The treatments usually took place on Friday afternoon, and afterward Tana Collard’s three children would be in a stupor for most of the weekend.
Once a month Collard would drive her children—Monté, now 19, Carrie, now 15, and Travis, now 14—the 130 miles from their home in Victoria to the San Antonio office of Dr. Deborah Spiva. There the children would sit in recliners, intravenous lines inserted in their arms, and watch soap operas or stare at fish in the aquarium or doze while bottles of immunoglobulin dripped into their bodies for up to three hours.
The Collards first met Dr. Spiva in August 1984. They were living in the Rio Grande Valley, where Tana’s husband, John, was finishing his training as a laboratory technician. Earlier that summer Monté had begun suffering a series of inexplicable illnesses: sore throats, headaches, recurring boils. During one particularly severe episode, in which Monté had nearly intolerable headaches, John and Tana took him back to the family’s general practitioner, who recommended that Monté see a specialist in immune disorders: Dr. Spiva at Humana Hospital Metropolitan in San Antonio.
When Monté arrived at the hospital, Dr. Spiva, who headed the team handling the teenager’s case, admitted him to intensive care. To the Collards, she seemed to be a new type of physician—a woman bursting with confidence and command who also looked stylish and elegant. She impressed them with both her scientific knowledge and her warmth and caring.
The diagnosis was that Monté had a variety of ills: herpes zoster, oral candidiasis, and spinal meningitis. Dr. Spiva put him on a battery of drugs and in a little over a week discharged him. Tana and John couldn’t have been more grateful; they credited Dr. Spiva with saving their son’s life. For the Collards, Monté’s recovery would be the last good thing to happen for a long time.
In the course of her treatment of Monté, Dr. Spiva had discovered the cause of his susceptibility to infections: she said he was suffering from Job’s syndrome, an inherited disorder of the immune system. A diagnosis of Job’s syndrome is not a happy event. Victims, Dr. Spiva said, are vulnerable to the most common sorts of bacteria and are at risk for repeated, life-threatening infections. Because it is characterized by recurring boils, the disease takes its name from the unfortunate biblical character. So rare is Job’s syndrome that many medical reference books have no entry for it.
At a meeting with Monté and his parents, Dr. Spiva explained the gravity of the situation. “She looked me straight in the face and said, ‘It’s not the quantity of life, it’s the quality of life,’” Monté recalls. “I didn’t know what to feel. I was very shocked and very scared.”
Worse, after testing Carrie and Travis, Dr. Spiva found that they also had inherited the disease. Dr. Spiva told the Collards that if the children remained under her care, they could possibly live into their early twenties. After that, the doctor said, all the family could do was hope for a miracle.
The Collards had always been active, frequently taking family camping and skiing trips. But Dr. Spiva advised them that the slightest injury or infection could lead to death. The children began bathing two to three times a day in Betadine solution to prevent infection, and Tana regularly scrubbed down the house with bleach. Dr. Spiva had a special warning for sixteen-year-old Monté: she told him that sex could be fatal. “She said if I contracted a disease from a sexual experience, I could die shortly thereafter,” he remembers.
From the time of the diagnosis, the family was in shock. Because of the rarity of the disease, they couldn’t find anyone else who had been through it. Dr. Spiva became their sole source of information and comfort. Tana found that nothing could eliminate her growing despair, even after Dr. Spiva put her on fairly high doses of a powerful tranquilizer. One Friday afternoon, after the treatments had been going on for seven months, Tana put her three dazed children into the car, drove toward a bridge, and decided to go off it. At the last minute she put on the brakes. “I don’t know what stopped me. I got out of the car for a few minutes and just stood there. Then I got back in. The kids never said a word. I don’t know how I managed to get home,” she says.
The children were also confused and frightened. “I felt like who cares about school or anything, since we’re not going to make it to be anything,” says Travis, who cries at the recollection. “I really didn’t care about having friends or anything.” As the youngest, Travis was terrified of witnessing the death of his siblings.
In 1985 the family moved again, back to their native New Mexico, hoping that the clean air and water would help prolong the children’s lives. But during the fall of that year Monté’s health began to decline again. He was increasingly susceptible to boils and various fungal infections, and he couldn’t shake a perpetual lethargy. John Collard called Dr. Spiva. She told him Monté’s dose of immunoglobulin should be doubled. John and Tana conveyed the recommendation to Dr. Eugene Kippel, their pediatrician, who had been continuing Spiva’s treatments.
Dr. Kippel urged that the family see another immunologist first. The Collards agreed, and the children’s medical records were eventually sent to Dr. William T. Shearer, the chief of the departments of allergy and immunology at Texas Children’s Hospital in Houston. Shortly after Texas Children’s received the records, the staff contacted Tana and asked her to bring her family to Houston as soon as possible. “I thought, ‘My God, they’re really dying.’” Tana recalls.
Tana and the children flew there right after Christmas. The children spent the day having extensive tests done—the cost was almost $9000. Early the next morning Tana received a call at her hotel from Dr. Shearer, who asked her to come to his office.
Panicked, she rushed over, and the doctor met her in his waiting room. He escorted her into his office and told her to sit down. He took her hand in his. “I can imagine what you have been through emotionally and financially,” he said. “But there is nothing wrong with your children. There is no immunodeficiency. There is no Job’s syndrome.”
The Collards, who estimate their medical bills ran to the high five figures, have hired San Antonio personal injury attorney Clem Lyons to sue Dr. Deborah Spiva. But the Collards have to get in line for their day in court. To date, fifteen other malpractice suits have been filed against Dr. Spiva. Suits brought by Jimmey Smarr, 34, Michael Curnett, 41, and Dorothy Nell Pierce, 71, allege they suffered permanent injury due to excessive doses of steroids prescribed by Dr. Spiva. Hazel Topoleski, 40, claims she was subjected to experimental treatments for a condition she did not have. And Robert Moore, 66, alleges he was diagnosed and treated for cancer when he was actually suffering from another condition.
The rest of the suits are not brought by the patients themselves, because those patients are dead. The suits are brought by their survivors, who claim Dr. Spiva’s negligence caused the deaths. The family of Gloria Villarreal, 33, claims she died because of overdoses of steroids ordered by Dr. Spiva. Juan Jose Garcia, 31, and Richard Collins, 52, died, their families allege, because Dr. Spiva mistreated their hemophilia. And Johnny Van Cleve Elkins, 29, Mildred Weilbacher, 46, Mary York, 52, Clarence Bays, 59, Walter Neville Haynes, 61, Mary Elizabeth Gard, 77, and Margaret Moreno, 78, all died, the suits claim, because of Dr. Spiva’s mishandling of their cancer. On the advice of her attorney, Dr. Spiva will not discuss any malpractice cases.
An Easy Target
“I have done nothing wrong,” says Deborah Spiva. She agreed to meet me in a hotel room in Miami, Florida, where she has recently found employment doing immunology research. She will not disclose where she works; she says former colleagues from San Antonio have tracked her down before and ruined her prospects for other jobs.
Her dark hair is pulled tightly back off her face into a ponytail, a change from her usual chignon. She is a tall, big-boned woman of 39 who favors boldly colored outfits and matching spike-heeled shoes. She likes jewelry and wears a lot of it, large gold-and-amethyst rings, several gold chains, and gold earrings. Blue eyeliner dramatically rims her blue-green eyes. Though she smokes almost continuously, her manner is calm and confident. It is possible to see in her the bright, determined woman with the limitless future her friends remember.
People who grew up with Debby Spiva can’t believe her career is ending up in a shambles. For most of her life she was considered someone special, someone with the brains, ambition, and drive to be the best at whatever she undertook. And for as long as anyone can remember, what she wanted most of all was to be a doctor.
Spiva says the past few years have been Kafka-esque. She has been subjected, she says, to “a public rape.” But she intends to keep fighting, because as she sees it, the victims in all this are not the patients she is accused of harming. The victim is Deborah Spiva. She maintains that she is a victim of a backward and sexist medical community. It is a community, she says, that is worried about mounting competition and economic pressures, and as a young woman with a thriving practice, she became an easy target for other doctors’ fears.
But what happened to Dr. Deborah Spiva is more than the destruction of a once-promising career. It is a lesson in the ways of the medical profession. For years doctors who felt that she couldn’t be trusted, that she might even be dangerous, were reluctant to take any action against her. Fearing she would retaliate in court if they tried to stop her, they simply made sure she moved on. Finally, though, a few doctors decided that she must be stopped. They turned to the government agency responsible for disciplining physicians, the Texas State Board of Medical Examiners. But for more than a year the board’s investigation of Dr. Spiva lay neglected in a file cabinet, another one of its backlog of cases. Meanwhile, Dr. Deborah Spiva moved from hospital to hospital.
The Ideal Girl
No one worked harder at being the ideal girl than Deborah Anne Spiva. She was born in 1947 in Fredericksburg, a Hill Country town founded in the nineteenth century by German immigrants whose ethic of frugality and conservatism still very much pervades the place.
The Spivas were one of Fredericksburg’s best-known families. Debby’s father, Vern, was a dentist. He was a tall, handsome, easygoing man who was active in community affairs. His wife, LaVerne, universally known as Dippy, was strong-willed and sharp-tongued. She was the more socially ambitious of the two and proud and protective of her family. Debby was the oldest of the Spivas’ three daughters. Diana Dee, “DeDe,” was born in 1948, and Dorothy Jane, “Dotty,” in 1951.
In 1955, when Debby was seven, the first accidental death struck the Spiva family. That year a Fredericksburg doctor, a close friend of the Spiva family, performed a tonsillectomy on three-year-old Dotty. She died shortly after surgery.
Debby says “a reaction to something” caused her sister’s death. “Back then,” she says, “I don’t know that anybody knew that much about immunological phenomena or allergic reactions.” Over the years people have suggested that her sister’s death pushed Debby to become a doctor, pushed her to make up for the loss. “If it had, I would have done pediatrics and surgery,” Spiva responds. “It was such an isolated event. And pediatrics was just not what I wanted to do.”
From her earliest years, Debby Spiva was an achiever. The 1965 edition of the Mesa, her high school yearbook, is punctuated with pictures of Debby. She graduated among the top ten in her class; she was a senior twirler, varsity basketball guard, saxophone player in the band, member of the German club, student council vice president, coeditor of the yearbook, and member of the National Honor Society. Debby was also rewarded for her ability to think on her feet. In 1965 she was on the debate team that came in second at the state championship. In her high school speech class she was selected the Best Girl Extemporaneous Speaker and the Best All-Around Girl Speaker.
There were students in Fredericksburg who were more gifted than Debby, but there were few who were more determined. Several of her classmates recall that she could hardly be described as a natural athlete, but she spent hours shooting baskets and ended up making the varsity team. Her need to succeed could make her abrasive at times. High school science teacher Hubert Nixon told the San Antonio Light, “She was very reluctant to give in, even when she was obviously wrong.” A classmate recalls, “You couldn’t win an argument with Debby.”
In 1965 Debby left Fredericksburg for the University of Texas, where she worked to stand out academically and socially. She was chosen for Orange Jackets, a prestigious UT service organization whose uniform was a badge of social acceptance. She was on the varsity debate squad, was a nominee for outstanding student and for Bluebonnet Belle, and was selected for Phi Beta Kappa. But Debby’s plans were larger than just joining the right college organizations. Unlike so many students—especially female students in that era—Debby had a clear, unwavering vision of her future beyond the campus. She was going to be a doctor. It was an ambition formed before the great social upheaval of women’s liberation and affirmative action and one that set her apart from her peers.
Today Spiva says he can’t remember when she first decided on a medical career. “It just sort of seemed to make sense. Daddy had a clinic at home and I hung around. It was familiar.” Despite the familiarity, her parents did not encourage her. “Daddy had gone to Baylor in the thirties and forties when women in medicine had a tough time, so he discouraged me because of that. Mother was really cool about it.”
In 1969 Debby, who majored in zoology and minored in chemistry, graduated with honors. That fall she enrolled at a new medical school, the UT Health Science Center at San Antonio.
Just as she had in high school and college, Debby rose swiftly to the top of her medical school class. She won a Legislators Merit Scholarship, she served on the school’s admissions committee, she was the editor of the yearbook, and she received an award for academic achievement from the American Medical Women’s Association. “Debby was in the first group of students to go through the full graduating program here. She’s a charming person, so quick and bright and colorful. She was clearly a star,” recalls Dr. James George, a faculty member at the medical school.
George is a hematologist, a specialist in diseases of the blood. He is a tall, slim man with strong features and a warm manner who chooses his words with care. He encouraged Spiva’s interest in academic medicine, arranging a course of study for her that would groom her for a teaching position at the medical center. “We pictured her as our first homegrown faculty person in our hematology division,” he says. “She had the ambition, and she had the ability.”
Students spend their first two years of medical school in classrooms and laboratories. In the third year, however, they get their first clinical experience, accompanying senior faculty members, interns, and residents on teaching rounds. For part of her third-year rotation Spiva was one of four students assigned to Dr. George.
She seemed to thrive on hard work. Teaching rounds began at nine-thirty, but George often arrived at the hospital at seven in the morning and found that his star student had gotten there even earlier. It was also noted, as it would be throughout her career, that Spiva had a way with patients. George recalls several patients saying that Spiva was the first physician who ever seemed to really care about them. Another unusual quality also surfaced in medical school. Hospitals are hierarchical places, and doctors are clearly at the top of that hierarchy. But unlike many physicians, Spiva treated the rest of the staff—the nurses and the technicians—as equals rather than subordinates, earning their admiration.
In the last two years of medical school, students narrow their career choices and plan internships and fellowships accordingly. The fourth year is an all-elective year focused on the student’s area of interest. Spiva was interested in immunology, and because many immunological problems are blood-related, she decided to become a hematologist. “Every time you picked up a journal the field was changing. There was fascinating technology. And I kept finding funny immunological problems,” she says.
Dr. George, by then Spiva’s faculty adviser, was helping to make an academic hematologist out of her. He arranged for her to do her laboratory research on a rare anemia. He hoped the project would result in a publishable paper. His hopes were fully realized.
“She had an incredible talent for making experiments work,” Dr. George says. “I remember sitting at the bench, looking at the results, thinking, ‘This is incredibly beautiful.’” The results were published in 1974 in the American Journal of Medicine, under the names of Dr. Spiva, Dr. George, and Dr. David Sears, then the head of the school’s hematology division. It was the first of Debby’s papers in which the experiments worked out just perfectly.
George then arranged for Spiva to spend two months at the University of Connecticut Health Science Center to do a special study with a friend of his. Following that, in 1973 she went for her internship and residency to Strong Memorial Hospital, the teaching hospital of the University of Rochester in New York, where both George and Sears had trained.
Dr. Tom Anderson, now the head of the hematology and oncology section of the Medical College of Wisconsin, was a chief resident during Spiva’s second year at Strong. He remembers that she was considered vivacious and outgoing. She did an adequate job, and it looked as if she had a reasonable career ahead of her, he recalls.
However, one incident sticks in Dr. Anderson’s mind. During rounds one day, Spiva gave a presentation on a potentially fatal disorder known as disseminated intravascular coagulation, in which the body’s clotting mechanism goes out of control. What struck Anderson was the superficiality of Spiva’s presentation. “It was one of the few times that I saw a significant question from the chairman of medicine of a synopsis and the data,” he says.
Spiva calls Rochester a “great learning experience.” She says that she not only learned a lot clinically but also learned about the human qualities required to be a good doctor. She was particularly influenced by one faculty member, now dead, named Art Bauman. “Art Bauman was a tremendous clinician,” Spiva says. “When one of his patients died, they didn’t die alone. There’s a tendency when someone starts going bad, you feel so bad you step back. He didn’t do it. He was a great role model.”
After their residency ends, most doctors start looking for their first jobs. Spiva went back to school to pursue her goal of an academic career. She came home to Texas for a two-year fellowship in immunology at the University of Texas Health Science Center at Dallas, the home of Southwestern Medical School. The Dallas program involved no patient care; it was strictly research. Spiva says she was there to learn the basics in a field that was exploding with new discoveries.
Dr. Jonathan Uhr, the chairman of the microbiology department at the Health Science Center, was a co-director of Spiva’s postdoctoral fellowship. Uhr’s experience with Spiva fell into what had become the established pattern—her experiments worked out beautifully. But in a letter written years later to the Texas State Board of Medical Examiners at the request of a board investigator, Dr. Uhr indicated that there was a hitch: others could not get the experiments to work the way she had. And on experiments that required subjective analysis, he wrote, her colleagues simply did not see the same thing under the microscope that Spiva saw. To check her results, Spiva was asked to repeat her experiments using coded samples—that is, she did not know the content of what she was working with.
Uhr wrote that when Spiva worked with the coded samples, even she could not reproduce her own findings. He also wrote that both he and another supervising physician “were very suspicious that Dr. Spiva was incapable of reporting the truth.” He continued, “We could not distinguish whether she had consciously reported false results or whether she had convinced herself that the observations were real.” He also reported, “Her performance during this time was so bizarre that I dictated a note for my files after she had been in the laboratory for 10 months. This is the only note of this type that I have dictated during 25 years of supervising students and fellows in the laboratory. During this period, I have probably trained approximately 100 young scientists.” That note, dictated on April 30, 1976, concluded that Spiva’s findings “represent her unconscious expectation of what the results should be.”
Before Spiva completed her fellowship in Dallas, her family was shaken by another death. Over the Thanksgiving holiday in 1976 her father and two of his friends went on a hunting trip, spending the night in a trailer in West Texas. The three were found dead, asphyxiated by fumes from a small stove they had used as a heater.
People recall that Debby was the strong one in her family. “My father was very much the get-up-and-get-about-your-business person. When things happened to our family before, I just sort of did,” she says. As she looks back on his death now, she brings an almost stoic acceptance. “One thing struck me: if you had to pick how you were going to die, how better than to not know it, to be with your friends doing what you want to do. He didn’t get old and sick.”
So Spiva went on. According to the career plan, she was to complete her training in Dallas and return to San Antonio for yet another postdoctoral fellowship, this time in hematology. For administrative purposes, Spiva was asked to complete a formal application, with recommendation letters from Rochester and Dallas.
A positive letter from Rochester arrived. On September 14, 1977, a letter from Dr. Uhr arrived. It was brief and did not mention his doubts about Deborah Spiva’s work. He described the studies she participated in, then concluded: “Dr. Spiva’s excellent background in clinical medicine together with her training in cellular immunology should enable her to tackle important problems in immunohematology.”
Today Uhr declines to talk about his experience with Spiva. “I wish she’d never been at Southwestern, that we’d never heard of her,” he says. Of the letter he wrote to the Board of Medical Examiners regarding his former student, he says, “I felt it was so important that it was a matter of conscience.”
In his letter to the board, Uhr also wrote that he didn’t have enough evidence to stop Spiva’s career: “Dr. Spiva acknowledged no problem on her part during our interactions with her and showed no evidence of any insight that she had a problem. On our side, we had no definitive evidence that she had committed fraud, only that she was not able to present a true account of her findings.” But for the first time, a doctor who thought that Deborah Spiva could not be trusted simply let her move on.
The Switched Samples
Spiva returned to San Antonio in 1977. Dr. George was surprised that during her fellowship in Dallas no papers had appeared under her name. But Spiva, the champion extemporaneous speaker, had plenty of reasons. “She had many stories about what went wrong, why this, why that. They were all accepted,” he says. Today Spiva says that she was not trying to do publishable research while in Dallas.
Her program in San Antonio was divided into two parts: a clinical year to be followed by two years of laboratory research. She began seeing patients again. George remembers one occasion when he was treating a leukemia patient with chemotherapy. Leukemia is a cancer of the blood cells that are produced in the bone marrow. In chemotherapy, drugs are given in carefully controlled doses to the patient. The desired result is that the drugs will destroy the abnormal cells in the bone marrow and that after chemotherapy the marrow will replace itself with healthy cells, putting the patient into remission.
Dr. George recalls that in preparation for the patient’s chemotherapy, he asked Spiva what the white blood cell count was. She said the patient had 50 per cent normal cells—meaning that chemotherapy could begin. “I checked casually and found the patient had no normal cells and that chemotherapy would have been a disaster,” George remembers. “I said, ‘What happened?’ She said, ‘So-and-so told me.’” Dr. George found that other faculty members had had similar experiences with Spiva. At the end of Spiva’s clinical year George warned Spiva that her credibility was in jeopardy. “I thought I was being real tough on her, that she was an errant youth who needed a little counseling,” he says.
In spite of concerns about her accuracy, Spiva received a satisfactory evaluation for her clinical year and proceeded to become a research fellow in the hematology division—which was going through personnel changes stemming from political turmoil.
From 1978 to 1980 Spiva’s research work was supervised by Dr. David Sears. In December 1979, however, George approached Spiva and asked her to do some hematology experiments with him. She had developed a technique that could quickly and accurately measure selected proteins bound to the surface of circulating blood cells. By then, George says, he felt she was “flaky but legitimate.”
Spiva measured the reactions on the experimental plates and presented the results to George. The experiment had been a success, perfectly proving his hypothesis. He recalls his reaction when he saw the perfect results: “At that moment I thought, ‘This is too good to be true.’ And when you say that, the dam breaks.”
In a letter Dr. George wrote to the Board of Medical Examiners, he described what happened next. To either confirm or put to rest his suspicions about Spiva, George came up with a plan. He told her he wanted to rerun the experiment. As in the first project, all the steps until the last were to be performed by the technician. Without telling Spiva, though, George had the technician switch the control and the experimental samples, mislabeling them so she would not know what had been done. After the experiment was completed, George stopped by the technician’s desk to pick up Spiva’s results. As he wrote the board, without a word the technician handed him the sheet. Instead of showing opposite values, Spiva’s results were identical to those of the first experiment. George was sure that Spiva had fabricated the data.
He knew Spiva was at work in a laboratory on the floor. He remembers dreading the walk down the corridor; he believed that his revelation could lead to the end of the career of the young doctor who had been his protégée. She was working at her bench when George came in.
“Debby, there’s a problem with the experiment,” he recalls telling her.
“It seemed to me to work out perfectly,” she replied.
Then he said, “Debby, the samples were switched, and you have fabricated these data.”
Without a trace of hesitation or emotion, Spiva replied that she knew they had been switched; she said the technician had told her. “Then I recorded the data just as we had done the first time so that the data charts would be consistent,” Spiva said. Instead of Debby Spiva, it was Jim George who was reeling from the confrontation. Next, as he recounted in his letter, he and Spiva conducted a search through the laboratory’s wastebaskets, looking for the tapes from the machines that had printed out the lab data, so that they could reconstruct the experiment. They couldn’t find them. Nor could they find the experimental tubes and plates from which the counts were taken. George says Spiva apologized for having thrown away everything so quickly.
George went back and talked to his technician. She confirmed that she had said nothing to Spiva about switching the samples. That afternoon George went to Sears to discuss what had happened, but Sears was angry that George had set a trap for Spiva.
The next day George had a three-hour discussion with Spiva. He told her he could never trust her again. Then he said that he felt she needed psychiatric help and that he would like to assist her in obtaining it. At that suggestion, George wrote, “she exploded.”
Although George says he was absolutely convinced that Spiva had fabricated the results, he realized that proving his accusation would be difficult since she denied the charges—it would be Dr. Spiva’s word against the technician’s. He also saw that his evidence was not sufficient to ask her to leave the program or to withhold her certificate of performance. After debating how to proceed, George told her that he would inform only two other people on the faculty, physicians she was doing collaborative experiments with. Beyond that he would not pursue the matter. He added that if he was ever contacted for a recommendation, he would not tell of the incident, but he would decline to recommend her for a position, which would be seen as a very negative sign.
One of the doctors George spoke to was Richard Pope, who is now in the department of medicine at Northwestern University Medical School. Pope already had doubts about Spiva’s veracity. Concerned about the flawless results of her experiments, he too had coded the samples she was working on and found that her data reflected not what was really being measured but what Spiva had assumed was being measured. Pope had ended the experiments. “The reason we couldn’t do anything against her was that we had no proof that would stand up in a legal setting. It was her word against ours,” Pope says. “And even if we showed her data, she always had excuses why it wasn’t the case. She’s pretty smart and quick on her feet. What could we have done?”
After their confrontation, George and Spiva had little interaction. He began to hear stories that he was trying to destroy her career and was pushing her off the project in order that she not get credit. He says that he reran the experiment she had done for him, using the technique she had developed. “The experiment did work out, although not quite as she said it did,” he recalls.
Because of staffing changes taking place in the division of hematology, there was no opportunity for an appointment for Dr. Spiva. George says he would have prevented her appointment in any case. Spiva says her plans for an academic career went awry because of circumstances beyond her control, both in and out of the hematology division. “It was a giant upheaval. It was at the same time that the feds were cutting back and grants were disappearing. So I left at the same time as a lot of friends who had been on a similar track,” she says.
When asked about the accusations in the letters of Uhr and George, she says, “I know about those letters. They’re not true.” On her lawyer’s advice, she declines to discuss the accusations further.
Vampires and Werewolves
With no prospects at the medical center, Spiva decided to go into private practice in 1980. By that time her personal life had also taken a new direction. Toward the end of her fellowship in San Antonio she met Fred Cecere, a tall, burly, outgoing Army doctor from Massachusetts. He was at the medical center in San Antonio to get extra training. For Cecere it was love at first sight. “He says he remembers meeting me and he made this giant decision,” Spiva says.
Spiva had a rule never to date other doctors, but she and Cecere became friendly, and he started spending more time in the laboratory. Soon he got an apartment in the building she was living in. They were married in 1981. “There wasn’t anything else to do,” she says. “He was going to stay forever. When he said he wouldn’t squawk about me not changing my name, it was a good deal.” They eventually bought a large home in the gentrified King William section of town and spent their spare time restoring it.
Through a family friend, Spiva was put in touch with Dr. O. Roger Hollan, a founder of San Antonio Medical Associates (SAMA), a small, prestigious private group of internal medicine specialists that was formed in the fifties. SAMA’s downtown offices are in the same art deco high rise as the Nix Medical Center, long considered the city’s society hospital.
After Spiva’s initial contact with the group, Dr. Karl Hempel, a rheumatologist with SAMA, contacted Dr. George for a recommendation. George did not tell him about the episode with the experiments, but as he had warned Spiva, he did not give her a recommendation. He recalls telling Hempel that the hematology faculty had been concerned about Spiva’s credibility during her clinical year of training. In sworn testimony before the Board of Medical Examiners, Hempel (who, like all his SAMA colleagues, declined to be interviewed) said, “We called and got recommendations from the hematology department there and did hire her.”
In June 1980 Deborah Spiva went to work at SAMA, specializing in hematology and immunology. The Nix was her primary place of practice, but she also applied for and received privileges—the right to admit and treat patients—at several other San Antonio hospitals, including Humana Hospital Metropolitan, Baptist Memorial, and Santa Rosa Medical Center.
In the beginning, her association with SAMA seemed to be a good one. Her parents’ social contacts were beneficial in helping to establish her practice, and she found that being a female doctor had its advantages. “A lot of patients wanted a woman doctor, particularly women patients with breast cancer or ovarian cancer,” she says.
Her days started and ended with hospital rounds at the Nix, where she saw about fifteen patients; the rest of the day she would see the same number of patients in her office. Along with her heavy patient load, she did independent research and published papers.
When Spiva describes her approach to medicine, one word she often uses is “aggressive.” She says she assiduously followed medical literature to give the most-current treatments. She also took an aggressive approach to diagnosis. While patients with undiagnosable, nagging symptoms might be described by other doctors as the “worried well,” Spiva was determined to find the cause of their distress. In doing so, she concluded that many of her patients had terrible, rare illnesses that required powerful medication and extensive hospital treatments. She also concluded that San Antonio was an extraordinary breeding ground for an exceedingly rare hereditary disorder known as porphyria. It is a condition so unusual that most doctors in this country never see a single case, but Spiva eventually diagnosed and treated about thirty victims.
In porphyria the body produces excessive porphyrins, a component of hemoglobin, which imparts the red color to blood. The disease is diagnosed through specific tests of blood, urine, and feces. Porphyria can affect the brain, most of the organs, and the skin—victims are susceptible to acute sunburn with minimal exposure. Because of this phenomenon and the sometime occurrence of mental disorders, it has been hypothesized that the supposed vampires and werewolves of days gone by may actually have been porphyria sufferers. There is no cure, but drugs alleviate some symptoms.
One of the people who Spiva discovered had the disease was Hazel Topoleski. Topoleski, now 40, is a supervisor in the Harlandale Independent School District. Until she saw Spiva, no doctor could tell her what was wrong. An ophthalmologist sent her to a neurologist, who put her on medication for vertigo, but Topoleski still did not feel well. In 1983 her gynecologist, unable to come up with a diagnosis, sent her to Dr. Spiva. According to court documents, on that first visit Dr. Spiva said she thought she knew what was wrong with Topoleski. “I thought she was just wonderful,” Topoleski recalls. “Very sharp and caring. I felt maybe I was lucky this time. I felt I don’t care what it is, just as long as I know.”
Two weeks later Topoleski went in to discuss test results. Finally, after years of seeing doctors, she had an answer: Topoleski had a type of porphyria. “Dr. Spiva said it was the disease of vampires and werewolves. She used those words. That was a real shock,” Topoleski says.
Spiva believed that porphyria resulted in another condition: hyperviscosity, or thickening of the blood. To keep both conditions under control, Spiva had her porphyria patients undergo regular pheresis treatments. During pheresis blood is withdrawn from a patient. In some cases a portion of the blood—the platelets, for example—is removed, and the remainder is transfused back into the patient. In other cases donor blood is transfused. Pheresis is an invasive procedure, performed in the intensive care unit at the Nix. As with all blood transfusions, patients run the risk of contracting hepatitis or having an allergic reaction to the blood products.
According to court records, Spiva told Topoleski that pheresis was the only treatment available for her condition. On September 2 Topoleski began her weekly treatments at the Nix. Spiva was there to greet her. Then a plastic valve was inserted into a vein in Topoleski’s arm, and the three-hour procedure to control her disease began. Topoleski was one of many of Dr. Spiva’s patients to undergo pheresis.
A Problem with the Records
By 1984 Deborah Spiva looked to all the world like a success. In four years she had developed a thriving practice with a prestigious group. She received many referrals from other doctors and was generous in her referrals to them. Such referrals make for both goodwill and good fees. Because of the nature of the illnesses of many of her patients and the complicated treatments she prescribed—such as pheresis—Spiva generated large medical bills, which generated large payments to the Nix and to SAMA. And as other doctors even now attest, Spiva had a way with patients; most of them loved her.
But just when life should have been most satisfying, things started to unravel. For one thing, according to a letter written by Dr. Hollan to the Board of Medical Examiners, SAMA was unhappy with Dr. Spiva’s record-keeping, a vital part of a medical practice. Doctors communicate with each other about a patient’s care through the chart. Patient charts must accurately reflect diagnoses and treatments so errors are not made by other physicians or nurses. And a doctor’s records are the source of billing information. From testimony at a hearing before the Board of Medical Examiners and from depositions taken in malpractice cases, it has been established that Deborah Spiva’s record-keeping could be described as eccentric. Important information on test results would be missing from patients’ charts, values from lab tests would change inexplicably from entry to entry, unusual therapies were ordered, and contradictory diagnoses would appear.
In his letter Hollan also said that Spiva was also not as active a participant in the practice as the group would have liked; she often failed to attend management meetings. SAMA was also concerned about her research methods—she was publishing papers without having colleagues review her findings first. Members of the group had discussed those problems with Spiva over the years; she usually promised to try to do better. But Dr. Hollan felt he had no reason for serious concern until February 12, 1984. In his letter to the state medical board, he recounts what happened that day: “While making rounds, I heard the nurses discussing the questionable need for transfusing a patient with a normal hemoglobin. I suggested that the blood not be given until the order was clarified, since it involved Dr. Spiva. About the same time I heard a rumor about a patient who was very angry about Dr. Spiva and was threatening to sue her. Then her husband requested a conference on March 9 to discuss Deborah’s problems with the group.”
Then, as Dr. Hollan wrote in his letter, another rumor surfaced—that Spiva was not board certified in hematology. Though she had passed her internal medicine exams in 1976, she twice failed to complete her hematology boards. She said in a deposition that she thinks she had an allergic reaction to the air conditioning in the room in which the exam was given. Today, Spiva says she never told anyone that she had passed her hematology boards, only that she was eligible to take them.
But that wasn’t all. In March two papers with Spiva as principal author came to Hollan’s attention. One, on pheresis, was published in the journal Plasma Therapy Transfusion Technology and listed Dr. Charles Robinson and Dr. James Langley as coauthors. Robinson, the chief pathologist at the Nix, discovered he was her coauthor when Spiva brought him a copy of the paper. “I reckon I was a little dumbfounded,” he says. “But the horse was out of the barn.” The data came from tests he had run on patients of hers, but he says he can’t comment on the accuracy of her paper because he “never had an opportunity to review the data.” Dr. Langley, who was then the medical director at the South Texas Regional Blood Bank, says that he was never informed by Spiva of the paper, even after its publication. The other paper was on pheresis as a treatment for systemic lupus erythematosus; the coauthor of that paper was her husband, Fred Cecere.
The Spiva-Cecere paper raised some troubling questions. According to a detailed memo written by Dr. Hempel, the paper documented the pheresis treatments done at the Nix on nineteen patients with lupus. But the nurse in charge of the Nix intensive care unit, where pheresis was done, said she didn’t know of nineteen such patients. In the paper the patients were identified by number only. Spiva was asked to provide her colleagues with the patients’ names. According to the SAMA memo, she declined to identify five of them. Of the patients she did identify, there were numerous discrepancies between the laboratory data Spiva and Cecere gave in the paper and the laboratory data recorded on the patients’ charts at the Nix. Most disturbing of all to her colleagues was this discovery: three of the patients she identified as being helped by the pheresis treatments were dead at the time she documented their therapy.
On April 10 a meeting of SAMA members was called to discuss the paper with Spiva. By then, another problem had come up. Some physicians had notified that doctors at SAMA of questions regarding one of Spiva’s patients, a middle-aged professional woman whom Dr. Spiva had diagnosed as having porphyria and hyperviscosity. The treatment Spiva had prescribed was her usual one: pheresis. According to minutes dictated by Hempel, the group received a copy of the letter that Dr. Spiva had sent to Guardian Life Insurance about the need for aggressive therapy for this patient. Yet when the patient’s records at the Nix were checked, her colleagues found no evidence of either condition. The lab results were in fact normal, or at least they were normal on the slips printed out in the Nix laboratory. Another set of data, handwritten by Spiva, did not match the hospital’s.
The April 10 meeting did not go well for Spiva. She says it brought to a head the difference in her philosophy of medicine and that of the rest of the group. She contends that often her colleagues, because of fears of malpractice, did not give patients adequate treatment or adequate doses of medication for intractable diseases. As for their concerns about all the rare diseases she saw, she says, “I saw a lot of patients who had been seen by six or seven doctors and were undiagnosed. They had had excellent tests, and the common stuff was ruled out, so all that was left was weird stuff.” She also says her colleagues were sexists. “I don’t know if they were ready for me. None of them had been in school at the time there were aggressive women doctors with opinions. There were some people in the group who didn’t want a woman, who did not want anything avant-garde or academic, and they said so.”
As a result of the meeting, it was mutually decided that Deborah Spiva would leave San Antonio Medical Associates and begin practicing on her own. The split was not entirely amicable. According to a SAMA memo, on April 23, 1984, Hollan requested Spiva’s resignation. Acting on the advice of her lawyer, Spiva refused to sign the letter of resignation. At three-thirty the next afternoon Hollan handed her a letter of termination. Her departure from the group was to be on June 30. To help her establish her own practice, Spiva was allowed to copy her patients’ charts. She says she took 1200 charts with her.
Even after she was gone, the SAMA doctors found themselves continuing to deal with nagging Spiva problems. In his letter to the Board of Medical Examiners, Hollan said that in May he was contacted by a former patient of Spiva’s who complained about his diagnosis. Spiva had told him that he had Von Willebrand’s disease, a rare hereditary blood disorder that resembles, but is generally not as severe as, hemophilia. She had treated him by administering an antihemophiliac blood factor to which he had an allergic reaction. Dr. Hollan checked the laboratory data from the patient’s chart; it was normal. In October, Hollan wrote, he was told of another patient whom Spiva had also diagnosed as having Von Willebrand’s disease. Hollan again checked the charts, again they were normal. Then another paper on treating porphyria with pheresis, cowritten by Spiva, came to his attention. Hollan stated in his letter that he tried to match up the cases described in the paper with charts at the Nix, and again there were major discrepancies.
During our day-long interview in Miami, the one display of emotion Spiva shows is when she describes what happened at SAMA: “We got a divorce. That’s really all I thought it was.” For a moment her eyes tear up, then she quickly regains her composure. “It was a worked-out agreement. It was a case of irreconcilable differences.”
For Spiva it was a chance to begin again. She set up her own downtown office, decorating it with antique furniture and plants. An aquarium was installed in the room where she administered chemotherapy. And her Yorkshire terrier regularly wandered around. “Doctors’ offices always scared the spit out of me—all that funny Naugahyde,” she says. “We had a sort of Fredericksburg office. Being sick is a big enough threat.”
A Bleeding Crisis
In hospitals there is one thing that rivals viruses for persistence and pervasiveness, and that’s gossip. By 1984 a major subject of speculation at the Nix was the activities of Dr. Deborah Spiva, who continued to practice there, even though her association with SAMA had been severed. One of her patients was a young hemophiliac, 31-year-old Juan Jose Garcia. At a Board of Medical Examiners hearing, extensive testimony was given about the case, although the board did not identify Garcia by name. Garcia entered the Nix on April 23, the day Dr. Hollan requested Spiva’s resignation. According to testimony before the Board of Medical Examiners, in general Garcia’s health was good; he had come in for elective surgery to repair damage done to his left wrist during a childhood bleeding episode. Garcia’s surgeon was Dr. John Evans, and his hematological care was handled by Dr. Spiva.
Hemophilia is an inherited disease in which the victim experiences uncontrolled bleeding because of extremely reduced amounts of one of two blood proteins responsible for coagulation; those proteins are known as Factor VIII and Factor IX. Since the late sixties the ability to isolate those clotting factors from the blood of normal donors has greatly increased the chances for hemophiliacs to have near-normal lifespans. Concentrates of these factors can be administered to hemophiliacs to stop bleeding crises.
Garcia’s hemophilia was a Factor IX deficiency; his blood contained only 1.5 per cent of the amount of the factor found in normal blood. When Garcia checked in for his wrist repair, Dr. Spiva was responsible for the administration of this missing factor (the brand name is Konyne) to prevent bleeding problems during surgery. To provide adequate protection, hematologists testified before the board, it is recommended that the amount of Factor IX be brought up to about 50 per cent of normal, a level that provides sufficient clotting action. Increasing the amount of Factor IX much beyond that level is unnecessary and potentially dangerous. Excessive doses of Konyne can lead to disseminated intravascular coagulation (DIC), the dangerous condition that Spiva had glossed over in her presentation while a resident in Rochester.
To prepare Garcia for surgery, Spiva ordered an infusion of 6000 units of Konyne, approximately twice the recommended dose, according to physicians’ testimony. In tests taken two hours after the infusion, Garcia’s level of Factor IX was 148 per cent. Garcia’s surgery on April 24 went well. The wrist was repaired, and there was no undue bleeding during or immediately after surgery. It is recommended that Konyne dosages be reduced following surgery, and doses are usually repeated at 12- to 24-hour intervals. On April 25 Spiva ordered that Garcia’s dosage of Konyne be brought down to 3000 units every six hours—an amount approximately three times the recommended postsurgical dose, according to testimony.
On April 27 Juan Garcia developed a troubling complication. The nurse on duty noticed that his right calf was swollen and hard to the touch; it looked like a hematoma, the result of bleeding into a closed site. Garcia told the nurse that he had had some bleeding in that calf when he had injured it about a week before surgery.
Any hematoma in a hemophiliac is cause for concern. What made this one particularly so was that it happened in spite of Garcia’s being on such high doses of coagulant. The drug circular that accompanies Konyne warns physicians to stop its administration in cases of unusual bleeding or evidence of DIC. There are several simple blood tests that are routinely done to check for DIC, hematologists testified, none of which were performed at the time. In response to the problem in Garcia’s leg, Dr. Spiva on April 29 ordered the dose of Konyne be increased to 5000 units every six hours.
She hoped, as she later testified before the board, that the increased dosage would stop the bleeding problem. It did not. The leg continued to be swollen and tender, and Garcia was in increasing pain. On May 4 Dr. Evans brought Juan Garcia back into the operating room to drain the hematoma. After the surgery a suction device was attached to the wound; it was later changed to a simple drainage bag. Under Spiva’s orders Juan Garcia continued to receive high doses of Konyne.
The night of May 5 was bad for Garcia. He bled continuously, so much that by morning he had lost about half of his blood through the drain in his leg, according to testimony. At seven-thirty in the morning the nurse on duty called Spiva to voice her concern. Spiva’s home in King William was about a five-minute drive from the Nix, but she told the nurse she was not feeling well; she had some kind of stomach upset and would not be able to come to the hospital soon. She did order over the phone that Garcia’s dosage of Konyne be increased to 12,000 units every six hours. According to a hematologist who reviewed the case for the Board of Medical Examiners, it was the largest dosage he had ever seen ordered. By nine-fifteen Garcia’s measured level of Factor IX was raised to 296 per cent.
To replace the blood Garcia had lost during the night, Spiva also ordered that he receive four units of washed, warmed red blood cells. Spiva later told the Board of Medical Examiners that washing and warming the blood was needed to avoid an allergic reaction to the transfusion. Hematologists testifying before the board said the procedure, which can take several hours to perform, was completely unnecessary. Garcia did not receive the first unit of this blood until the middle of the afternoon.
Around mid-morning, Spiva arrived at the hospital. Because no blood replacement had yet been given to Garcia, she ordered that he be transfused with three units of red blood cells. There is no evidence in the record that Spiva performed a physical on her patient that day.
That afternoon Garcia’s parents arrived for a visit. His mother, Rosa Garcia, said in an interview that she was surprised at her son’s obvious deterioration. At 5:35 the nurses moved Garcia into a chair in the room so his sheets could be changed and he could be given a sponge bath. Mrs. Garcia recalls what happened: “I noticed my son was real quiet. I started to talk to him, but he didn’t respond.” Juan Garcia’s parents were told to leave the room. A code—a situation requiring emergency assistance—was called. Doctors and nurses rushed in, and cardiopulmonary resuscitation was performed. It was unsuccessful; Juan Jose Garcia was dead. Dr. Spiva broke the news to the parents. “Dr. Spiva told us our son had passed away,” Mrs. Garcia says. “She said it had nothing to do with his hemophilia.”
In her testimony before the board, Spiva said the immediate cause of death had been aspiration—that is, Garcia had choked on vomit that was found in his windpipe after the attempt at resuscitation. She also said that his death was a result of shock due to loss of blood and that in his condition, Garcia never should have been allowed out of bed. Dr. George and Dr. Richard Parmley, the director of the South Texas Hemophiliac Treatment Center, who both reviewed the case for the board, testified that Juan Garcia had died from a hemorrhage in his brain. It was, they said, the final consequence of DIC induced by massive overdoses of Konyne ordered by Deborah Spiva. George said it was clear from reading the chart that Spiva had failed, until the last day of Juan Garcia’s life, to even recognize the signs of DIC. The hearing officer for the Board of Medical Examiners agreed with that conclusion.
In 1984 Dr. Stewart Johnson, a surgeon, began a year’s term as chairman of the Nix’s executive committee. Though he had been a fan of Spiva’s—they had frequently referred patients to each other—he later wrote to the state board, “The Transfusion Committee continually had problems with Doctor Spiva, however, she was able to convince us that she was doing the right thing. She told us that none of us are hematologists and could not totally understand the rational [sic] behind her thinking.”
By the end of the year many people at the hospital were baffled by the rationale behind her thinking. On September 26, according to a letter written by Dr. Johnson to the Board of Medical Examiners, a special meeting of the hospital’s executive committee was called; the charts of two patients of Spiva’s were reviewed. One was a patient who fit the description of Juan Garcia. The other was that of a middle-aged woman who was also a patient of Johnson’s. Johnson had performed what he later concluded, according to testimony, was an unnecessary splenectomy. The surgery had been done at the recommendation of Dr. Spiva, who had diagnosed a rare hereditary blood disease. The diagnosis, Johnson later testified before the Board of Medical Examiners, was not supported by the patient’s laboratory data.
After reviewing the records, the Nix executive committee unanimously voted to revoke Spiva’s privileges to practice at the hospital. According to his letter, Johnson telephoned her with the news; he told her of her right to appeal. She said she would not. Instead, she resigned.
Today Spiva says that following her departure from SAMA, she voluntarily resigned from the Nix. “That’s a closed club,” she says. “So that didn’t bother me. It’s like a men’s locker room.”
Leaving the Nix did not make a big dent in her practice. She was still seeing patients in her office, and she retained privileges at other San Antonio hospitals. In testimony before the Board of Medical Examiners, Dr. Hempel explained why Spiva’s former SAMA colleagues did not alert these other hospitals that she could not be trusted: “We have been very careful not to say anything bad about her to other physician members, so we have kept our talk to other physicians at a minimum. I have not been involved in any other actions against her at any other hospitals because she always thinks—she will tell you that there is a conspiracy against her, that people are out to get her. So we very carefully avoided pursuing her to another hospital.” Today some malpractice suits against Spiva also name the Nix and SAMA, accusing them of negligence for not warning patients about her.
But by the time Spiva left the Nix, Hempel had also found out about the unnecessary splenectomy and yet another porphyria patient of hers whose lab data showed that she did not have the disease. It was too much. In early November 1984 he notified the Texas State Board of Medical Examiners and told them they should investigate Dr. Deborah Spiva.
The Registered Letter
By the summer of 1984 Spiva had moved most of her hospital practice to Humana Hospital Metropolitan, another downtown facility. To treat her porphyria patients and others who she felt needed regular pheresis treatment, she persuaded the hospital administration to buy a cell separator, the approximately $10,000 machine used in the procedure. The decision was made without consulting Dr. John P. Whitecar, Jr., then the hospital’s chief of staff. Because pheresis was a new procedure at Humana Metropolitan, a committee was formed to oversee its use, and Whitecar sat on the committee. Although other doctors used the new machine, no one came close to the frequency of Dr. Spiva.
Whitecar, a hematologist and oncologist, had heard the rumors that Spiva had had some problems at the Nix. But the Nix was closemouthed about what had happened, and Whitecar says he could never pin anything down. “She already had privileges at the Metropolitan, and we hadn’t heard anything upfront from the Nix, so we decided to grandfather her in,” he says.
Unlike most of the doctors Spiva dealt with in San Antonio, Dr. Whitecar actually had some experience with porphyria; while doing a fellowship in hematology at the University of Minnesota, he had treated some victims of the disease.
He found Spiva’s beliefs about porphyria troubling. He had never heard that hyperviscosity, an easily measurable condition, was connected in any way to the disease. Pheresis is used in the treatment of hyperviscosity, but if the porphyria patients didn’t have that, then what was the pheresis for? Whitecar began calling porphyria experts around the country to see whether they concurred with Dr. Spiva’s methods. He did not have to make many calls—a convention of porphyria experts would fill the average living room—and none of them had seen hyperviscosity in their patients, nor did they use pheresis as a treatment for porphyria. “I then presented this data in a meeting,” Whitecar later told the Board of Medical Examiners. “She sat on the Pheresis Committee, and I presented it to her. She told me that I had called the wrong experts.”
By this time, Whitecar was concerned about Spiva. “I wasn’t sure her elevator stopped on every floor,” he says. The pheresis committee then reviewed some charts of Spiva’s porphyria patients. Whitecar told the board, “Except for the age and the sex, those notes were identical, as if they were produced by a word processor. And they all end up with the same three diagnoses; variegate porphyria, and they don’t all have that; hemolytic anemia, that’s another entity not shown to exist in variegate porphyria; and hyperviscosity. So at that point we knew we were in bad trouble.”
Prompted by Dr. Hempel’s complaint, the state Board of Medical Examiners had started an investigation of Dr. Spiva. On December 4 Raymond Juarez, an investigator with the board, visited Whitecar. Since receiving the call from Hempel, Juarez had been making the rounds in San Antonio. For several weeks he talked to about a dozen doctors who had dealt with Spiva, going back to her medical school days. Juarez found a tremendous unanimity of opinion. As Juarez later told the board, “They did feel that…there was some type of mental impairment. They didn’t feel that she was doing this for monetary reasons.”
Juarez asked the doctors to write to the board, summarizing their dealings with Dr. Spiva. Over the next several months nearly all of them did. The letters just sat there. For more than a year after Juarez’s initial interviews, while Spiva continued practicing medicine, the board took no action against her.
During his interview with Juarez, Whitecar told the investigator that the hospital was looking into her practices. Despite his concerns, Whitecar did not have any strong evidence against her. When challenged, Spiva responded with a wall of words.
Then, according to Whitecar’s testimony before the board, Deborah Anne Spiva, M.D., did John Philip Whitecar, M.D., a big favor.
Late in December, Spiva admitted an elderly retired lawyer to Humana. Her tentative diagnosis was leukemia. She ordered a variety of tests: a liver-spleen scan, a CAT scan, and a bone marrow aspiration and biopsy. Frequently, hematologists perform the bone marrow tests themselves, but Spiva asked Humana’s pathology lab to do them. The smears were made, and Dr. Thomas Snider, then the hospital’s chief of pathology, did the analysis. The lab tests were negative for leukemia, and the patient did not have any other significant blood disease. When Snider went to review the patient’s chart, however, he found a baffling note from Spiva. She also had checked the smears that were under the microscope at the pathology lab. Based on what she believed she saw, she wrote that the patient’s OKT8 suppressor cells were increased. She followed up with orders to administer Prednisone, a steroid, and Velban, a powerful antitumor agent.
OKT8 cells are lymphocytes, a component of the blood. What baffled Dr. Snider was that their presence cannot be detected by looking under a microscope; special tests must be done, tests that were not performed at Humana’s laboratory. After looking at the entries on the chart, Snider talked to Whitecar.
Whitecar immediately suspended the drug order, then sent the bone marrow slide to a laboratory at another hospital for independent confirmation of Snider’s finding. That report also came back normal. In his testimony to the board, Whitecar said, “In fact, she did us a favor by not doing the bone marrow herself, because I think, had she done it herself, it could not have come to anyone’s attention that the guy didn’t have what she said he had.”
On December 20, 1984, Whitecar suspended Dr. Spiva from practicing at Humana Metropolitan. This time, however, Spiva was not going to take her patient charts and go off quietly to the next hospital. She was going to fight. She remembers the events of December 20 quite well. “I was practicing, getting consults, chugging along. Guys from the Nix were consulting me,” she says. “And December 20, after lunch, I get a registered letter from Whitecar. That’s the first I knew of anything. That started everything. There was nothing specific in the letter; I didn’t know what he was talking about.”
She and her husband tracked Whitecar down by phone that afternoon and found out. “Basically, he didn’t believe in a particular disease, an immunological problem with suppressor cells, which had been in the literature since 1978,” Spiva says.
According to Spiva, her abilities as an immunologist threatened the self-esteem of many of her colleagues. “The field I was in was so new, a whole large segment of the medical community doesn’t understand and is put off by it.”
Spiva immediately took the first of what would be many court actions. Her lawyer, Jane Macon, a partner at Fulbright and Jaworski, went to district court for the reinstitution of Spiva’s privileges at Humana, saying Spiva’s patients’ lives would be endangered if she was not able to render care. On December 21 a temporary restraining order was granted, lifting her suspension. Humana responded by reinstating her privileges and establishing an ad hoc committee to review Spiva’s fitness to practice at the hospital. It was the beginning of an imbroglio of suits and countersuits that has not yet been resolved.
Spiva portrays the events after December 20 as a sort of vendetta orchestrated by John Whitecar: “I was really a nobody, and I’d obviously irritated people who were somebody. People who were my supporters when it happened turned around and testified against me—that’s understandable because they were young and wanted to get by too.” Whitecar says there is some truth to her accusation that he made sure steps were taken against her. As he told the Board of Medical Examiners, “One morning driving to work, at six o’clock in the morning I said to myself, why am I doing this? And then I realized that I knew there was a serious problem and if I walked away from it, then I would have to leave medicine. Because I didn’t want to prove those people right that say we can’t police our own selves.”
Whitecar’s term as chief of staff expired December 31 (he was succeeded by Dr. Snider). The executive committee asked that Dr. Frederick Buckwold, a specialist in internal medicine and infectious diseases and the newly selected chairman of the hospital’s department of medicine, conduct an investigation of Spiva. From his testimony before the board, Buckwold seemed to welcome the job about as much as an outbreak of salmonella. Buckwold considered himself not only a colleague of Spiva’s but a friend. He was also a recipient of her generosity with referrals. In 1984, he testified that she had sent about thirty patients to him, for billings of around $13,000, the largest block of referral income he had received that year.
Spiva’s lawyers contended to the board that she was being attacked by doctors who were her economic competitors. But Whitecar says just the opposite was true. “Along the way a lot of people gave me grief because of economics,” he says. “She was a big referrer. She sent people for a lot of inappropriate consults. She’d send a non-heart patient to a cardiologist.”
At the hospital a committee of six doctors was formed, and they were given 91 of Dr. Spiva’s charts to review. Before her actions could be considered unacceptable, three doctors had to agree that a chart deviated from accepted medical practice. Buckwold says that he purposely biased the committee in her favor—one of the doctors had even been the best man at her wedding.
The committee reviewed charts for two and a half months. The group concluded that eighteen demonstrated substandard care. On March 11 the ad hoc committee’s findings were presented to the hospital’s medical clinical board at a lengthy meeting. Two unanimous decisions were made. One, that a recommendation to revoke Spiva’s privileges should be sent up the hospital chain of command for final action. And two, that she was an immediate danger to her patients and her privileges to practice at Humana should be suspended for a second time, effective immediately.
These actions did not interfere with her right to treat patients elsewhere, however, as demonstrated by the phone call Buckwold told the board he made that evening to Spiva. “If I remember correctly, I gave her approximately 24 hours to make arrangements for the transfer of any patients she had in the facility to other physicians and/or transfer them to another facility.”
The privilege of practicing medicine is an enormously valuable one. A doctor who doesn’t voluntarily give up that privilege has the system firmly on her side. Spiva went back to court. On March 15 she again got a temporary restraining order lifting her Humana suspension. In the meantime, the hospital continued its laborious administrative procedures against her.
Then, abruptly, on June 26 Spiva short-circuited the process. She resigned. Her letter of resignation explained that she was doing so because of “disagreements with the medical staff over medical application, and academic interpretation.” The hospital administration felt the letter was at odds with reality and rejected her resignation. In response, that same day the hospital’s board of governors wrote to Dr. Spiva, informing her she could no longer practice at Humana Hospital Metropolitan. In less than a year, two San Antonio hospitals had forced her out.
Whitecar says now with some satisfaction, “She didn’t kill anyone at Humana.” But according to lawsuits and testimony from her former colleagues, the same claim cannot be made about the next two hospitals Deborah Spiva went to.
Two Unfortunate Patients
When Dr. Spiva started admitting patients to Baptist Memorial Hospital, Dr. Stephen C. Cohen, then the chief of oncology, warned an administrator that she should be watched. He knew firsthand about the concerns other doctors had had with Spiva. Cohen, a hematologist as well as an oncologist, had been asked earlier to review the charts of some of her porphyria patients while she was practicing at the Nix and was disturbed by what he found.
But because Spiva already had privileges at Baptist, it would be legally difficult to prevent her from practicing there. The easiest way to get her out would be to wait and see whether she did something wrong.
The first week of May, according to a court deposition, Spiva received a call from a medical school classmate, a doctor practicing in Jourdanton. He had a patient who had been diagnosed as having leukemia. The Jourdanton doctor wanted to transfer the young man to someone who was an expert in blood diseases, and he asked Spiva if she would take the case. On May 7 Johnny Van Cleve Elkins, a pump operator in South Texas, arrived at Baptist Hospital.
Johnny Elkins had been born and raised in Freer. He was muscular and good-looking—at 28, he still carried himself like the high school football star he once was. According to her testimony, Spiva ran another blood test on him and confirmed the diagnosis. Elkins had chronic myelogenous leukemia. With treatment, he could be expected to live two to four years. Elkins came from a close family; his parents, two sisters, and two brothers were distraught at the news. But Elkins’ sister Barbara Tenery remembers that Dr. Spiva offered them a great deal of hope. “We were told she was the best doctor in cancers of the blood in the area,” Tenery recalls. “She said he had a curable kind of cancer and he’d be able to go to work in two months.”
To get Elkins’ white blood cell count back down to normal, Spiva started him on a regimen of chemotherapy. The primary agent was the highly potent drug, busulfan, the drug of choice for his form of the disease.
The entry for busulfan in the Physicians’ Desk Reference, the standard reference work on pharmaceutical agents, begins with an italicized warning that the drug can arrest bone marrow function; busulfan should be reduced or stopped at the first such sign. The PDR also warns that the drug’s action is not immediate—it is common for the white blood cell count in a leukemia patient to increase during the first two weeks of administration before falling. If an overdose occurs, the effects on the bone marrow can be deadly.
To induce remission of leukemia, the recommended daily dose is 4 to 8 milligrams, with a preference for the lowest-possible dose. In her deposition, Spiva stated that on May 8 Johnny Elkins received his first daily dose of busulfan ordered by her—12 milligrams. On May 10 she revised her order—to 16 milligrams of busulfan a day. Two days after that she revised her order again. Elkins was then receiving 20 milligrams of busulfan a day, several times the recommended dose.
On May 17 Spiva discharged Elkins from the hospital with orders to continue taking 20 milligrams of busulfan a day at home. In spite of the eventual effect of the doses, Elkins at first responded exactly as the PDR predicted. His white blood cell count rose slightly and then began falling.
On June 11 Elkins was readmitted to Baptist Hospital, sicker than he had ever been. He was experiencing bleeding in his gums and nose, bruising, and hair loss. In her notes on that admission, Dr. Spiva wrote that he had had leukemia for two months—one month longer than it had been diagnosed. More strangely, she wrote that his original white blood cell count was 300,000, which she later revised in his records to 350,000, although it had never been documented as being higher than 170,000. In her deposition Spiva said this was a record-keeping error. But those new entries made it appear that Johnny Elkins was more dangerously ill than he actually was. She ordered some lab work done on his blood, and the results confirmed the warnings about the effects of busulfan. On June 14, she testified during a court proceeding, Elkins’ white blood cell count was below 500, a reading so low that the machine can no longer count the cells accurately.
In one sense, Deborah Spiva did at least part of what she had promised Elkins’ family that she would do. She did wipe out the cancer in his bone marrow. However, she also proved the accuracy of the Physicians’ Desk Reference. The amount of busulfan she administered destroyed not only the cancerous cells in his bone marrow, it destroyed the bone marrow, period, and with it, the body’s ability to fight infection.
On June 19 Spiva again discharged Elkins from the hospital. On June 24 he was back; he had hit his knee on the edge of a door, and an abscess had formed. He went home five days later, and he returned to the hospital on the Fourth of July for fever, chills, and gum bleeding. Elkins’ family was alarmed at his decline. Then a nurse who had recently left Baptist called Elkins’ brother one night and said the family should get another physician. On July 25 Johnny Elkins’ sister phoned Dr. Spiva and told her she was dismissed from her brother’s case.
The family turned Elkins’ care over to Dr. Cohen. When he looked at the chart, he was shocked by the dosages. Nurses who were concerned about Spiva’s methods also brought to his attention the case of another leukemia victim, a 34-year-old man who died from what Cohen found was an inappropriate cycle of chemotherapy.
Cohen brought the cases to the hospital review committee. The committee asked Spiva to come and explain her treatments. She never appeared. So Baptist Memorial Hospital then had its reasons for suspending her privileges to practice there, and did so.
In the meantime Cohen had brought in Buckwold to assist him on Johnny Elkins’ case. They tried to restore his immune system, but Elkins died October 6, 1985.
In her deposition in the malpractice action brought by the Elkins family, Dr. Spiva testified that she believed the cause of Elkins’ death had been the treatment he received under the care of Dr. Cohen and Dr. Buckwold.
After her problems at Baptist began, Spiva started admitting her patients to the Santa Rosa Medical Center. Dr. Derick Boldt, then the medical director of Santa Rosa, like so many others, had heard the rumors about Spiva. He couldn’t help but hear them—stories about misdiagnoses and incorrect treatments came from doctors practicing at his hospital. But Boldt is a man who hates rumors. “I don’t ever want to deal with a doctor on a rumor,” he says. “I insisted they bring me the facts.”
Boldt had a phone conversation with Whitecar about Spiva. Whitecar warned Boldt that she could cause serious problems. Boldt found the conversation insufficiently convincing. Then he turned to the Board of Medical Examiners. “I called and wrote. They just ignored me,” Boldt says. “They didn’t want to give me any information on the phone or anything on paper. That raised my suspicions—do they really have anything on the woman?” he says.
Finally, after months, the proof Dr. Boldt needed was found in the case of 33-year-old Gloria Villarreal. Villarreal, a mother of four, had been a patient of Dr. Spiva’s for several years. Her primary problem, Spiva testified during a deposition in a malpractice case, was systemic lupus erythematosus. Lupus is a chronic disease usually affecting young women. There is no cure, but flare-ups, in which connective tissue in any part of the body can become inflamed and damaged, can often be medicated with drugs. Lupus is considered an autoimmune disorder—one in which the body’s immune system begins attacking itself. For that reason steroids, which suppress the immune system, are often prescribed to control the disease.
Spiva had ordered pheresis for Villarreal when she was practicing at the Nix. By the time Villarreal entered Santa Rosa on December 2, 1985, she was a sick woman, suffering from diabetes and heart trouble, as well as, according to Spiva’s diagnosis, a rare disorder of the blood known as thrombotic thrombocytopenic purpura (TTP). On December 12 Villarreal successfully underwent a heart valve replacement and bypass. Following surgery, Spiva ordered enormous doses of steroids for Villarreal to treat what she considered a flare-up of lupus and TTP. In her deposition Spiva called it a “super-pharmacologic dose,” one used in “a heroic attempt to save a life.” Occasionally large doses, up to a gram, of steroids are prescribed for one to three days for severe flare-ups of lupus or arthritis. Such doses are dangerous, however, if a patient has diabetes, chronic infections, or hypertension. Villarreal had all three. In addition, Spiva ordered not one gram, but two grams of steroids, and not for one to three days, but for twelve days.
Over the course of those twelve days Villarreal began exhibiting common symptoms of steroid overdose: psychosis, kidney failure, persistent infections. Other doctors reviewing Villarreal’s progress wrote many requests in the chart that the steroids be reduced. The morning of December 27 Gloria Villarreal died of massive infection.
Shortly after Villarreal’s death, Dr. Spiva was suspended from the Santa Rosa Medical Center. Boldt called to give her the news, a call he did not relish making. “She was very likable, very personable. I felt bad,” he says. “I don’t like to see that happen to any doctor, it’s one of the most crushing things that can happen to a doctor.” He recalls Spiva’s reaction. “She was surprised. She was disappointed. She really didn’t think it would come to that.”
The Board Acts
Dr. Whitecar had helped get Spiva out of Humana, but he was still concerned about her actions and alarmed at the continuing body count that followed her from hospital to hospital. He had heard about the deaths at Baptist—that made him furious. He and others had spoken to an investigator from the State Board of Medical Examiners more than a year before, yet he knew that nothing had been done since then.
While driving to work early one morning in December 1985 he heard on the radio news that Dr. John Bagwell, a cancer specialist from Dallas, had been appointed to the board. Whitecar had met Bagwell several years before. Whitecar pulled into a 7-Eleven and phoned Bagwell to tell him about Dr. Deborah Spiva. He said it was a matter the board had to deal with immediately.
On January 16, 1986, an emergency executive committee session of the Board of Medical Examiners was called. The subject: Deborah Anne Spiva, M.D. That day four board members heard testimony from Dr. Hempel, Dr. Cohen, and Dr. Whitecar about their former colleague. Their comments were blunt. The recounted her involvement in several deaths and made it clear that they thought she was a danger to the public.
After hearing the testimony, the board members ordered that a full hearing on the case be scheduled as soon as possible. They also, fourteen months after being told by Hempel that her actions should be investigated, temporarily suspended the license of Dr. Spiva.
On January 20 her office was closed and her license confiscated by Raymond Juarez of the board, and she was informed that a hearing would be scheduled. And soon much of San Antonio knew about Dr. Deborah Spiva. Jerry Urban, a reporter for the San Antonio Express-News, obtained a transcript of the January meeting. Urban wrote a story about the hearing; he also passed a copy to the district attorney’s office. It was the first notice the office had had about her activities. An investigation was started into the deaths of Juan Garcia and of another hemophiliac, Richard Collins, who died after she treated him at the Nix, but the DA’s office decided it did not have sufficient cause to press charges. Ben Sifuentes, Jr., an assistant district attorney in the special crimes section, says the office is now looking into the case of Johnny Elkins.
The publicity from the January hearing resulted in a lot of calls to San Antonio personal injury lawyers. None of the sixteen suits filed so far has yet come to trial. On January 31, 1986, however, a settlement for an undisclosed amount was reached in the suit filed in October 1985 by Hazel Topoleski, one of Dr. Spiva’s porphyria patients. It turned out Topoleski never had porphyria but instead suffered from a form of migraine.
The defense mounted by Spiva resulted in a legal bonanza of its own. By early 1986 she was employing five law firms to handle her problems. One of her first actions was to bring a slander suit against Hempel, Cohen, and Whitecar for their January testimony. Those remarks were found by the court to be immune from prosecution. The slander suit was then amended to include remarks made outside the board room and expanded to include Buckwold; Joseph Dean McCracken, Spiva’s successor at SAMA; and Victorio Rodriguez, a physician at Santa Rosa. Included in the slander action were comments made by Whitecar, Hempel, and McCracken to Fred Cecere’s superiors at Fort Sam Houston regarding allegedly fabricated data in papers published by the couple.
If 1986 was turning out to be a bad year for Deborah Spiva, it was also a miserable year for the Board of Medical Examiners. The board was under fire from the Legislature and the press for its disciplinary procedures. Almost all of the disciplinary actions it took against doctors were kept secret; members of the public had no way of checking if their doctor had been reprimanded by the board. And chances were if a complaint had been filed against a physician, the physician had not been disciplined anyway; the backlog was so great that some cases lingered in the files for six years. Late last year the board began making available to the public a record of its disciplinary actions. And legislation to reform the board’s procedures further is scheduled for hearings this session. It includes proposals that would strengthen requirements for physicians to report questionable practices by their colleagues, and provide legal protection for physicians who speak out.
The case the board has prepared against Spiva turned out to raise as many questions as one of her patient charts. In June Travis County district judge Paul R. Davis found, in response to pleadings filed by Spiva’s lawyer Michael Sharp, that the charges against her were so vague—in one charge no patients were named—as to violate Spiva’s right of due process. On June 4 Judge Paul Davis restored Dr. Deborah Spiva’s license to practice medicine.
Austin lawyer and former assistant attorney general Paul Gavia was brought in by the board to handle the prosecution of the Spiva case. He started retracing the steps investigator Raymond Juarez had walked more than a year before, interviewing doctors in San Antonio. He rewrote the original charges, and on June 23, 1986, after months of delays, a Board of Medical Examiners hearing began concerning whether Deborah Spiva should be licensed to practice medicine in Texas. It ended July 11. Her husband was the main witness to testify on her behalf. As a parade of former colleagues testified that she was not competent, Spiva sat hunched over a legal pad, taking copious notes, rarely looking at her accusers, her face a kaleidoscope of tics and pained expressions.
“Some people, after they testified, would come up to me and tell me they still had a lot of affection for me,” she says. “They take you off at the knees and then say they have a lot of affection.”
Austin attorney Carla Cox was hired by the board to preside at the hearing. In October she issued her conclusion: Dr. Spiva’s license should be revoked. On December 3 the full board of medical examiners met to make a final decision on the recommendation. Spiva did not appear. The meeting took a little over an hour. After presentations by both sides, the board unanimously adopted Cox’s recommendation. It also found that Dr. Spiva was an imminent danger to the public health and safety and made the order effective immediately. Deborah Spiva became one of only 27 out of 42,784 doctors licensed by the state to be so disciplined last year.
An Uncertain Future
No one thinks Deborah Spiva was motivated by money, although while she was in practice the treatments she prescribed ran up enormous medical charges. When colleagues speculate on what went wrong, some say she has some sort of impairment that leaves her unable to distinguish between a lie and the truth. Others say that she was driven to discover diseases no one else could diagnose and that she would alter reality to fit this need. Some say her need for approval is so overwhelming that her pursuit of it became pathological. But mostly these men of science, so comfortable with the precise, esoteric vocabulary of medicine, use layman’s terms when describing Deborah Spiva. They say she’s crazy.
Spiva is all too familiar with the things that have been said about her, the talk that she is crazy. “That’s a good throwaway, that’s easy for people to buy, then they can live with themselves,” she says. “But there’s nothing in any of those records you could hang a psychiatric diagnosis on. How could I have been a solid citizen all these years, then December 20 [the day of her suspension from Humana Hospital Metropolitan], I’m crazy?”
When asked if she’s ever considered seeing a psychiatrist, she shakes her head. “Up to now, my life wasn’t that exciting.”
Spiva says her plans are uncertain. Fred Cecere is now at the U.S. Army Command and General Staff College at Fort Leavenworth, Kansas. She and her husband have talked about having children, but she adds with a smile that first they would like to live in the same city. It is hard, though, for her to make any plans with so much legal action pending. Last October she dropped her slander suit against her former colleagues, but she could refile it at any time. And there are all those malpractice trials to come. Her malpractice policy offers between $1 million and $3 million of coverage—and if she begins to lose her malpractice cases, she could quickly become personally liable for the rest. It is a more or less existential predicament—Spiva says she’s broke.
She is also fighting in the courts to get her license back. In February Judge Paul Davis, who restored it once before, did so again, pending Spiva’s appeal. He did, however, include the unusual stipulation that she not be allowed to treat patients. Judge Davis is scheduled to hear Spiva’s appeal in May.
Texas may end up with legislative reforms imposing stringent requirements on doctors to report the substandard care of their colleagues. But all the reforms in the world won’t work if physicians won’t see that there is a problem in the first place, if they allow questionable behavior to be talked away.
Even if Deborah Spiva does get her license back, she says the publicity has made it impossible for her to practice medicine again; she says she could never get malpractice insurance. That realization has been difficult for her. “Of course it’s painful. There’s no way it’s not,” she says. “What I’ll end up doing I really don’t know. I don’t know what doors have been closed. To have defined yourself as something and not be able to do that any longer is obviously painful. Especially when you did some good.”