ARDvark Blog Journal of Adhesion Related Disorder: November 2008

Stanford Surgeon's Procedures Raise Ethical and Legal Red Flags
Supporters say Camran Nezhat is a miracle worker -- critics call his operations bizarre and barbaric...

With a white surgical mask dangling rakishly below his chin, Dr. Camran Nezhat looks every bit the part in his promotional video: medical pioneer, gifted surgeon, millionaire inventor of operating room tools. The Stanford clinical professor, recruited from his lucrative Atlanta practice, is a rainmaker for the university's medical center and obstetrics and gynecology department. Since he arrived at Stanford in 1993, he has brought patients, prestige, and scores of surgeons to study at the Stanford Endoscopy Center, which he directs.
But along with his brother gynecologists, Drs. Farr and Ceana Nezhat, he has also brought trouble to this elite enclave of high-tech medicine.
Trailing him to Stanford are allegations of reckless and unethical medical conduct. Critics accuse the Nezhats of performing a bizarre and dangerous medical experiment on the rectums of vulnerable female patients and of falsifying data reported in medical journal articles.
In the past five years, 20 doctors and surgeons across the country have signed statements of serious concern about the Nezhats' surgeries and published research and have called for an investigation.
''In my experience in the fields of law and medicine, I can't imagine a group of men who have crossed the line in more ways in the field of bioethics than the Nezhats,'' said Andrea Scott, a Los Angeles attorney and bioethicist.
And if the allegations against the Nezhats are true, soon top Stanford administrators may face troubling questions about the extent to which they heeded repeated warnings about the Nezhats and investigated the charges against them.
While the American College of Gynecology's code of ethics requires members to report questionable medical practices, a top Stanford official threatened at least one doctor with a lawsuit if he continued to criticize the Nezhats.
''There are serious, serious problems going on at Stanford,'' said Dr. Tom Margolis, a former Stanford Medical School professor who has signed a sworn affidavit charging the Nezhats with misconduct. ''Certain people are covering this up because there is a hell of a lot of money going to Stanford because of the Nezhats.''
The Nezhat brothers have declined to be interviewed. Through their Atlanta attorneys, they deny any wrongdoing and question the motives of their accusers, citing professional rivalry and economic competition. Stanford officials say they have thoroughly investigated and rejected allegations of scientific fraud.
Camran Nezhat is embraced by a large cadre of supporters, including Stanford colleagues and patients, who admire him personally and are awestruck by his abilities in the operating room.
''People like (Nezhat) are a rarity,'' said Salinas gynecologist Dr. Rene Charles. ''I'd compare him to Michelangelo, in terms of his surgical skills.''
In a letter of support sent to The Chronicle, 39 Stanford nurses and other health-care staff members describe Nezhat as a worker of ''miracles'' who takes cases ''others have given up on.''
Yet doubts about the Nezhats date back well into the 1980s, when Camran emerged in Georgia as a pioneer in the nascent art of laparoscopic surgery.
And they have been rekindled by recent developments in an astounding malpractice case that has been languishing in Atlanta courts for six years.
That case could determine once and for all whether the Nezhats are the pioneering surgeons they claim to be or whether they catapulted their careers to Stanford on the basis of a dangerous and grotesque medical fraud.
BUILDING A PRACTICE, 1988
Camran Nezhat and his brothers grew up in prerevolutionary Iran, where each attended medical school. Camran emigrated to the United States in 1974 and completed his obstetrics and gynecology residency at the State University of New York at Buffalo.
In 1978, he received a two-year reproductive endocrinology fellowship at Medical College of Georgia in Augusta. Farr and Ceana followed their older brother to Augusta and eventually joined Camran's growing practice in Atlanta.
During the 1980s, while practicing at Atlanta's Northside Hospital, the Nezhats began to develop a reputation for their skills in laparoscopy, a type of surgery in which laser scalpels, miniature cameras and long-stemmed instruments are worked inside the body through dime-sized incisions.
They published scores of articles in medical journals, claiming a remarkable series of ''surgical firsts.'' They also developed a number of ingenious instruments for the laparoscopic operating room. A company they co-founded, American Hydro-Surgical Instruments Inc., eventually sold for $40 million.
Their specialty was treating endometriosis, a painful ailment afflicting an estimated 5 million American women. It is caused when cells that make up the lining of the uterus migrate and bind to other parts of the abdominal cavity, swelling with the monthly menstrual cycle, sometimes causing debilitating pain. The condition is often linked to infertility.
Northside Hospital began promoting the Nezhats, hiring a public relations firm to spread the word about the doctors and their accomplishments. Camran was featured in Newsweek and the Chicago Tribune, and on MSNBC, CNN, ABC's ''20/20'' and elsewhere.
The brothers garnered a reputation as some of the world's foremost innovators of laparoscopic surgery, attracting cash-paying patients from around the globe.
THE MULLEN CASE, 1991
Suffering from endometriosis, 28-year-old Stacey Mullen flew from Southern California to Atlanta's Northside Hospital in 1988 to be operated on by Camran Nezhat. The surgery was quick, the pain was gone, and Mullen was elated as she walked out of the hospital the next day.
''I was ready to name my firstborn after Camran Nezhat,'' she said.
But, as often happens, the endometriosis and the pain returned. And in December 1991, Mullen flew back to Atlanta for what she thought would be another ''quick little surgery.''
The surgery, however, was neither little nor quick.
Camran and his brother Farr, with colorectal surgeon Dr. Earl Pennington assisting, spent hours using laparoscopic techniques to cut Mullen's colon and rectum free of nerves, blood vessels and connecting tissue. Her ''mobilized'' rectum was pulled inside out through her anus, and suspected endometrial tissue was removed. Her patched-up rectum was then pushed back inside.
Then the complications began.
Hours after surgery, part of her colon dropped out of her body as she sat on the toilet. For months, she suffered from extreme constipation. Sometimes she burped up her own feces.
Mullen never regained normal use of her bowel. Eventually, she received a colostomy and must insert a tube into an opening in her side to go the bathroom.
In December 1993, after nearly two years of continuing pain, she filed a malpractice suit against the Nezhats. ''Those bastards ruined my life,'' she said.
THREE ARTICLES, 1993
Shortly after taking Mullen's case, attorney James Neal discovered two medical journal articles that the Nezhats and Pennington had published after Mullen's operation.
The first appeared in Fertility & Sterility in May 1992, describing a single case using the new pull-through procedure for treating rectal endometriosis. ''As with all new procedures,'' the article said, ''there are no data to establish its safety.''
The second was published in the September 1992 issue of Surgical Laparoscopy & Endoscopy. It detailed a series of 16 rectal surgeries, similar to Mullen's, performed in late 1991 and early 1992 - the period during which her surgery took place.
Yet Mullen's case - and her complications - were not mentioned.
The article listed only a single complication: The doctors had to perform traditional open abdominal surgery in order to complete the suturing of one patient's bowel.
''This procedure has been performed safely in this initial series,'' the Nezhats wrote, and they claimed fewer problems than would be expected with regular open abdominal surgery.
The Nezhats aggressively publicized the ''success'' of the new procedure. It was touted by Ethicon Inc., the Johnson & Johnson subsidiary that made the instruments the Nezhats had used. ''For the estimated 185,000 women who suffer from endometriosis of the rectum, this new advance provides them with relief from the digestive symptoms,'' the company said.
At a 1991 American Fertility Society meeting in Orlando, and a 1992 convention of the American College of Obstetricians and Gynecologists in Las Vegas, Ethicon promoted their instruments and the Nezhats, even including a video of the surgery.
But skepticism about the Nezhats and their procedure was beginning to grow. The lack of complications did not make sense for such radical bowel surgery, doctors said. Some surgeons who viewed the promotional video were puzzled: They could not see evidence of endometriosis.
Stories began circulating in the surgical community around Atlanta's Northside Hospital. The medical journal articles said the average operating time for the surgeries was three hours, but during the time of the study, the Nezhat operating room had been burning lights deep into the Georgia night.
Then Neal discovered a third journal publication, written by one of Nezhat's Atlanta colleagues and published more than a year after Mullen's operation.
The article in Surgical Endoscopy described a ''pilot'' study testing the same procedure on pigs in order to assess its safety on humans.
''Some damage to the sphincter might occur,'' the authors wrote, but the long-term effects were unknown: The pigs were ''sacrificed'' before they awoke from anesthesia.
Neal and Mullen were stunned: Not only had the Nezhats omitted Mullen's case from their series - and in doing so did not report her complications - they apparently had tried out the new procedure on her and other women before it was tested on pigs.
Nezhat attorney David Walbert said the pig study ''had nothing whatever to do with the safety and efficacy'' of the human surgery described in the medical journals. The purpose of the pig experiment, he said, was to determine whether the procedure was suitable for treating cancer.
'BARBARIC,' 1993
When Neal began contacting medical experts about Mullen's surgery, many sent him letters and affidavits calling the operation radical and experimental; they characterized it as ''bizarre'' and ''barbaric.'' It resembled a cancer surgery that had been discredited years before, after complication rates as high as 50 percent were reported.
The surgery had not been vetted before a Northside Hospital Institutional Review Board, the usual requirement for an experimental procedure.
''Normally you go before an IRB, come up with scientific background, present a plan, torturous documentation, nine pages of informed consent, and you cannot charge for it,'' said Ohio general surgeon Dr. Francis Barnes.
Mullen and her insurance company, however, were billed $9,900 for the rectal surgery. She eventually ran up more than $1 million in additional medical expenses as a result of the operation, according to Neal.
Neal also learned that Mullen - and possibly four other women whose cases were included in the Nezhats' articles - had signed an unusual document, recently created by the Georgia legislature. It was called a ''waiver of informed consent,'' and it set aside a patient's right to detailed information about a surgery.
''This is incomprehensibly unethical,'' said Arthur Caplan, director of the University of Pennsylvania Center for Bioethics and one of the nation's foremost medical ethicists. ''You can no more sign away your right to informed consent than you can voluntarily sell yourself to slavery.''
''I never knew I was signing such a document,'' Mullen said. ''I thought it was a regular consent form.''
Yet the most disturbing discovery was made in Mullen's own medical records. In his operative notes, Camran Nezhat wrote: ''There was evidence of severe endometriosis of the rectum.''
But Mullen's pathology lab report disclosed that there had been no endometriosis on the wall of her rectum at all - just a few cells in the adjoining fat. The surgery had not been necessary in the first place.
16 MEDICAL RECORDS
Neal went to court and demanded to see the medical records of the 16 other patients the Nezhats had operated on in Georgia, convinced they would show complications, more waivers of informed consent, and surgical data different from what was reported in the Nezhat articles.
But the Nezhat legal team refused to turn them over, citing privacy concerns of other patients - at least 10 of whom signed affidavits opposing any release.
Mullen was given the waiver form by mistake, they explained, and she was told about the procedure's risks. Medical experts for the Nezhats also insist that the rectal surgery was not experimental, so no Institutional Review Board process was required.
''In my opinion, the surgery performed on Mary (Stacey) Mullen was a necessary procedure and would not require any special consent form for experimental surgery,'' said Dr. Robert R. Franklin, a clinical professor in the department of obstetrics and gynecology at Houston's Baylor College of Medicine.
The Nezhat lawyers also argue that Mullen's rectal surgery did not cause her bowel problems. ''She reported constipation before the procedure,'' said Walbert.
THE FIRST WARNING, 1993
In the early 1990s, Stanford Medical School's department of obstetrics and gynecology was in trouble. Despite the school's lofty reputation, the department was not fully accredited.
The Chicago-based Accreditation Council for Graduate Medical Education demanded more ''surgical volume'' before it would upgrade the program's ''provisional'' status.
Yet when Dr. Nick Spirtos heard that Stanford was recruiting the Nezhats, he could not believe it.
Spirtos is a Palo Alto gynecological oncologist with an august reputation of his own. Like the Nezhats, he is a clinical professor, which means he serves on the school's voluntary teaching faculty with surgical privileges at the medical center. He also holds the elected post of deputy chief of the obstetrics and gynecology department.
During the past nine years, he has become a leading critic of the Nezhats and their Stanford defenders.
''I think everything they've written is fraudulent,'' said Spirtos, whose office is just one floor below the Nezhats' in an upscale medical office building near Stanford. ''I don't think they should be allowed to practice medicine.''
Spirtos had traveled with colleagues to a gynecology convention in Florida to see the 1991 presentation by Camran and Farr Nezhat sponsored by Ethicon. The program included videos of two new Nezhat operations, one of them showing the rectal procedure that would be performed two months later on Mullen.
''We couldn't believe what we saw,'' Spirtos said, noting that there was no evidence of endometriosis. ''The surgeries didn't make any sense.''
But before they could quiz the Nezhats about their presentation, Spirtos recalled, the Nezhats left the podium, refusing to answer questions.
Two years later, after studying their journal articles, he warned university administrators not to bring them to Stanford. Spirtos argued that the Nezhats' published data were simply too good to be true.
But Spirtos said his advice was ignored.
''It was a perfect marriage,'' he said. ''The Nezhats had all the dough in the world but no title. And Stanford needed desperately to have surgical volume to legitimize their (obstetrics and gynecology) department.''
NEW TROUBLE, 1993
Within two years of the Nezhats' arrival in Palo Alto, Camran became director of the new Stanford Endoscopy Center for Training and Technology. And Ethicon, which had retained Nezhat as a surgical investigator, agreed to provide a $125,000 annual grant to the center.
Quickly, the Nezhats began pairing up with surgeons outside their immediate discipline - including specialists in cancer, heart and brain surgery - with the goal of expanding the use of minimally invasive surgical techniques.
The practice troubled Spirtos, and when he learned that Camran Nezhat intended to operate on a patient of one of Spirtos' medical partners, he wrote in protest to Dr. Mary Lake Polan, the chief of the obstetrics and gynecology department.
The patient was a 74-year-old woman who had undergone extensive surgery for the removal of pelvic cancer, and Spirtos told Polan that the patient's cancer had spread so extensively that laparoscopic surgery would be useless.
''Certainly, (Nezhat) has no experience in this area (treating cancer), and it seems to me serious patient care issues are being placed on the back burner in your headlong rush to promote the Nezhats,'' he said in a 1993 letter to Polan.
Despite Spirtos' protests, Nezhat and Stanford cancer surgeon Dr. Nelson Teng went ahead with the operation.
The patient was on the operating table for seven hours and was hospitalized for seven days afterward. Her bladder and bowel were punctured during the operation, Spirtos said, and the doctors could not remove all the cancer. In his report to the university's ''quality assurance'' review committee, Spirtos charged that Nezhat, credentialed as a gynecologist, was performing cancer surgeries, a specialty that requires years of extra formal training. He also laid out four other Nezhat cancer cases for the quality assurance review committee.
''No other hospital would allow a gynecologist to perform (cancer) surgeries,'' said Spirtos.
But his hope for a quick review of the five cases soon faded. ''Stanford sat on those cases for years,'' he said.
NEZHAT'S AFFIDAVIT, 1994
Meanwhile, Mullen and her attorney continued to press for the release of the files on the 16 other women who had undergone the rectal procedure. And the Nezhats continued to refuse.
In a sworn 1994 affidavit, Camran Nezhat declared it would disrupt his practice for months if he were ordered to produce records demanded by Mullen's legal team.
He described a filing system with 20,000 patients, each listed only alphabetically, with no index, no computer database and no cross-referencing by type of treatment, surgery performed, or journal publication.
''I would . . . have to manually review every single patient record . . . to determine whether the record referenced a patient whose procedure was the subject of a journal article,'' he testified.
The affidavit shocked Nezhat's critics, who say it has cast a pall on the validity of the Nezhats' research ever since.
''I've been doing this kind of research for 25 years. There is a substantial problem if you cannot link patient records to publications,'' said Dr. David Grimes, former chief of obstetrics and gynecology at San Francisco General Hospital, who briefly served as a paid expert to Mullen's legal team.
How, asks Grimes, can the Nezhats publish extensive studies based on old charts and old data involving hundreds of patients over many years if those patients' files are not indexed or cross-referenced?
Grimes was not the first doctor to question the Nezhats' research. Long before they publicized their controversial bowel surgery, competitors and collaborators alike were skeptical of the brothers' claims of surgical firsts and problem-free procedures. In 1987, Dr. Harry Reich, a world-renowned laparoscopic surgeon at New York's Columbia-Presbyterian Medical Center, agreed to collaborate with Camran Nezhat on a surgical study of 105 tubal pregnancies.
But Reich was bothered by Nezhat's repeated failure to share his data on 40 patients to be included in their article in the Journal of Reproductive Medicine.
''So we had to delete the data from the paper,'' Reich recalled.
The Nezhats' lawyers say Reich never requested any data that were not provided.
In 1990, a Nezhat report in the journal Obstetrics and Gynecology also raised eyebrows. The Nezhats stated they had performed 4,000 laparoscopic surgeries without injuring a ureter, the tube connecting the kidney and bladder.
Their claim drew a sarcastic response from three Yale University doctors: ''The authors are to be congratulated. . . . Either these surgeons had other complications, perhaps as serious, or they possess an unbelievably high level of skill and judgment.''
Other articles in which the Nezhats claim to have reviewed thousands of old cases include:
-- A 1995 textbook article describing 214 complications among 6,949 cases in Atlanta and Stanford from 1982 to 1993.
-- A 1996 medical journal report of severe urinary tract endometriosis in 28 women among 2,226 treated for endometriosis from 1989 to 1994.
-- A 1997 study examining 5,300 surgeries dating back to 1988, counting up 11 hernias caused by insertion of the laparoscope.
Atlanta attorney Walbert scoffs at accusations of medical fraud. ''Many, many surgeons'' have conducted research with the Nezhats, he said. ''Those who have any knowledge have never claimed there was anything 'bogus' about any of the reports.''
Dr. Sally Tazuke, a Stanford reproductive endocrinologist who has worked with Camran Nezhat frequently, said his reported complications are low because he is exceptionally good at what he does - even while taking on the riskiest cases. ''If I were a patient, I would sign up with him. I'd send any family member,'' she said.
Skeptics say the stakes are high. Dr. Thomas Lyons, an Atlanta gynecological surgeon who believes the Nezhats have published journal articles with phony data, said medical fraud can lead unsuspecting doctors to hurt their patients.
''This is as dangerous a situation as you can run into in medicine, because people may be making medical decisions based on something that doesn't exist,'' he said.
If someone ever questioned the veracity of his own data, Lyons said, ''The first thing I would do is throw that data right in their face. . . . The best defense in the world is the truth.''
NEAL'S LETTER, 1995
In January 1995, Mullen's attorney, James Neal, wrote to Stanford, alerting the university to the allegations his legal team was making against the Nezhats. As a former hospital counsel himself, he said he thought they would appreciate a copy of the Mullen lawsuit.
''I feel that your institution should have the opportunity to evaluate these matters . . . given your understandable and overriding concern for the patients within your institution,'' Neal wrote.
But Stanford took no action.
Instead, Margaret Eaton, a university lawyer, forwarded the letter to Nezhat's attorney in Atlanta, with a note saying that ''we do not intend to respond to this letter, nor are further communications from Mr. Neal welcome.''
In June 1995 the Accreditation Council for Graduate Medical Education approved full accreditation to Stanford.
ALLEGATIONS, 1996
A year later, Neal sent Stanford a thick package of documents, laying out in more detail the charges against the Nezhats and asking Stanford to investigate.
Dr. Richard Popp, Stanford's senior associate dean for academic affairs, said Neal provided a ''massive amount'' of what he called ''disorganized'' information.
Popp finally opened an inquiry into the charge of scientific misconduct. But university officials contend that by that time, some of the allegations, including Neal's claim of medical journal fraud, had been thrown out by the Georgia courts.
Neal, who freely admits that he has become obsessed with exposing the Nezhats, was running up a list of legal setbacks. In his dogged pursuit of the Nezhats, he was building a reputation as a crank.
He was disqualified from the malpractice case by a Georgia judge in 1995 for ''unethical behavior'' and could no longer represent Mullen. After a federal judge last year tossed out his attempt, on behalf of another client charging malpractice, to use racketeering charges against the Nezhats, Neal was charged with contempt of court. The judge also assessed $384,000 in ''sanctions'' against the plaintiff and her remaining attorneys. The sanctions are on appeal.
Neal denies the unethical conduct allegation, and the contempt of court charge was recently dropped. The only thing he is guilty of, he says, is aggressively representing his clients against institutions willing to look the other way.
''These guys are bad doctors, some have even said evil, and they have to be stopped,'' he said.
WITNESS, 1996
Shortly after Dr. Tom Margolis joined Stanford as an assistant professor and chief of pelvic surgery, Farr Nezhat invited the newcomer to watch him perform a complex laparoscopic procedure.
During the operation, Nezhat cut the patient's ureter. Margolis, who had also served as director of urogynecologic/pelvic surgery at Northwestern University Medical School, assumed it was an accident, a known but unwelcome complication of the difficult surgical technique. He stepped in to assist Nezhat in repairing it.
But a short time later Margolis learned that, in a post-operative review session and the operative report, Nezhat described the cut as deliberate. He said he sliced the ureter to remove endometriosis that could have blocked urine flow.
Margolis was outraged. He said that he saw no endometriosis on the ureter and that the pathology report proved it.
''It was clear that Dr. Nezhat was performing an unnecessary procedure,'' he said in a sworn affidavit.
THE POLAN MEETING, 1996
More than two years passed before Stanford's quality assurance committee took up the review of the five cancer cases in which Spirtos had alleged improper surgeries by Camran Nezhat.
Just before the review committee was finally set to meet, Dr. Mary Lake Polan, chairman of obstetrics and gynecology, dropped by Margolis' office. He was one of the physicians reviewing the cases.
''We need to make sure that Nezhat is cleared on all these (cancer) cases,'' she told him, according to his affidavit.
Ultimately Margolis - and the other members of the quality assurance committee - voted in favor of Nezhat on all charges.
Polan said Margolis' allegations are false.
''I adamantly deny the statements attributed to me and deny there has been any pressure to exonerate any physician during the quality of care committee process," she declared in a written response to The Chronicle.
Margolis' decision to vote to exonerate Nezhat would haunt him for more than a year, until finally he had to act.
THE SHUER LETTER, 1998
In April 1998, Margolis met with Dr. Lawrence Shuer, chief of staff of the medical center. He told Shuer about the cut ureter incident and the pressure Polan had allegedly exerted on him.
''He (Shuer) acutely and abruptly ended our conversation, and I was excused from his office,'' Margolis said.
More than a year later, when Shuer learned Margolis was still criticizing the Nezhats and Stanford, he sent a written warning:
''Rest assured that Stanford Hospital and Clinics intends to pursue its full legal remedies if these defamatory and libelous statement do not cease,'' Shuer wrote.
Furious, Margolis, who had left Stanford to practice with Spirtos at the Women's Cancer Center in Palo Alto and Los Gatos, wrote back, saying that Shuer's job as chief of staff was ''patient protection not doctor protection.''
''The data which (the Nezhats) have published, including the rectal eversion procedure, is fraudulent, yet their publications are being accepted as standards in the surgical community. Stanford, by not auditing this clinical data, has ignored the concerns of scores of surgeons,'' Margolis wrote.
STANFORD'S DUTY, 2000
Defenders of the Nezhats at Stanford dismiss both Spirtos and Margolis as jealous competitors. But other medical experts say Stanford should have demanded a review of the 16 cases and has shirked its responsibility to verify the Nezhats' research claims.
''Stanford has a duty to review this,'' said Dr. Warren Grundfest, chairman of Biomedical Engineering at UCLA and an expert in new medical technologies. ''Serious allegations have been made by credible people, but Stanford has played like an ostrich with its head in the sand.''
But Stanford officials contend they are not obligated to review the 16 patient records because the rectal surgeries were performed in Georgia before the Nezhats came to the West Coast. Shuer said the procedure in question has never been performed at Stanford.
It was appropriate for the Nezhats to leave Mullen's case out of the medical journal, according to Stanford, because she was ultimately found not to have rectal endometriosis like the other patients.
Stanford reviewers have never asked the Nezhats or Northside Hospital for the records to verify the accuracy of the other 16 cases. ''We have no right to the records and do not want to violate patient privacy,'' said Stanford's lawyer Debra Zumwalt.
The university also never interviewed Mullen or the 20 doctors who have expressed concern over the Nezhats' research.
According to Stanford, the appropriate institutions to investigate the Nezhats are Northside Hospital, the Georgia Medical Board and Mercer University, where the Nezhats were clinical professors at the time of the surgeries. ''Stanford will carefully review the conclusions of those investigations,'' said Popp.
But a spokesman for Mercer, a Macon, Ga., medical school founded in 1986, said the school has no investigation pending.
The Georgia Medical Board's investigation of the Nezhats is continuing. The board will not comment on its status.
Stanford attorney Zumwalt said Margolis' complaint to Shuer regarding the cut ureter incident was never put in writing. Shuer said he asked Margolis for more information, and none was provided, but the case has now been identified and is being investigated by the quality assurance committee.
The university said the Nezhats have been cleared of allegations that they operated outside their specialty. Officials would not comment, however, on any details of the five quality assurance cases because they are confidential.
''One thing I can point out,'' said Zumwalt, ''is that doctors and patients and their families can reasonably disagree as to how aggressive to be in treating terminal diseases.''
GEORGIA COURTROOM, 2000
Mullen has refused to engage in monetary settlement talks with the Nezhats and promises to continue her suit until the records of the 16 other women are made public.
''My life has been changed in a very horrible and profound way by the experiment (that) Camran Nezhat has conducted upon me without my knowledge,'' Mullen said in an affidavit. ''I despair that other women will be injured by well-meaning surgeons who believe Camran Nezhat's article that there were no complications from this new surgery.''
In November, after a battle spanning six years - and six judges - Superior Court Judge Melvin Westmoreland in Atlanta ordered a confidential release of the records to Mullen's lawyers, and in January, the Nezhats and Northside Hospital turned them over.
While the records remain sealed, medical experts hired by Mullen's legal team to review the documents have written Judge Westmoreland expressing their concern about what the records contain, and urging that they be unsealed, in the public interest. ..
William Carlsen can be reached at wcarlsen@sfgate.com. Sabin Russell can be reached at sabin@sfgate.com.

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