed. But Midei’s work should be assessed by the standard of the time when it was performed. We may never know the real answer here. There are almost certainly other successful interventional cardiologists out there today who practiced then in a way similar to Midei. But in all fairness to Midei it is true that until the time he was fired there had been absolutely no criticism of his work at any time. Surely the entire hospital and cardiology community has to bear some responsibility here.