STATE COLLEGE -- When anesthesiologist Dr. Danae Powers joined the Centre Community Hospital staff in 1992, she remembers hearing a warning about another anesthesiologist there, Dr. Edward Dench Jr.

"They told me he was a troublemaker."

Dr. Danae Powers, an anesthesiologist who was once chief of staff at Centre County Hospital, now works at surgical centers and outpatient clinics. View larger image. (John Beale, Post-Gazette) Also in Day Three: Doctors pay for reporting suspicions Doctors who spoke out Day Two: When right can be wrong A negative data bank listing isn't easy to erase Rules of fair play don't always apply Doctors who spoke out Day One: How the tables turn on doctors Dispute over treatment of heart patients derails career Doctors who spoke out About the team Audio Clips: Steve Twedt talks about the series

Dench, who this month completed his one-year term as president of the Pennsylvania Medical Society, said his "troublemaker" label started in 1991 after he informed hospital officials that a fellow anesthesiologist was working three and four surgeries simultaneously, leaving nurse anesthetists in charge as he moved from operating room to operating room. Dench told them the doctor was billing Medicare for all the procedures.

"That put them on record, that if they got caught by Medicare, they had knowledge of it," Dench said.

Within a month, he said, he started getting written up for various infractions and was told he was uncooperative.

He further alienated his supervisors when he refused to handle simultaneous surgeries on different floors. To Dench, that was unethical and probably illegal, partly because he would have been billing for procedures where he wasn't always present. The administrator told him, "It won't matter. It would help the schedule work better and you won't get caught."

It didn't take long before Powers, too, grew concerned about practices at Centre Community, which is the primary hospital not only for the 38,000 permanent residents of State College, but also for Penn State's 40,000 students.

Powers, who had worked at organ transplant programs in Pittsburgh and Atlanta, had gone to State College because her husband was from the area and they thought it would be an ideal place to raise a family.

But she couldn't ignore the problems she saw at Centre Community.

She spoke to her supervisors at the hospital after noticing that patients were being wheeled into surgery without standard preoperative workups that might alert the surgical staff to problems, or with inaccurate information about their conditions. Nurses also told her some anesthesiologists would go to lunch in the middle of a surgery, leaving responsibility for monitoring the patient to a nurse anesthetist.

Powers said her department chair told her not to worry about it.

"Nothing changed," Powers said.

But Powers did worry -- for her patients and for her own potential liability. In late 1993, she consulted a lawyer about how to respond in case the hospital ever asked her to do something she thought was improper. "He said, 'The Nazi Defense will not work. You cannot say they made me do it. I had no choice. It was my job or else.' "

So she wrote a memo in March1994 to the hospital board and chief of staff, detailing the problems and dangers of what she deemed sloppy medicine.

'Life became miserable'

	John Beale/Post-Gazette
	Dr. Danae Powers, an anesthesiologist, criticized patient care at Centre County Hospital.

After that, she said, "My life became miserable at the hospital. The scheduling became absolutely unbearable. They started trying to slander me. They started making stuff up about me. I got written up for the first time since I had been there."

Later that year, Powers' fears about poor care were realized when Charles Conrad, 69, of Bellwood, Blair County, died after elective knee surgery at Centre Community.

To avoid unnecessary bleeding during the operation, a tourniquet had been applied above Conrad's knee. Once the operation was done, the tourniquet was removed, but doctors could not restore blood flow to his leg.

Powers, who was not involved in the original operation, was called to help with emergency surgery on Conrad's deteriorating leg. When she checked his chart, she saw that he had a history of systemic atherosclerosis -- hardening and blocking of his arteries -- that should have precluded use of a tourniquet, and probably the surgery.

Realizing the gravity of his condition, Powers said, she begged the surgeon to transfer Conrad to another hospital that might be better equipped to care for him, but was told he was too sick to move. Later that weekend, Conrad's heart stopped and he died in Centre Community's intensive care unit.

"No one ever feels good about a bad outcome, even if there's nothing that can be done to prevent it. Can you imagine how it feels when you know it didn't have to happen?" She went to her department chief and other administrators, upset. She was again told not to worry.

The hospital, in fact, seemed more concerned with Powers than with correcting the problems she was pointing out.

In May 1995, she received a letter from the hospital president, rebuking her for "derogatory, if not slanderous, remarks relative to other physicians." The next month, she received a critical evaluation, calling her "uncooperative at times" and saying she did not always adhere to medical staff bylaws, rules and regulations.

Asked about Powers and Dench, Robert Martin, Centre Community's longtime outside legal counsel, said: "They were uncooperative." He said hospital officials believed the anesthesiology department had divided into two warring camps, bickering over schedules and refusing to cover for each other.

"It reached a point where there was no question but that the hospital had to go to an exclusive contract, where the contract guaranteed that the physicians would in fact work together." The fact that the new group did not include Dench and Powers, Martin said, is the real reason behind their complaints now.

And he dismisses suggestions that Dench and Powers faced reprisals for pointing out patient care problems.

"Nothing could be further from the truth. We expect all physicians to raise concerns about quality of care," Martin said. "There wasn't a quality of care issue. The issue was an anesthesiology staff where there was no cooperation."

Another death

Months after Conrad's death, though, quality of care became an issue again.

On June 25, 1996, William Curley, 73, the retired director of Penn State's food service and father of Penn State Athletic Director Tim Curley, entered Centre Community for a routine hip replacement.

A day later, he was dead.

A subsequent lawsuit brought by Curley's widow, Florence, revealed that a nurse anesthetist had suggested the surgery be postponed while Curley, a diabetic with heart disease, high blood pressure and unstable angina, was evaluated further. The anesthesiologist refused to delay the operation, and apparently did no preoperative evaluation. In depositions for the civil suit, two colleagues said the doctor "had admitted to them that he did not perform preoperative evaluations because he was not paid for them."

Despite his frail condition, Curley received "the same dosage of anesthesia as would have been provided to a healthy, young male," precipitating his death, according to court documents. The jury awarded Florence Curley $750,000 against the physician, a judgment later upheld by an appeals court.

After the Curleys learned about Powers' previous criticisms, they also sued the hospital board, noting that she had alerted the hospital that charts were not being read before surgery. The suit was settled for undisclosed terms, but hospital attorney Martin cautioned against reading too much into that.

"We settle a lot of cases. There are a lot of factors that go into that," he said.

Because of the family's prominence, publicity from the Curley case brought new scrutiny of Centre Community, both from its State College neighbors and state officials.

In July 1997, Centre Community, which is changing its name to Mount Nittany Medical Center, was cited by the Pennsylvania Department of Health for several deficiencies in its anesthesia department.

State inspectors found that patients were not evaluated before or after surgeries, there was no record that outpatients had been told of potential risks of anesthesia, and there was a "lack of established criteria for safe administration of anesthesia."

Martin downplayed the report. "They're always going to find deficiencies. And when a deficiency is noted, it is corrected."

Four months later, though, state inspectors slapped the hospital again "for not actively pursuing" quality improvement in the surgical and obstetrics departments. For a second time, they found that there was no record of pre-anesthesia evaluation, this time for expectant mothers. Eight patients had no record of a post-surgical visit from an anesthetist.

Investigating the critic

The hospital, meanwhile, had launched its own investigation -- of Dr. Danae Powers.

In a Dec. 13, 1996, memo, hospital President Lance Rose told the chief of staff to look into Powers' "disruptive conduct and possible breach of patient confidentiality" because Powers "has raised an issue of quality of patient care in the Anesthesia Department."

Six months later, Rose notified Powers and Dench that Centre Community would be contracting out anesthesia services so "all current anesthesia privileges granted to members of the Anesthesia Department will terminate on Jan. 1, 1998." That included both of them, although Powers said she had been told some arrangement would be made so she could continue there.

That same month, the 150 or so members of Centre Community's medical staff elected Powers, then 39, as chief of staff. "Everybody was hoping Danae could do something," to raise quality, said Dr. John Newkirk, a plastic surgeon there at the time.

As one of her first tasks, Powers appointed obstetrician/gynecologist Dr. Michele Manting-Brewer to head an ad hoc committee "to look into quality mechanisms at the hospital." Manting-Brewer got back to Powers within two weeks.

"She came to me and said, 'Danae, there is not a true quality assurance mechanism going on in any department in this hospital. The one that comes closest is the ER, and [its system is] really poor. But it's happening nowhere. There's no real review, there's no thoroughness.' "

The hospital, meanwhile, was trying to respond to the sudden critical attention from the state.

In an August 1997 memo to Centre Community's board, Rose told them that a state health official "had been called by four physicians on the hospital's medical staff alleging quality issues and lack of reporting of these issues."

He added: "I felt the board should be aware that members of the medical staff are attempting to negatively impact on the hospital's license to operate."

Powers' final, fateful move came Oct. 8, 1997, when she took her concerns directly to the hospital's board chairman who, she recalled, said little during their 30-minute meeting.

Eight days later, Powers fielded an inquiry from a reporter at the local newspaper, the Centre Daily Times. "He asked me for comment because he had been told by Lance Rose that I was going to be gone as of Jan. 1." Less than five months into her tenure as chief of staff, she was about to lose her hospital privileges.

Powers sues

In December 1997, as Powers prepared to leave Centre Community, she filed suit against the hospital, alleging it had negligently allowed preventable patient deaths. The hospital told the Centre Daily Times that the suit was an attempt to derail the contract with the new anesthesia group. It later settled the suit with Powers for an undisclosed sum.

After some patients canceled elective surgeries at the hospital following publicity about Powers' suit, 98 members of the medical staff, presumably including several who'd voted for Powers to be chief, signed their names to a full-page ad supporting the hospital's quality reviews.

But later that year, state inspectors again criticized Centre Community for its "deficient" quality assurance program, citing the hospital's ineffective process for reporting "any unusual incidents," including unexpected deaths.

Martin said that whatever problems the hospital had before, they've been resolved with the exclusive contract held by a group that includes the anesthesiologist sued by the Curley family. He called it "presumptuous" to interpret Powers' and Dench's exclusion as an act of reprisal.

But the problems haven't gone away. In fact, Centre Community is currently facing a lawsuit from obstetrician Dr. Terrence Babb, who says the hospital retaliated against him for reporting substandard care that included the deaths of two mothers shortly after they gave birth.

Today, Powers still works in the State College area, primarily at local surgical centers and outpatient clinics. In 2002, she became a member of the state's Patient Safety Authority at the recommendation of Centre County Republican Sen. Jake Corman, who cited her uncompromising commitment to patient care. Corman said he received many calls of protest -- he won't say from whom -- when he proposed Powers for the group.

"That tells me it must be a good appointment," he said.

	John Beale/Post-Gazette
	Dr. Edward Dench, Jr., immediate past president of the Pennsylvania Medical Society, now must travel from Ohio to Maryland to find work as an anesthesiologist. He is lobbying for statewide peer review panels so physicians can appeal to a body of experts outside their hospital.

Dench works independently as well, as far away as Ohio and Maryland. As immediate past president of the 20,166-member Pennsylvania Medical Society, he lobbied for statewide peer review panels so physicians who face peer review can appeal to a body of experts outside their hospital if they believe the process is unfair. He hopes to make that a national campaign.

The discouraging part for Powers is that former colleagues have told her that area hospitals have started including contract clauses that make it harder for physicians to challenge their hospitals over patient care issues and limit the hospitals' liability for patient care problems. She fears that by advocating for better care, she's made it harder for other physicians to speak up.

"A bunch of attorneys got rich, the hospital got a road map" for hospital administrators to deter complaints, "and the doctors who are still there have it worse," Powers concluded.

"If I had it to do over again, I wouldn't."

Tomorrow: Frustrating efforts to fix the system