Missouri State Board of Healing Arts Ethics Complaint

Dear Missouri Ethics Commission,

Ethics Complaint Fell on Deaf Ears

State Board of Registration for the Healing Arts of Missouri
Systematic Dysregulation of Public Safeguards and Potential Solutions

This ethics complaint is being filed against the Missouri (MO) State Board of Registration for the Healing Arts (SBRHA),1 the SBRHA Executive Director Connie Clarkston, and the SBRHA Attorney – Counsel, Frank Meyers, JD. This complaint is structured into 10 major areas of unethical regulatory conduct. Each section contains this writer’s opinion regarding what the SBRHA should do to correct their unethical conduct, and this is described in a manner that illustrates the nature of the unethical conduct. Many of the SBRHA’s unethical actions continue to cause harm as they have propagated disinformation about patient care and they refuse to acknowledge their publicly filed false claims. The SBRHA refuses to tell the truth about cancer testing and unnecessary surgery – important aspects of care which they already filed lies about in court. By concealing the truth about patient care and punishing honesty, the SBRHA committed acts which are the exact opposite of their legislated duty. The SBRHA has a responsibility to address the numerous instances of unsafe and unethical conduct committed by their licensee Dr. Kamani Lankachandra (Dr. KL) e.g. she provided disinformation to the ACGME about months of patient care, committed perjury in her April 2014 deposition about unnecessary surgery, misrepresented Dr. Snodgrass’s 2011 academic status at UMKC in a Spring, 2013 postgraduate reference letter that she sent to the Georgia Composite Medical Board, and she committed perjury when she testified under oath on about July 2nd or 3rd, 2014. Residents at UMKC that were placed on probation were supposed to, per university policy, be able to appeal the decision. Dr. KL was asked why she wrote Dr. Snodgrass was on probation on about 12 29 2010. A few minutes later she said, still under oath, that probation and remediation are the same, something that is not supported by the subsequent testimony of Dr. Jill Moormeier, which occurred less than two hours after the court teleconference with Dr. Lankachandra. Dr. Moormeier is UMKC’s Accreditation Council on Graduate Medical Education (ACGME) Designated Institution Official (DIO), and she is the leader in charge of the residency programs at UMKC.

In addition to witnessing Dr. KL commit perjury during court, the SBRHA reviewed Dr. Snodgrass’s resident evaluations created by Dr. KL and discovered numerous bizarre and incompetently documented assessments of Dr. Snodgrass, and yet they remained complicit in enabling her incompetent resident evaluations. Dr. KL’s written evaluations often contained vague, harsh criticism; e.g. she wrote claims stating that Dr. Snodgrass lacked energy, that he blamed others, and that he refused to learn. There was not a single example documented to illustrate any of the aforementioned claims from April 2011. Furthermore, Dr. KL’s incompetently documented resident assessments were not limited to April 2011. The SBRHA acted unethically by (1) identifying the aforementioned bizarre documentation but not disciplining Dr. KL’s medical license for incompetence and then by (2) filing the incompetent assessments in court as if they were legitimate. Instead of addressing Dr. KL’s dishonesty or areas of demonstrated incompetent documentation, the SBRHA acted unethically by concealing the dishonesty. Furthermore, the SBHRA violated professional ethics even more by punishing Dr. Snodgrass for his true reports about unsafe patient care.

The SBRHA failed to address the dishonesty and corruption, the routine lying about academic matters as well as patient care, and they have punished a physician for honestly reporting unsafe patient care. Please provide your kind consideration to the following four sections of this complaint (1) the overview of the complaint, (2) the details of the complaint, (3) the references, and (4) the enclosed supplementary materials.

Overview of the 10 aims – the SBRHA should

I. Acknowledge the lies about months of reckless breast cancer testing and that they did not disclose this to their recent auditor – who gave them a rating of “good.”

II. Acknowledge that Dr. Snodgrass faithfully reported several patient care standards violations to The Joint Commission2 in 2012 and that it was unethical for the SBRHA to exploit unsafe patient care to berate him as a liar during his 2014 trial.

III. Acknowledge that Dr. Kamani Lankachandra (Dr. KL) made false claims about Dr. Snodgrass’s academic status in 2013 and 2014 to different state medical boards. The false claims appear to be disparate to each other, i.e. inconsistent and were related to whether Dr. Snodgrass was on probation or remediation when he was at UMKC.

IV. Acknowledge Dr. Snodgrass completed 44 months of ACGME accredited training,3 and that Dr. KL made misleading claims in 2013 to the MO SBRHA regarding her ability to document his clinical competency. It was unethical of the SBRHA to contest this, and it was unethical of them to refuse to accept prior documentation of training as well as for them to refuse to address the dishonesty of Dr. KL. In her letter written on May 25, 2011, Dr. KL documented the quality of Dr. Snodgrass’s patient care as appropriate for his level of training and that he completed 34 months of pathology training. However, in the fall of 2013, when Dr. Lankachandra was asked to document Dr. Snodgrass’s clinical competency on a different form, the Postgraduate form provided by the SBRHA, Dr. Lankachandra wrote that she was unable to answer the question of whether he was clinically competent because he left the residency program (June 27, 2011). Dr. Lankachandra could have informed the SBRHA that she documented the same information about patient care on the form that she signed on May 25, 2011.

In contrast to Dr. Lankachandra’s sudden inability (2013) to report that Dr. Snodgrass was competent for his level of training, she maintained her ability to write negative statements about him.

Dr. Lankachandra was able to evaluate Dr. Snodgrass’s performance negatively in several other areas such as his professionalism and his work with peers.

Connie Clarkston and Frank Meyers, JD, were informed about the postgraduate training letter signed on May 25, 2011 by Dr. Kamani Lankachandra. Instead of addressing the highly questionable evaluations made by Dr. Lankachandra, Ms. Clarkston and Mr. Meyers repeatedly berated Dr. Snodgrass as incompetent.

Dr. Snodgrass in other performance domains such as his interactions with peers.

It was unethical of the SBRHA to facilitate this additional dishonesty and refuse to redress it. The SBRHA should acknowledge the deception and apologize for abusing discretion and relying on a doctor who committed perjury (April 2014 and July 2014) to assess Dr. Snodgrass while concomitantly rejecting the earlier letter Dr. Lankachandra wrote, a letter which contained information that answers the critical question about physician competency on the SBRHA’s postgraduate training form.

In retrospect, Dr. Snodgrass should have had Dr. Lankachandra sign and mail the “SBRHA’s postgraduate training form” in 2011. Given that Dr. Snodgrass had witnessed Dr. KL make numerous false claims in evalautions during residency training, he did prudently ask the UMKC GME Office run by Dr. Jill Moormeier to store the “ACGME Postgraduate training form.”

The SBRHA should not change their assessment of the quantity of training because a pathologist who committed perjury changes her mind.



V. Acknowledge that the April 2014 deposition of Dr. KL contained multiple false claims about patient care.

VI. Acknowledge that it was unethical for the board members to have Connie Clarkston, the SBRHA’s Executive Director, to communicate shocking news via only formal letter without any competent explanation. Ms. Clarkston wrote Dr. Snodgrass an official letter on 11 20 2013 with instructions to obtain a ($10,000) multidisciplinary evaluation without specifying why, other than the bizarre and unfounded belief that such an evaluation could be “very insightful.”4 It was grossly unethical to communicate shocking information in such a manner and without competent rationale. These acts of dysregulation are discussed further in the detail section of this report.

VII. Acknowledge that the SBRHA demonstrated numerous instances of unethical conduct against the cardiologist Dr. Antoine Adem. The SBRHA should implement a plan to prevent similar misconduct from occurring in the future.

VIII. Acknowledge that the SBRHA committed numerous unethical and incompetent acts against the psychiatrist Dr. Surendra Chaganti. The SBRHA should devise a plan to prevent similar unethical conduct from occurring in the future. For example, many medical boards might ensure that the board members know how to read FDA drug labels and identify that Marinol is acceptable for use in elderly patients.

IX. Acknowledge that it was unethical to show partiality by trusting a pathology program director who lied under oath in court. According to Johnson and Chaudhry, state medical board members should have a passion for the judiciary, and that means the board members should evaluate reports of patient harm without showing partiality.5 Being a program director who commits perjury does not mean that one’s expertise in looking at cells under the microscope transfers to an increase in integrity and honesty. The SBRHA appears to have a conflict of interest related to their plans to build collegial relationships with medical school deans in order to increase the primary care workforce and their refusal to uphold the statutes as it relates to a physician who is a department chair and program director at one of those universities. It is unethical for the SBRHA to selectively enforce the statutes and enable some doctors to be above the law, to commit perjury repeatedly about patient care and then for the SBRHA to help conceal the dishonesty. If the SBRHA Board Members had a passion for the judiciary as Johnson and Chaudhry assert is important for board members, then they probably would be more concerned with the truth about patient care and stop exploiting patients who were harmed or received unnecessary surgery in order to conceal the errors and dishonesty of a physician who has significant clout at the university.

X. Acknowledge that the phrase “lives are at risk,” does not justify the SBRHA’s repeated acts of lying about patient care. The SBRHA should acknowledge that repeatedly lying about patient care does not improve the integrity of the profession, does not make patients safer, and may decrease patient safety.


Details of the 10 categories of ethical complaints including suggestions for consideration

I. The SBRHA should acknowledge that the breast cancer specimens at the UMKC Pathology Department were routinely subject to prolonged ischemic times from January-to-June 2011. The SBRHA should apologize for wrongfully exploiting months of unsafe patient care in an effort to punish Dr. Brett Snodgrass for his credible and accurate reports to regulators such as the ACGME.6 The SBRHA should apologize for not addressing UMKC’s lies about breast cancer testing as well as for filing the false claims in court against Dr. Snodgrass on July 3, 2014.

The SBRHA used their state-given investigative authority to prevent evidence of their dishonesty from being evaluated by the auditor. The SBRHA did not disclose that they have enabled a physician to repeatedly commit perjury, that they filed many lies about patient care into court, and that they still, as of March 1, 2016, refuse to tell the truth about the months of reckless breast cancer testing.

According to the American Society of Clinical Oncology, 2010 Guidelines for testing for estrogen receptors on breast cancer specimens, “The time from tumor removal to fixation should be kept to ≤ 1 hour.”

Frank Meyers, JD, withheld the medical records and the allegedly documented breast lumpectomy “ischemic times” from the court. This withholding of medical records from court while filing false claims about patient care in court is unethical and manipulative. It can mislead others to form erroneous conclusions about the quality of care that patients with breast cancer received. Misleading others to believe something that is not true is particularly relevant to the subject of medical regulation. In medical law cases, the burden of proof is not “beyond a reasonable doubt,” but it is “more likely than not.” Thus, one can create a convincing argument by utilizing many lies and withholding the relevant medical records to deceive another person sufficiently to think that the lie is more probable than the truth. Since concrete evidence is not needed in such cases, making false claims about medical facts and patient care in court has been a recurring theme for the SBRHA and has been done against physicians such as Dr. Chaganti, Dr. Adem, and Dr. Snodgrass. This is particularly relevant as the dishonesty and unethical conduct committed against physicians does not merely harm the physician, but it also can harm patients and create an unsafe healthcare system. The dysregulation has helped foster a culture of dishonesty and condoned unsafe patient care. The SBRHA has repeatedly enabled a Missouri physician to lie about patient care as well as academic matters, and they have given no guarantee that there will be a foreseeable end to the dishonesty.

The SBRHA passed their 2015 audit with a rating of “good.” It is worthy of consideration, and possibly further evidence of unethical conduct that the state medical board has used their authority as an investigator of Missouri to conceal or “keep hidden” relevant records regarding patient care. With regards to the SBRHA’s enablement of dishonesty by Dr. KL, and punishing Dr. Snodgrass for his truthful reporting, the SBRHA used their state-given investigative authority to selectively investigate reports of unsafe patient care in order to prevent evidence such as medical records that would prove their dishonesty from being retrieved from TMC and then being evaluated by the auditor.

E. The SBRHA could deceive the auditor either passively or actively. An example of passive deception or tacit collusion would be that none of the SBRHA mentioned that they needed to obtain the reports from TJC to uphold the statutes. This lack of investigation would occur because no member wanted to provide evidence of their dishonesty or the false claims that they filed in court. Active concealment would be having The Joint Commission reports, finding out about the audit, and then shredding them. Hopefully, the dishonest claims about patient care that the SBRHA filed in court are a result of passive deception, which is less deceptive and less unethical. This can occur when the investigators and board members choose not to look for records that they know will likely reveal that the SBRHA has done the opposite of the legislature’s intent.

The SBRHA probably did not want others or the auditor to know about the numerous standards violations that occurred or that Frank Meyers and the SBRHA tried to frame Dr. Snodgrass as having lied to TJC. However, a state agency such as the Missouri Ethics Commission can prove that the SBRHA has been passively or actively concealing numerous records of wrongdoing and dishonesty. A regular citizen can provide no evidence of the dishonesty regarding patient care because the medical records belong to the hospital, and the standards violations are kept out of the hands of the public by The Joint Commission.

The SBRHA did not disclose to the auditor or to the public – in spite of their numerous false claims against Dr. Snodgrass – that they have enabled a physician to repeatedly commit perjury, that they filed the many lies about patient care into court, and that they still, as of March 1, 2016, refuse to tell the truth about the months of reckless breast cancer testing. The board manipulated the evidence – prevented the related medical records and claimed documentation from entering the court, and this may have generated false impressions about patient care. Again, since the burden of proof in medical regulatory cases is “probable cause,” or “more likely than not,” their false claims about patient care are able to create a healthcare culture characterized by deceit instead of the expected integrity and excellence.

The prolonged “ischemic times” for the lumpectomy specimens occurred because the breast tissue would often sit on the counter in the “Gross Room” for more than an hour while waiting to be accessioned by the Gross Room Attendant. Even when a lumpectomy sat on the counter without formalin for less than an hour, the ischemic time could still be greater than an hour because the specimen has to go from the surgical operating room to radiology, and then to the counter top or table until it was accessioned.

Accessioning occurs when a specimen is entered into the pathology computer system and given a specimen number. It was not until after the accessioning that the lumpectomies were permitted to be placed in formalin. Therefore, accessioning of a lumpectomy means that the excised piece of the breast, also known as a lump of breast tissue, is “logged in” to the pathology computer system and given a surgical pathology number. “Ectomy” means to excise or remove, and “lump” is a part of something. Thus the word, “lumpectomy” means to remove a lump, and the words “breast lumpectomy” mean to remove a lump of breast tissue. This is different from a mastectomy where the entire breast is removed.

After being accessioned, the lumpectomy was placed in 10% Neutral Buffered Formalin. The excessive time that the lumpectomy spent sitting on the gross room counter created a normative practice of guideline-discordant care, which is an ischemic period of greater than one hour. Furthermore, the ischemic time was not always less than 30 minutes as the UMKC GME Office misled the ACGME to believe. Sitting on the Gross Room counter waiting to be accessioned and then placed in formalin certainly would not permit an ischemic time of less than 30 minutes, and it is unethical for Mr. Meyers to file such claims in court against Dr. Snodgrass. The SBRHA has a duty to their patients, not a duty to win in court by exploiting patients that received unsafe care. This is grossly unethical as Mr. Meyers exploited unsafe patient care to punish Dr. Snodgrass for accurately reporting reckless cancer testing that he had disclosed twice to Dr. KL and as he also informed Dr. Jill Moormeier in 2011. Even if a lumpectomy only spent 45 minutes sitting on the gross room counter without formalin, the overall ischemic time may be more than an hour. This occurs because after being removed from the patient, the lumpectomy is brought to the radiology department where x-rays are taken to ensure that the tumor was removed. The radiologist looks at the x-ray to make sure that they see the tumor and that the surgeon removed the tumor instead of normal breast tissue. Then the lump of breast tissue would be carried on a radiographic board, usually accompanied by a developed x-ray, in plastic wrap to the Pathology Department at Truman Medical Center.7 Dr. Snodgrass estimates that the mean ischemic time was somewhere between one and two hours.

The importance of minimizing the ischemic time was emphasized in 2010 when additional evidence was published showing that the longer the ischemic interval, the greater the amount of false negative tests for estrogen and progesterone receptors.8 In 2010, the American Society of Clinical Oncology and College of American Pathologists published a guideline recommending that the ischemic intervals should be less than one hour in order decrease the “false negative” testing of the breast cancer for estrogen receptors (ER) and progesterone receptors (PR).9

  • Parenthetically, Dr. Lankachandra had a meeting with the residents in the fourth quarter of 2010, and she informed them about the importance of placing specimens in formalin as soon as possible. Thus, she was concerned about the quality of patient care and took efforts to ensure that the quality was improved. However, she did not appear as concerned about the matter when I informed her, in person, in the gross room, about the prolonged ischemic times in January 2011. After being informed that breast lumpectomy specimens were sitting on the counter without being processed in a timely fashion, she replied that she would address it at the upcoming faculty meeting.

  • The prolonged ischemic time placed the breast lumpectomy specimens at increased

    risk for testing as “falsely negative” for estrogen and progesterone receptors by the test method known as immunohistochemistry (IHC).8 IHC was the method used to test breast cancer specimens for the presence of ER and PR at TMC-HH in 2011. The pathology department sent some of the specimens to an outside lab for additional testing for ER and PR using another method, but there is no guarantee that this method would be performed on the lumpectomy specimens that had the longest ischemic times. The send-out tests were usually carried out on the breast cancers that appeared indeterminate, or in-between the positive and negative cut-off values as determined by the IHC method. If a lumpectomy specimen should have tested as weakly positive if it were given a brief ischemic time, then a prolonged ischemic time could cause that specimen to test as completely negative. Thus, specimens that should have tested as positive may have tested as negative due to the prolonged ischemic times. This particular negligence probably did not cause any deaths, but it may have subjected some women to more aggressive treatment regimens without the benefit of the less toxic hormonal therapies.

N. Regardless, UMKC lied about this testing to the ACGME and the SBRHA punished Dr. Snodgrass for his accurate report to the ACGME by berating him a liar before the Honorable Commissioner. The SBRHA filed UMKC’s blatantly false letter in court to portray Dr. Snodgrass as a liar, and the SBRHA did this at the expense of patient safety and honesty.

O. The UMKC Pathology Department did most of their work at the Truman Medical Center (TMC)– Hospital Hill TMC Pathology Department. The address was

Truman Medical Center – Hospital Hill
2nd Floor Pathology Dept.
2301 Holmes Street
Kansas City, MO 64108

The medical records are electronically preserved, easily accessible, and they belong to TMC.

Due to the recalcitrant nature of the medical board, and their repeated refusal to communicate with me, I reluctantly shared accurate information regarding their regulatory misconduct and that related to the dishonesty about patient care online.10 Mr. Meyers refused to talk with me over the phone as I politely asked him via email in December 2013. The SBRHA exploited patients that received unsafe care and filed false claims against me, at the patient’s expense, in court. Therefore, I shared true and verifiable information online about the unsafe breast cancer care.10 My aim was to provide the public with sufficient information to evaluate the SBRHA’s claims for themselves. Considering that the SBRHA disciplined me for performing my fiduciary duty, and withheld the medical records preventing me from being exculpated about the allegations of lying about breast cancer, I thought it necessary to share truthful information with the public. Patients are therefore able to consider the SBRHA’s publicly filed false claims along with accurate reports of patient care as they evaluate physicians. The SBRHA will assert that this is not professional, but they call lying about patient care professional. Furthermore, patients have a right to evaluate accurate information along with the false claims about patient care that the SBRHA filed in court. The information shared online about the SBRHA’s dishonesty originated in parallel with that of the Veterans Administration Healthcare Scandal of 2014. The scandal at the VA consisted primarily of lies about the “wait times” of ignored veterans. The breast cancer scandal at UMKC and propagated by the SBRHA was predominately related to untruthfulness about the “ischemic times.” of neglected breast lumpectomies.

On July 3, 2014, the SBRHA filed verifiably false claims in court against Dr. Snodgrass regarding months of reckless breast cancer testing that occurred at the UMKC Pathology Department from January-to-June 2011. The SBRHA falsely berated Dr. Snodgrass as a liar for his 2011 faithful report to the ACGME regarding months of reckless breast cancer testing characterized by prolonged ischemic times. The prolonged ischemic times risk false negative tests for estrogen and progesterone receptors, a factor that influences treatment and quality of life, but not overall survival.

Lies filed in court against Dr. Snodgrass in 2014 –Unethical Conduct of Mr. Meyers
Frank Meyers, JD, the Missouri (MO) State Board of Registration for the Healing Arts’ (SBRHA) attorney, was informed in court on about July 03, 2015, that the UMKC Graduate Medical Education Department lied to the ACGME in late 2011 or 2012 about months of reckless and unsafe breast cancer testing at Truman Medical Center – Hospital Hill. In addition, Mr. Meyers witnessed the UMKC Pathology Chair and Program Director, Dr. Kamani Lankachandra, make false claims under oath in court, via telepresence (video conference before the honorable commissioner) on or about July 2 or 3, 2014. Mr. Meyers nonetheless filed her previous deposition claims – from April 2014 in court against Dr. Snodgrass to berate his moral character. It was unethical of Mr. Meyers to rely on the deposition testimony of a known perjurer as evidence to try to punish Dr. Snodgrass and “protect” the public. It was unethical of Mr. Meyers and the SBRHA to permit the dishonesty and to propagate the lies – especially egregious was their propagation of lies about patient cancer care.

Dr. Snodgrass disciplined for reporting unsafe patient care
Systemic dishonesty in healthcare regulation. Neither the LCME, ACGME, nor the Missouri SBRHA opened a single patient chart.

The false claims about breast cancer testing were written by the UMKC GME Office in a letter signed by Dr. Jill Moormeier, to the ACGME around late 2011, or possibly early 2012 – Dr. Snodgrass was not provided with a copy of this letter, but was only shown it during the pre-trial deposition and then asked about it again during the trial. Although the falsified letter about breast cancer testing was signed by the UMKC GME Office’s Dr. Moormeier, it was probably written based on intentionally false information provided by the UMKC Pathology Chair and Program Director, Dr. Kamani Lankachandra (Dr. KL).
1. The lies were written by the UMKC-GME office to Amy Dunlap (married and now her name is Amy Beane) of the ACGME and the letter signed by the UMKC Designated Institution Official (the ACGME-DIO), Dr. Jill Moormeier. The date was in the latter half of 2011 or in early 2012. The SBRHA did not provide Dr. Snodgrass with the letter. Dr. Snodgrass first became aware that the UMKC GME office lied to the ACGME about months of breast cancer testing during his pretrial deposition in June 2014.

2. State agencies can inquiry of Dr. Jill Moormeier and ask how she concluded, as described in her letter written to the ACGME, that the UMKC Pathology Department was often documenting the ischemic time, including during the months of January to June 2011.

T. UMKC made, at least, two lies to the ACGME (in late 2011 or early 2012), and Frank Meyers, JD, of the SBRHA, filed these lies in court against Dr. Snodgrass on July 3, 2014. The lies that were made by UMKC to the ACGME were
1. We always have an ischemic time of less than 30 minutes.

2. The Pathology Department “often [sic]” documents the ischemic time.

U. This is how one can determine that the claims made by UMKC to the ACGME about breast cancer testing were not true:
a. Ask the UMKC Pathology Department to show you the surgical pathology reports of 10 breast lumpectomy specimens from January-to-June 2011 so that you can calculate the mean “ischemic time” to make sure that it was less than 30 minutes as was claimed in the letter to the ACGME.

b. Ask the SBRHA to provide you with the letter that UMKC wrote to the ACGME about breast cancers in 2011.

c. If the SBRHA “lost” the letter, ask the ACGME -acgme.org – or UMKC for it.

V. The SBRHA should acknowledge that forcing physicians into years of litigation with them for reporting months of reckless cancer testing is unethical.4 The transcripts and letters of Snodgrass v. SBRHA are available online at The exhibits were not uploaded by the Administrative Hearing Commission. The letter about breast cancer that UMKC sent to the ACGME was an exhibit, but should be available by contacting the SBRHA, UMKC, or the ACGME. The Shortened URL is http://bit.ly/BoardReform. Full link https://archive.org/stream/Snodgrass-v-SBRHA/Snodgrass%20v%20SBRHA%202013%202014#page/n0/mode/1up

II. The SBRHA should acknowledge that Dr. Snodgrass faithfully reported several standards violations to The Joint Commission (TJC). Also, they should apologize for trying to make his true statements appear as if they were lies. The SBRHA should also acknowledge that the April 2014 deposition of Dr. KL regarding TJC standard violations was not necessarily perjury, but was vague and misleading. The SBRHA should apologize for making Dr. Snodgrass appear as if he were a liar for his faithful and true reports to TJC. Specifically, Dr. KL was not asked if my reports were correct, but she mentioned other, irrelevant information – that the administration at TMC helped her in dealing with TJC.

A. This explains how to determine the claims about The Joint Commission Reports by Dr. Snodgrass were true:
1. Contact The Joint Commission (TJC) on Accreditation for Healthcare and inform them that you are an agency of the state of Missouri. Their website is http://www.jointcommission.org/

2. Ask TJC about the Truman Medical Center Lakewood laboratory and/or pathology department from the first half of 2011 – ask whether there were any standard violations, specifically with reference to the microbiology culture.

3. Inform TJC that you would like to know if Truman Medical Center Hospital Hill laboratory or pathology departments violated any standards in 2011 or 2012. Then you can ask whether a Dr. Snodgrass reported any of those standard violations to them. [Instead of addressing the unethical and unsafe conduct – the state medical board filed Dr. Lankachandra’s April 2014 deposition in court against Dr. Snodgrass – on July 3, 2014 – creating the false impression that Dr. Snodgrass lied to TJC. The SBRHA should apologize for their unethical actions of: (1) failing to protect the public by not addressing TJC standards violations and (2) making Dr. Snodgrass appear as a liar for his veritable reports to TJC.

III. The SBRHA should acknowledge that the UMKC Pathology Chair and Program Director, Dr. Kamani Lankachandra made several false claims about Dr. Snodgrass’s training at UMKC.
A. Dr. KL falsely informed the Georgia Composite Medical Board in 2013 that Dr. Snodgrass was on probation. 

Ethics Complaint Details 

B. The SBRHA should acknowledge that Dr. KL made a significant false claim on the postgraduate training form that she sent to the Georgia Composite Medical Board. She informed them that Dr. Snodgrass was previously on probation at UMKC, and this dishonest act caused Dr. Snodgrass to report her lies to future employers in Massachusetts who then rescinded an internship at St. Elizabeth’s hospital because Dr. Snodgrass was – according to the change in assessment by the UMKC Pathology Chair – on probation while at UMKC.

C. Dr. Kamani Lankachandra (KL) made a false claim in court via telepresence and under oath on about July 2nd or 3rd, 2014, when she claimed that probation and remediation are the same. The DIO Dr. Moormeier testified immediately after her in live court and when she was asked by the Honorable Commissioner Karen Winn whether probation and remediation are the same she replied ~ “Ooh no. They are not the same. Only one is reported to state medical boards. Only probation is reported to state medical boards, remediation is not.” Dr. Lankachandra had been the pathology chair (evaluator of other doctors) and program director (evaluator of residents) by then for four years, but she claimed they were the same. It was unethical for Frank Meyers to witness this additional dishonesty and then continue, without concern that she also lied about patient care in her April 2014 deposition, to file Dr. KL’s lies in court against Dr. Snodgrass.

IV. Acknowledge that Dr. KL made false or misleading claims in writing to the SBRHA in 2013 when she wrote that she could not assess his competency because he left the program even though she already documented nearly identical information in the letter of ACGME Core Competencies.

A. The SBRHA should acknowledge that Dr. Snodgrass completed 44 months of ACGME training – including 12 months of general surgery at Carolina’s Medical Center followed by 34 months of ACGME-accredited training at the UMKC Pathology Department.

B. The SBRHA should acknowledge the training certificate from Carolina’s Medical Center. Connie Clarkston and the SBRHA should apologize for asserting that a quadruply signed document is invalid because a physician that Dr. Snodgrass never met made a negative comment about his performance during his surgical internship. 

Executive Director Connie Clarkston lied to the NPDB and Courts
It was egregiously unethical and deceitful of the Missouri State Board of Registration for the Healing Arts’ Executive Director Connie Clarkston to sign a letter stating that Dr. Snodgrass’s training certificate – which she had – was invalid


C. The SBRHA should acknowledge the letter of ACGME Core Competencies signed by Dr. Kamani Lankachandra.

D. The SBRHA should acknowledge that Dr. Snodgrass left the UMKC Pathology Department on June 27, 2011, and that he completed most of his June pediatric surgical pathology rotation – which moves him closer to 45 months of ACGME-accredited training.

E. The SBRHA should acknowledge that lying about patient care and physician competency does not protect the public.

F. The SBRHA should acknowledge that they have failed to evaluate Dr. Snodgrass and other licensees in a competent and equitable manner and that they will establish processes and procedures to prevent similar types of regulatory misconduct in the future.

G. The SBRHA should take steps to ensure that Dr. KL will not continue to make false claims to future state medical boards as she has done once to Georgia and several times to Missouri.

Dishonesty was rewarded by Ms. Clakrston and the Missouri Board of Healing Arts
The state medical board of Missouri enabled Dr. Lankachandra’s lies to be propagated indefinitely and the board did nothing to improve the integrity of physicians.

V. The SBRHA should acknowledge that it was unethical of them to file Dr. KL’s 2014 deposition in court against Dr. Snodgrass without addressing the dishonesty about patient care or the medical misinformation. Dr. KL’s April 2014 deposition appears unethical or incompetent because she claimed that neck dissections are massive procedures and then she said, “I did not cause that.” First, neck dissections are not all massive procedures.11 It was unethical for the SBRHA to witness such a lack of medical knowledge, or incompetence and then file it in court. There are many types of neck dissections, and they are not all “radical neck dissections.” Indeed, Dr. KL’s misdiagnosis of a benign pleomorphic adenoma as a malignant “carcinoma ex-pleomorphic adenoma” resulted, per the surgical pathology log, in a level 2-4 unilateral neck dissection – to check lymph nodes for the spread of the “malignant carcinoma.” The SBRHA acted unethically in this additional instance in several ways. First, the SBRHA did not address Dr. KL’s false claim about the “massive” nature of neck dissections. Second, the SBRHA did not address the dishonesty related to causing a minor neck dissection – the patient did fine regardless, but she lied about it and then referred to Dr. Snodgrass as a liar, another act of perjury.

The state medical board should address physicians who either lie about or do not understand the care that they rendered – a characteristic that Dr. KL demonstrated in her April 2014 deposition. The care occurred on about June 20-22, 2010 and was related to an intraoperative misdiagnosis.

Ms. Clarkston and the Board Members acted lofty, dismissive and were dishonest
Ms. Connie Clarkston of the Missouri Board of Healing Arts was lofty and dismissive. Ms. Clarkston enabled her attorney to file myriad lies about patient care into court.

The SBRHA should review surgical pathology report S-10-003342 from Truman Medical Center Hospital Hill – as well as the associated operative report, and they should consider the operative note, whether the surgeon performed a level 2-4 unilateral neck dissection, and whether Dr. KL’s intraoperative misdiagnosis played a role in causing the patient to receive unnecessary surgery. The SBRHA should evaluate whether Dr. KL’s April 2014 claims of not causing an unnecessary neck dissection and stating, under oath that Dr. Snodgrass lied are consistent with (1) the surgeon’s operative note and (2) the surgical pathology report.

dishonesty is rewarded in Missouri
Did Ms. Clarkston investigate the reports of dishonesty or patient harm in an equitable manner?

The SBRHA should establish means to prevent them from filing false claims about medical information in court in the future. For example, the SBRHA should not propagate misinformation from a senior physician regarding what constitutes a neck dissection.

The SBRHA may have acted unethically by not addressing the lack of competent medical knowledge demonstrated by Dr. KL, in spite of her being the physician who assesses the competency and professionalism of resident physicians.

The SBRHA acted unethically by filing a doctor’s misinformation in court against Dr. Snodgrass while concomitantly asserting that Dr. Snodgrass lacked sufficient training and skills to be licensed as a physician.

VI. The SBRHA should acknowledge that it was unethical for them to instruct Dr. Snodgrass to obtain a multidisciplinary evaluation without specifying why. This $10,000 test was ordered without a reasonable rationale on November 20, 2013.

A. The Missouri State Board of Registration for the Healing Arts instructed Dr. Brett Snodgrass to obtain a multidisciplinary evaluation without specifying the purpose of such an exam – an unfathomable, reckless, unethical, incompetent, and deceptive regulatory practice nearly akin to rectal feedings of patients by CIA Physicians and staff.12 These were acts that allegedly were for safety and security – yet no reasonable person would think that ordering a $10,000 drug evaluation for no stated reason would make sense or that giving food rectally to prisoners would have any benefit of security. This egregious conduct is unethical and illustrates a state medical board that may not be fit to regulate – at least not as they presently are, a deceptive agency that conceals months of patient harm and enables doctors to commit perjury about the care that they provided. Multidisciplinary evaluations are typically used to evaluate drug addictions, and Dr. Snodgrass had already met with the hospital wellness committee in October 2010, where he met with a multidisciplinary panel consisting of the former chair of the UMKC Family Medicine Program, a psychiatrist, and a psychologist. They made no allegation of drug abuse or drug problems and returned Dr. Snodgrass to work in the pathology department with only monthly counseling meetings. The SBRHA should not use state authority to harass people with instructions to obtain bizarre and expensive tests without providing any rationale. This was unethical for the board to do, and it was unethical for Connie Clarkson to write the letter, which can be found on the Board’s website or at the shortened URL http://bit.ly/BoardReform. As the SBRHA’s executive director, Ms. Clarkston should have sufficient experience in the medical field to understand that when physicians instruct patients to get tests or evaluations, there should be a reason. However, she provided no basis for the instruction but nonetheless told Dr. Snodgrass to obtain an expensive, multi-day, in-hospital, multidisciplinary drug evaluation.

B. On November 20, 2013, the SBRHA instructed Dr. Snodgrass to obtain a multidisciplinary evaluation through standard mail only. They did not specify why, and this is an example of poor communication – a dangerous practice for physicians, especially when ordering tests or exams. It is unethical for medical boards to order $10,000 drug evaluations, a type of study where a person goes to live in a hospital for several days while being evaluated for drug issues.
C. Connie Clarkston is significantly responsible for overseeing this unethical conduct. Acknowledge that it was unethical for the board members to have Connie Clarkston, the SBRHA’s Executive Director, instruct Dr. Snodgrass via a formal letter in the mail only, to obtain a $10,000 multidisciplinary clinical drug evaluation without specifying why, other than the bizarre claim of it could be “very insightful.” It was unethical or incompetent for the SBRHA to believe that such an evaluation could be “very insightful,” without specifying how or why any reasonable person would arrive at that conclusion. It was also unethical for the SBRHA’s Executive Director, Connie Clarkston, to write the letter to Dr. Snodgrass with full knowledge that she was not providing a reasonable explanation to establish why Dr. Snodgrass should obtain such an evaluation. Ms. Clarkston, as the executive director of the SBRHA, should understand the importance of there being a clinical rationale for the ordering of clinical evaluations. Furthermore, as the SBRHA’s executive director, she should know that communication is critical to obtaining accurate information from consultants, such as those providers who perform multidisciplinary evaluations.

Paid for incompetence is the status quo in Missouri
The state medical board of Missouri is unnecessarily slow. They are paid to be incompetent, paid to lie, and they are paid to be slow

D. Connie Clarkston’s conduct was, by the professional standards that she probably is familiar with, unethical as well as evidence of negligence or incompetence.

E. If lives are at stake, then Missouri probably needs medical regulators who demonstrate far higher standards than the current SBRHA. If the safety of the public is at stake as the state medical board has argued, then we probably should have a medical board director who is not grossly negligent when they document why they want a particular clinical evaluation. Whether the move to establish safe and competent medical regulators occurs through retraining, firing, or simply apologizing and admitting wrongdoing, the grossly unethical and incompetent regulation should stop.

VII. The SBRHA should acknowledge it was unethical for their agency to commit fraud or gross misrepresentation against the Cardiologist Dr. Antoine Adem and the SBRHA should implement a plan to prevent fraudulent regulation from occurring again in the future.

a. The SBRHA should acknowledge that fraud and misrepresentation do not protect patients, but that it creates an unnecessary burden on physicians who provided excellent patient care. Dr. Adem is one of those doctors, and there is robust evidence that he provided excellent patient care.
b. Please see the enclosed article – which is also found at
i. URL – http://www.esciencecentral.org/journals/novel-insight-into-the-quality-of-assessment-of-physicians-2375-4273-1000155.php?aid=66342

ii. PDF – http://www.esciencecentral.org/journals/novel-insight-into-the-quality-of-assessment-of-physicians-2375-4273-1000155.pdf

VIII. The SBRHA should acknowledge it was unethical of their agency to try to discipline Dr. Surendra Chaganti for providing – “by the books,” “U.S. Food and Drug Administration-approved” excellent patient care. The SBRHA should take measures to ensure that they and their staff know how to read FDA-drug labels. Many physicians would probably take measures to prevent their attorneys from filing blatantly false claims about FDA approved medications in court. Once the SBRHA has established a policy to ensure that the doctors on the SBRHA know how to read FDA drug labels, they should train their staff how to read them including how to identify a drug’s contraindications. Please see attached manuscript describing the SBRHA’s unethical regulatory conduct.

IX. The SBRHA should acknowledge that it is unethical to show partiality to senior physicians in their same profession solely because of one’s academic title. The SBRHA should acknowledge that it was unwise of them to trust the April 2014 deposition of a pathologist, Dr. KL, who lied under oath in court in July 2014. The SBRHA should acknowledge that enabling a doctor who committed perjury to be the main assessor of the professionalism of future physicians is grossly unethical – at least without first acknowledging and correcting the dishonest physician behavior.
A. The SBRHA may have a conflict of interest between their doctors who work at universities and the protection of the public. The SBRHA has previously written on page four of their newsletter that their plan is to work with medical school deans to increase the number of primary care physicians in Missouri.

A Conflict of interest is found in the SBRHA’s April 01, 2015 newsletter http://pr.mo.gov/boards/healingarts/newsletters/2015-04-01.pdf
Facilitating and overlooking repeated dishonesty about patient care by a senior faculty member at a university may be done to strengthen the relationship between the state medical board and the dean of the medical school, something that would be beneficial to the SBRHA’s plans as described on page four of their April 1, 2015, newsletter.13

They permitted a university pathologist to claim she could not evaluate my academic performance in 2013 even though she had already documented nearly identical information on the letter of ACGME Core Competencies from 2011. It is hard to win a court case when the SBRHA repeatedly empowers a dishonest physician to make false claims -even about patient care under oath.

According to the American Medical Association Council on Ethical and Judicial Affairs (AMA-CEJA), physicians should not be silent about the SBRHA’s repeatedly egregious and unethical conduct that is akin to corruptions. Doctors who witness the SBRHA’s numerous instances of unethical actions have a fiduciary duty to speak out against it.14

According to Scutchfield and Benjamin (18th US Surgeon General),
…in the case of physicians’ responsibility to consider the character of their colleagues, the Council (AMA-CEJA) has called on the profession to abandon the “conspiracy of silence” surrounding unprofessional behavior, and has noted, “Incompetence, corruption, or dishonest or unethical conduct on the part of members of the medical profession is reprehensible.”
Furthermore, in dealing with knowledge of a colleague’s misconduct, “A physician should expose, without fear or loss of favor, incompetent or corrupt, dishonest or unethical conduct on the part of members of the profession.”
Enhancing professionalism and addressing physician misconduct should remain major agenda items for organized medicine, with particular focus on strengthening the medical profession’s responsibility and accountability.15

The SBRHA’s enabling of the Dr. KL to lie multiple times to our medical regulators – even about patient care – is probably considered corruption and is in stark contrast to the recommendations by the previous US Surgeon General. Furthermore, it is the fiduciary duty of physicians such as this author to report and try to stop the unethical conduct of the SBRHA.14

B. The SBRHA should not show partiality to doctors who lie about patient care regardless of academic title, and they should take means to prevent this from occurring again in the future.

X. The SBRHA should acknowledge that lying about months of breast cancer care does not protect the public.
A. The SBRHA should acknowledge that using the phrase, “lives are at stake,” does not grant them a pass to place more lives at stake through reckless and dishonest regulation.

B. Acknowledge that using the phrase “lives are at risk,” does not mean it is okay for regulators of medicine to lie or to be incompetent. Lies about patient care do not protect patients, and the SBRHA should no longer withhold relevant medical records from the courts. The SBRHA should acknowledge that they are not above the law, and they should be held to the same standards as other physicians. The SBRHA members and staff should acknowledge that they are not above the law, and they should establish plans to prevent the egregious regulatory misconduct in the future.

C. The SBRHA should make plans to keep themselves from appearing grossly incompetent or negligent in the future with regard to matters related to patient care and medical knowledge. SBRHA members should acknowledge that evidence-based medicine plays a role in their job. Physicians are appointed to the SBRHA so that they may use their expertise to evaluate the care provided by licensees, but many of the present and all of those that were on the SBRHA from 2010-2014 have repeatedly failed to assess licensees in a competent manner. In contrast, a physician whom they claimed to be incompetent – Dr. Snodgrass – published an article illustrating the SBRHA’s profound lack of medical knowledge and explaining how a competent medical regulator would go about assessing the appropriateness of the coronary artery stent procedures performed by their licensee Dr. Adem.16

D. The SBRHA should acknowledge that it is not appropriate for them to use state resources to discipline doctors that are more competent and knowledgeable than themselves – doctors such as the interventional cardiologist Dr. Antoine Adem and the psychiatrist Dr. Surendra Chaganti.16

Dishonest regulation may be facilitated by assumptions
Making assumptions about important matters of patient care has been Connie Clarkston’s modus operandi.


1. Missouri State Board of Registration for the Healing Arts website. Available at: http://pr.mo.gov/healingarts.asp. Accessed March 1, 2016.

2. The Joint Commission. Accreditation, Health Care, Certification. Available at: http://www.jointcommission.org/. Accessed March 1, 2016.

3. Photographs of Dr. Snodgrass’s certificates and documentation of 44 months of ACGME-accredited postgraduate training- every month denied by the SBRHA. Available at: https://twitter.com/BrettSnodgrass1/status/703386555071639553. Accessed March 1, 2016.

4. Brett Snodgrass, MD v. Missouri State Board of Registration for the Healing Arts – entire case exhibits were not uploaded. 2013 – 2014. Available at https://archive.org/stream/Snodgrass-v-SBRHA/Snodgrass%20v%20SBRHA%202013%202014#page/n0/mode/1up. Also available at: http://bit.ly/BoardReform. Accessed March 1, 2016.

5. Johnson D, Chaudhry H. Medical Licensing and Discipline in America. Lanham, MD: Lexington Books; 2012. Avialable at: http://www.amazon.com/Medical-Licensing-Discipline-America-Federation/dp/0739174398. Accessed March 1, 2016.

6. Snodgrass v. Missouri State Board of Registration for the Healing Arts – Verdict from Honorable Karen A. Winn, Commissioner on October 30, 2014. http://archive.org/details/Snodgrass-v-SBRHA. Accessed March 1, 2016.

7. TMC – Truman Medical Centers. Available at: http://www.trumed.org/. Accessed March 1, 2016.

8. Qiu J, Kulkarni S, Chandrasekhar R, et al. Effect of delayed formalin fixation on estrogen and progesterone receptors in breast cancer: a study of three different clones. Am J Clin Pathol. 2010;134(5):813-819. Available at: http://ajcp.oxfordjournals.org/content/ajcpath/134/5/813.full.pdf. Accessed March 1, 2016.

9. Hammond ME, Hayes DF, Dowsett M, et al. American Society of Clinical Oncology/College Of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol. 2010;28(16):2784-2795. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2881855/pdf/zlj2784.pdf. Accessed March 1, 2016.

10. Snodgrass, BT. Breast Cancer Scandal. 2015. Available at: http://drsocial.org/forums/topic/1057/breast-cancer-scandal. Accessed March 1, 2016.

11. Iype EM, Sebastian P, Mathew A, Balagopal PG, Varghese BT, Thomas S. The role of selective neck dissection (I-III) in the treatment of node negative (N0) neck in oral cancer. Oral Oncol. 2008;44(12):1134-1138. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18486527. Accessed March 1, 2016.

12. Annas GJ, Crosby SS. Post-9/11 Torture at CIA “Black Sites” — Physicians and Lawyers Working Together. N Engl J Med. 2015;372(24):2279-2281. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1503428. Accessed March 1, 2016.

13. Arts MBoRftH. Healing Arts News, (Apr. 1, 2015);29(1):1-20. Available at: http://pr.mo.gov/boards/healingarts/newsletters/2015-04-01.pdf Accessed March 1, 2016.

14. Margolis JD. Professionalism, fiduciary duty, and health-related business leadership. JAMA. 2015;313(18):1819-1820. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25965224. Accessed March 1, 2016.

15. Scutchfield FD, Benjamin R. The role of the medical profession in physician discipline. JAMA. 1998;279(23):1915-1916. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18486527. Accessed March 1, 2016.

16. Snodgrass B. Novel insight into the quality of assessment of physicians. Health Care: Current Reviews. 2016;4(155):1-4. Available at: http://www.esciencecentral.org/journals/novel-insight-into-the-quality-of-assessment-of-physicians-2375-4273-1000155.pdf. Accessed March 1, 2016.

Supplementary material – enclosed
I. Reference #16 – regarding the SBRHA’s harassment of the interventional cardiologist Dr. Antoine Adem. See lines 749 and 832-835 above. This describes the SBRHA’s unethical conduct over a period of more than two years related to the interventional cardiologist Dr. Antoine Adem.

II. Manuscript describing the SBRHA’s 5.1 years of unethical conduct related to the psychiatrist Dr. Surendra Chaganti.

III. Unethical letter written on November 20, 2013 by the SBRHA Executive Director Connie Clarkston to Dr. Snodgrass. See lines 92-100, 612-630 for information regarding the unethical nature of the letter. Furthermore, the letter states “please do not hesitate to contact us.” I did contact the SBRHA several times and they refused to provide any additional reason about why I should obtain a multidisciplinary evaluation. Our leaders should be able to articulate why they want someone to go live in a hospital for several days. Connie Clarkston was unable to do that, but she did help enable a pathologist, Dr. KL, to make numerous incompetent evaluations of a resident – such as December 29, 2010 where she wrote “he has not recovered to anyone’s satisfaction.” Dr. KL was asked by Dr. Snodgrass’s attorney on about July 2nd or 3rd 2016 what he was to recover from. Dr. KL had no reply. This is grossly incompetent documentation by Dr. KL, and Frank Meyers was in court when he saw Dr. KL fail to give a reply to the critical question about Dr. Snodgrass’s evaluation written by Dr. KL on 12 29 2010. According to Dr. KL, Dr. Snodgrass was to remain on probation because he has not recovered to anyone’s satisfaction. Instead of addressing the incompetent documentation, Connie Clarkston and Frank Meyers propagated the dishonest and incompetent evaluations and have refused to acknowledge that a physician who is a residency program director should have sufficient clinical insight to know that if she writes that a “resident has not recovered,” then something should be done. Dr. KL did nothing reasonable after 12 29 2010 and instead of addressing Dr. KL’s inability to competently communicate critical information, they apparently instructed Dr. Snodgrass to obtain a multidisciplinary evaluation. Similar to how the SBRHA and Frank Meyers enabled the Dr. KL to lie and then disciplined Dr. Snodgrass at the expense of patient safety, Connie Clarkston made bizarre and harassing efforts towards Dr. Snodgrass at the expense of ensure that Dr. KL could communicate critical information and assessments to those that she manages.

IV. A print-out of the letter that Dr. Snodgrass received where his job at St. Elizabeth’s hospital was rescinded after he informed them – about what Dr. KL informed the Georgia Composite Medical Board – that Dr. Snodgrass was on probation when he was at UMKC. According to Dr. Thomas Nasca, CEO of the ACGME and Dr. Jill Moormeier, Dr. Snodgrass was never on probation at UMKC. In spite of this blatant dishonesty and extensive harm caused by false claims filed with the GCMB, Connie Clarkston refused to address the dishonesty and punished Dr. Snodgrass. This is unfathomable perversion of the role of a Medical Board Executive Director, and Connie Clarkston should, at the very minimum, acknowledge the dishonesty made by Dr. KL multiple time to the Missouri SBRHA. However, Connie Clarkston has actually enabled and empowered Dr. KL to propagate her lies, and this is an egregious violation of basic ethical principles.

lying about breast cancer care
Lying about patient care matters

Comments and Suggestions are Welcome.

What do you think can be done to ensure that physicians in Missouri stop lying?



Missouri State Board of Healing Arts Ethics Complaint

Novel insight into the quality of medical regulation by the State Board of Registration for the Healing Arts

Author: Brett Snodgrass, MD


In the United States of America (USA), state medical boards (SMBs) are legislatively established to ensure that only competent physicians are practicing medicine and that those physicians act in a professional manner.1 Typically, the enforcer of laws, rules, and regulations needs to understand and be compliant with them. Thus, an SMB should be able to demonstrate a range of medical knowledge broad enough to discern between competent and negligent patient care. Similarly, SMBs should demonstrate professional conduct, as they are the assessors of physician professionalism. This report describes the numerous efforts to discipline interventional cardiologist, Antoine Adem, MD by the Missouri State Board of Registration for the Healing Arts (SBRHA). This took place during the years of 2012-2014 for events, which occurred from 2008-2010.2-4 It describes an SMB’s scientifically unmeritorious, underhanded, and relentless efforts to punish a physician for providing excellent patient care.

Case Report

The relevant events began in March 2008, when Dr. Adem’s decision to place a stent in one of Patient S.B.’s coronary arteries was called into question by the Medical Care Appraisal Committee (MCAC) of MO’s Jefferson Regional Medical Center (JRMC).3 The MCAC obtained external review of S.B.’s records, and on May 21, 2008, the hospital’s medical executive committee (MEC) requested Dr. Adem provide responses to concerns raised by the reviewers. On July 7, 2008, Dr. Adem wrote a letter purportedly from cardiologist Dr. Timothy Catchings, referred to as the “Catchings letter,” and gave it to the JRMC CEO, Dr. Lloyd Ford. The letter was written on Dr. Catchings’ letterhead and had a forgery of Dr. Catchings’ signature. The letter claimed Dr. Adem’s decision for percutaneous coronary intervention with stent placement of Patient S.B. was a reasonable decision.3  The Catchings letter listed criteria from the American College of Cardiology 2005 guidelines for percutaneous coronary intervention as evidence that supported Dr. Adem’s decision to place a coronary stent in Patient S.B. In addition, the patient improved after Dr. Adem placed the coronary stent, an outcome that the guidelines state doctors should expect.5

An inquiry of Dr. Catchings at Missouri University Medical Center revealed that he did agree with the medical care as described in the forged letter.3 However, the JRMC MEC decided to revoke hospital privileges from Dr. Adem for unethical conduct in forging Dr. Catching’s signature on a letter to Dr. Ford, and for allegedly providing negligent medical care.6

HRC endorses care provided by Dr. Adem

The law requires that a doctor who loses clinical privileges must report it to the SBRHA. On September 23, 2010, Dr. Adem sent a letter to the SBRHA informing them about his forgery of the Catchings letter.3 As part of the hospital by-laws, Dr. Adem was able to have a hearing with another committee known as the Hospital Review Committee (HRC). On June 7, 2011, the HRC concluded that Dr. Adem’s provision of patient care was appropriate and that he engaged in unethical conduct by creating the Catchings letter.6 The HRC voted 2:1 that Dr. Adem’s privileges be reinstated, and their recommendation was given to the MEC that possessed final decision-making authority. The MEC decided not to follow the HRC’s suggestion and terminated Dr. Adem from the hospital. Given Dr. Adem’s admission to forging a letter, and the HRC’s determination that Dr. Adem provided appropriate patient care, one might expect that the issue would be quickly resolved.

SBRHA begins effort to punish good care

On April 3, 2012, the SBRHA filed a complaint with the MO Administrative Hearing Commission (AHC) seeking to discipline Dr. Adem for XI counts. Counts VI, VII, and VIII were voluntarily dismissed by the SBRHA on May 31, 2013. Count I claimed Dr. Adem committed unethical conduct for forging the Catchings letter. Counts II, III, IV, V, and IX were five disciplinary claims, each for the alleged inappropriate placement of a coronary artery stent or stents in one of five different patients. On April 17, 2014, Commissioner Sreenu Dandamudi deemed that Dr. Adem’s license was subject to discipline for forging Dr. Catchings’ signature on the letter that Adem gave to Dr. Ford on July 7, 2008.3 This ruling didn’t start the discipline but meant that discipline was to be imposed by the SBRHA. Dr. Adem had another meeting with the SBRHA. On November 24, 2014, the SBRHA issued a public reprimand of Dr. Adem’s medical license.4 As part of the public reprimand, Dr. Adem was required to inform all hospitals and clinics where he worked that he had been reprimanded.4 Although the final discipline of a public reprimand for Count I may seem appropriate, the course by which the SBRHA arrived at that outcome is, in the words of Commissioner Dandamudi, “perversely ironic [sic].”2

The medical board lacked knowledge

It is unclear how SBRHA formed the false inference that the coronary artery stent placements by Dr. Adem were negligent and unnecessary. The SBRHA cited no peer-reviewed literature or scholarly work in support of their claims of negligent patient care. Parenthetically, in 1999, Nishioka et al. reported findings from a study that evaluated intravascular ultrasounds’ (IVUS) ability to assess the significance of epicardial coronary artery stenosis.7 They found that a lesion luminal area of < four square millimeters (mm2) is a simple and “highly accurate criterion for significant coronary narrowing.”7 Identification of significant coronary narrowing is a prerequisite for coronary stenting.

coronary artery stent placement
Each of Dr. Adem’s patients improved after he placed a stent in their coronary artery. The state medical board tried to discipline him anyway.

The SBRHA’s efforts to discipline Dr. Adem for the allegedly inappropriate patient care was blatantly unmeritorious as none of the five patient’s six epicardial coronary arteries had a lesion luminal area of more than four mm2.2  Count II against Dr. Adem was for alleged negligent and unwarranted medical care of 45-year Patient E.O. The patient had a stent placed in the left anterior descending coronary artery (LAD) that had a luminal area of 3.4 mm2, and a stent placed in the right coronary artery (RCA) that had a luminal area of 2.9 mm2. Count III against Dr. Adem alleged negligent care for his stenting of 70-year Patient L.M.’s mid-LAD that had a luminal area of 2.8 mm2. Count IV alleged Dr. Adem negligently placed a stent in 53-year Patient J.E.’s mid-LAD that had a luminal area of 3.7 mm2. Count V was intended to discipline Dr. Adem for placing a stent in 68-year Patient P.J.’s mid-LAD that had a luminal area of 3.8 mm2. Although the SBRHA dropped counts VI, VII, and VIII, they did not drop all of their grossly inaccurate claims of negligent care. Count IX intended to discipline Dr. Adem for placing a stent in 52-year Patient J.N.’s LAD that had a luminal area of 3.1 mm2. Since the SBRHA asserted Dr. Adem provided negligent care to five different patients, they continued their abuse of Dr. Adem and filed Count X asserting that he had committed repeated negligence.2 Count XI alleged that Dr. Adem was willfully and continually performing unnecessary procedures.2 A government agency that regulates the practice of medicine should be able to discern negligence, repeated negligence, and unnecessary procedures from appropriate patient care. However, the SBRHA demonstrated profound ignorance by their repeated failure to competently assess the appropriateness of coronary stenting for five different patients.

Commisioner Dandamudi’s ruling

On September 24, 2013, Commissioner Dandamudi issued a report of proposed findings and facts of law.2 In the proposed report Commissioner Dandamudi dismissed Counts I, II, III, IV, V, IX, X, and XI against Dr. Adem. The only change between the September 24, 2013, proposed report and the final April 17, 2014, ruling was regarding the latter’s decision not to dismiss Count I.2,3 Commissioner Dandamudi dismissed the SBRHA’s allegations of negligent care as follows:

SBR [SBRHA] alleges that on the basis of the charges in Counts II, III, IV, V and IX in the Complaint, cause exists to discipline Dr. Adem’s license pursuant to§ 334.100.2(5) RSMo on the basis of “repeated negligence.”

SBR has presented no evidence that any of the patients in Counts II, III, IV, V and IX ever complained about the care they received from Dr. Adem, that there were any complications during or after their procedures, or that they are even aware that the care Dr. Adem provided them is forming the basis of charges against Dr. Adem. SBR also presented no evidence that the procedures described in Counts II, III, IV, V and IX were unnecessary or harmful to the patients whose procedures formed the basis of those complaints.2

Commissioner Dandamudi’s 2013 proposed report further illustrates the severity of the misconduct by the SBRHA.2 In the report Commissioner Dandamudi described the SBRHA’s conduct as “unfathomable and deeply disturbing[sic],” “wholly unworthy of a state agency[sic],” and suggested that the SBRHA may have committed fraud.2 After the SBRHA’s expert witness Dr. Jonathan Tobis gave deposition opposing their claims of negligence, the SBRHA tried to have everything related to him stricken from the court record so that they could punish Dr. Adem for providing care that their witness Dr. Tobis did not report as negligent or unwarranted. Commissioner Dandamudi wrote the following of the State Board of Registration (SBR):

            In the July 10, 2013 Hearing, SBR [SBRHA] moved to strike all references to the testimony of its expert, Dr. Tobis… It is clear from the record that SBR did not introduce and did not want to introduce Dr. Tobis’ deposition testimony because it did not support the allegations in the Complaint against Dr. Adem.8

blame good docotrs
State medical board tried to conceal the deposition testimony of Dr. Jonathan Tobis so that they could punish Dr. Adem

Further questions about the objectivity and integrity of the SBRHA are raised because they had to get Commissioner Dandamudi to extend their pre-arranged deadline for the taking of depositions from the expert witnesses.3 The SBRHA’s failure to comply with the initial deadline may be secondary to their inability to find a cardiologist that agreed with their unfounded, unscientific, and whimsical assertions that Dr. Adem provided unsafe patient care. Cardiologists Dr. Bouhasin and Dr. Ahmad both testified to the appropriateness of Dr. Adem’s care for the five patients, and they both disagreed with all of the SBRHA’s allegations of inappropriate patient care.

Commissioner Dandumudi wrote the following about the dismissal of Dr. Kern’s deposition from the record.

The July 2, 2013 Order excluding the testimony of Dr. Kern… was based solely on the SBR’s [SBRHA’s] acknowledged deficiency … in Dr. Kern’s testimony and its unreasonable tardiness, well outside the time frame set forth in the Scheduling Order… the Board had ample time to prepare for hearing. However, the Board failed to do so until three weeks prior to a hearing that was scheduled eight months earlier at the request of both parties…

In his Motion in Limine, Dr. Adem argued in part that Dr. Kern’s deposition testimony did not state and SBR did not adduce exactly what records Dr. Kern relied on to forn1 the basis of his opinions in this case… Dr. Kern could not produce necessary evidence for cross-examination that Dr. Kern claimed he relied on. The SBR attempted to cure these deficiencies by attempting to take an additional deposition of Dr. Kern on July 5, 2013 just a few days before the scheduled hearing. Allowing the SBR to take another deposition of its expert months after the deadline for such depositions and just a few days prior to the scheduled hearing would have significantly prejudiced Dr. Adem. Excluding the unreliable testimony of Dr. Kern was an appropriate decision based on the circumstances.2

The SBRHA planned to use Morton Kern, MD, as an expert witness, but his deposition was ultimately stricken from the record because no one was aware of how or why he arrived at his conclusions. Thus, four cardiologists including Dr. Adem supported the care provided by Dr. Adem. In contrast to the competent and reliable testimony of the cardiologists that supported Dr. Adem, neither Dr. Kern nor the SBRHA was able to specify which particular documents and images Dr. Kern relied on to form his assessment. After failing to communicate with Dr. Kern and appropriately ascertain what documents he used to render his opinions during the deposition, the SBRHA sent him a FedEx package of documents and records. Again, and without effective clinical communication, they were sent back to the SBRHA. Commissioner Dandamudi wrote the following about the SBRHA’s posthoc efforts made during the July 2013 hearing to try to improve Dr. Kern’s April 2013 deposition:

            Indeed, during the offer of proof, Dr. Kern was unable to state with certainty whether the material SBR [SBRHA] sent him was what he had previously reviewed and relied on to form the basis of his opinion.”2

Medical board demonstrated poor communication

According to Leonard et al. “effective communication and teamwork is essential for the delivery of high quality, safe patient care.”

communication failure
Doctors that follow in the footsteps of the state medical board treat people as objects, or mere assignments to complete.

Legislators and health care reform activists may be interested in encouraging policies and laws that ensure the SMBs are composed of those that can communicate and work in teams effectively. In spite of over eight months to prepare to depose a cardiologist for the trial, the SBRHA could not perform one competent deposition with accurate documents of a physician that supported their claims of negligence.

Commissioner Dandamudi further wrote:

What is particularly egregious about SBR’s [SBRHA’s] “offer of proof’ [made during July 2013 trial] is that it is completely inconsistent with Dr. Kern’s April 18, 2013 deposition testimony. This Commission need not look any further than the first patient case, patient E.O., to determine that the offer of proof is grossly inaccurate at best and a fraudulent misrepresentation to this Commission at worst. In his deposition on April 18, 2013, Dr. Kern was specifically asked the following regarding what he reviewed in the patient E.O. case, “the only materials that you reviewed prior to issuing this February 22nd, 2010, report and prior to providing your testimony today were the two cardiac catheterization reports, one with the stress test, one without, and two CD-ROM disks of angiographic procedures.” Dr. Kern answered “correct” in response to this question about his review of patient E.G.’s case. However, SBR in its offer of proof regarding what Dr. Kern relied on in formulating his opinion in the E.O. case (see SBR Exhibit 6), submitted approximately 40 pages of medical records that he did not list as records he relied on in his deposition testimony.

How SBR expects this Commission to reconcile the plain language of what Dr. Kern said he relied on to formulate his opinion in the patient E.O. case with what is included in Exhibit 6 is unfathomable and deeply disturbing. Specifically, SBR Exhibit 6 includes a Procedure Log, office note, and Complete Patient Report, none of which Dr. Kern indicates that he relied on. SBR’s “offer of proof’ in Exhibits 4-8 appear to be nothing more than a conscious attempt to make Dr. Kern’s review more robust than what it actually was. This Commission notes that SBR’s blatant mischaracterization of the materials that Dr. Kern reviewed is an affront to this tribunal and reflects, at best, recklessness that is wholly unworthy of a state agency.10

Medical board committed fraud

Commissioner Dandamudi also wrote that the SBRHA committed, “what seems to be an intentional mischaracterization of important evidence.”2 It is presumably true that the SBRHA was acting in a manner that they believed to be the interest of the public. However, their false belief of practitioner negligence persisted in spite of extensive evidence to the contrary and no competent evidence supporting their allegations of unwarranted procedures. The SBRHA’s fixed, false belief appears to have contributed to their grossly unethical, unsound, and reckless conduct.


The SBRHA tried to frame Dr. Adem several times by (1) an attempt to conceal the testimony of their expert witness Dr. Tobis, (2) by misrepresenting what documents their other expert witness, Dr. Kern reviewed, (3) by trying to depose Dr. Kern a second time a mere five days before the hearing at the AHC which could prevent Dr. Adem from effectively cross-examining him, and (4) by fabricating false claims of negligent care based on no apparent scientific rationale. According to Chaudhry et al., physicians are given due process by state medical boards.11 However, this report demonstrates that such equitable regulation is not always present. Furthermore, the SBRHA’s conduct is unconscionable as they made extensive effort to try to frame Dr. Adem. The SBRHA tried to conceal the exculpatory testimony of Dr. Tobis’ deposition, filed blatantly dishonest and scientifically unmeritorious claims alleging unsafe patient care in court, and intentionally mischaracterized very important evidence.2

Discipline has a purpose

One definition of discipline is “to punish or penalize in order to train and control.”12 Other than the broad and somewhat vague claim of “protecting the public,” the role of physician discipline by SMBs has not been clearly espoused by regulators.11 This case raises several questions about the functions of SMBs and their role in physician discipline.

Questions about SMBs

First, what did attempting to discipline Dr. Adem for providing safe patient care train him to do? Second, how is the November 24, 2014, public reprimanding of Dr. Adem’s medical license for giving the Catchings letter to Dr. Ford on July 7, 2008, expected to benefit the public since the delay in the administration of discipline was more than six years? Third, since the information about the Catchings letter was already public, what benefits are likely to be obtained by the SBRHA further publicizing the letter using a public reprimand of Dr. Adem’s medical license?4,6

A question
Why did the state medical board try to punish the cardiologist for providing excellent patient care?

Fourth, since Dr. Adem was already extremely remorseful for forging the Catchings letter, should one expect that he will further change his behavior because of the public reprimand?2,4 Fifth, if a single act of misrepresentation or fraud is a threat to the public, should consideration be given to the need to discipline the members of the SBRHA for their deceptive regulatory conduct and efforts to frame Dr. Adem? Sixth, if clinical incompetence is a threat to the public, is it concerning that none of the eight doctors on the SBRHA demonstrated sufficient medical knowledge to either know that Dr. Adem’s provision of care was appropriate or to review a relatively straight-forward article by Nishioka et al. and then recognize that the care was appropriate? Each of the five patients that received a coronary artery stent by Dr. Adem had less than four mm2 of luminal area for the blood to flow through. Thus, instead of making guesses about whether Dr. Adem provided safe patient care, the SBRHA should have reviewed the medical literature.7 Seventh, why did no physician on the SBRHA intervene to stop their attorneys from litigating after their witness Dr. Tobis gave a deposition that did not support the SBRHA’s allegations of negligence? Eighth, why did no one on the SBRHA ask Dr. Adem what his therapeutic rationale was prior to tossing the case to their attorneys to being two years of costly litigation? According to Berwick, “crystal clear expectations about the unacceptability of disruptive and disrespective behaviors” is essential to improve the triple aim of improved outcomes patients, better population health, and more affordable care.13

safety matters
Medicine is not the only profession that saves lives, and regulating such a profession does should not endow the regulator with the right to commit fraud and be incompetent.

The disruptive regulator

The SBRHA’s disruption of the practice of medicine was profound, and investigation and research into the causes of the unacceptable regulatory conduct are needed. There may be conflicts of interest involving the SMB attorneys who are paid hourly and rewarded instead of punished for filing false claims in court. Policy makers might consider the societal burden that a dysregulated, clinically ignorant SMB places on the public. The SBRHA’s harassment of doctors that provide excellent patient care has several negative effects. First, it prevents patients from seeing their physician as it will likely require them to spend a significant amount of time trapped in depositions, obtaining expert witnesses, and working alone or with their attorney to file myriad rebuttals to the plethora of dishonest claims filed by the SMB. Second, by reducing the number of healthcare providers, it does not decrease the cost of care. Third, the societal burden of paying attorneys more than $100 per hour to litigate for years either raises the cost of the licensure fee or is a burden on taxpayers. In addition to the attorneys, there are numerous costs that include the Commissioner, costs of expert witnesses, and the myriad of staff needed to process the frivolous claims. Unfortunately, society obtains no reward on investment and does not become safer in spite of hundreds of thousands of dollars being spent on the SBRHA’s litigatory whims.

paid to lie
The Missouri Board of Registration for the Healing Arts’ budget for 2015 was more than two million dollars. Committing fraud and paying attorneys $110/hour are reimbursable expenses.

Fourth, the perverse discipline teaches physicians that their provision of excellent patient care can be punished by forcing them into years of litigation with a government agency that is not above filing numerous blatantly false claims in court.

The harm that results from the egregiously deceptive and ignorant actions committed by the SBRHA’s attorneys is compounded by the careless oversight of the physician members of the SBRHA. The poorly communicating and inattentive physicians are more akin to a rubber stamp that often do not check to see if what their attorneys are filing in court is consistent with the high-quality medical evidence. The integrity and excellence mentioned in the SBRHA’s newsletter is an illusion resulting from their detached personnel, abysmal state of medical knowledge, and payments that increase linearly with their dishonesty.14 Ignorance is indeed bliss for those medical regulators and their staff that are paid for their harassment of good clinicians such as Dr. Adem.


The quality and accuracy of medical regulation is an understudied topic and those interested in health care policy, quality, and regulation might identify this largely unstudied area as an untapped resource with rich potential for future discovery. This case clearly illustrates that doctors are not right simply because they are members of the SBRHA. The “expert” assessments that assess the appropriateness of care provided by other physicians should be accompanied by scientific literature. Dr. Adem endured years of harassment because of the ignorance of those on the SBRHA. The doctors on the SBRHA could have perused the medical literature to form an educated opinion about the appropriateness of Dr. Adem’s decision to place stents in the five patients. Unfortunately, such easy and effective communication is not practiced in MO by the SBRHA. They did not communicate with Dr. Adem or their cardiology colleague Dr. Kern effectively. The SBRHA did not communicate effectively with their witness Dr. Tobis nor did they properly identify that he though the care rendered by Dr. Adem was fine. The SBRHA had difficulty obtaining cardiology expert witnesses. At the end of the day, the SBRHA committed numerous acts far more egregious than anything Dr. Adem did, and they wasted hundreds of thousands of dollars. What are stakeholders to take away from a situation where a licensee is more ethical and competent than the entirety of the SBRHA? Disciplinary actions, even fraudulent actions result in national and international effects secondary to the robust communication system between regulators.11 Thus, dishonest and unethical medical regulation as in MO, USA, pose a significant risk for untrue healthcare assessments to be disseminated globally. It may be prudent for policymakers to consider the need for independent assessment of regulatory decisions made in other jurisdictions such as states that are identified to have high rates of regulatory misconduct. Given the repeated demonstration of regulatory misconduct, ignorance, attempted concealment, misrepresentation, and fraud in MO by the SBRHA, further investigation and study is critical to determine the extent of regulatory misconduct by state medical boards.

Questions about the extent of medical board misconduct

Is MO a unique state with a severely dysfunctional SBRHA, or are other states at risk of regulatory fraud? Is MO the only state with a disruptive SMB, or do some other SMBs possess an inadequate fund of medical knowledge and a lack of good judgment? Future studies are needed to evaluate the quality of medical regulation and the effects that a disruptive regulator has on the quality of medical care.


  1. Chaudhry HJ, Gifford JD, Hengerer AS. Ensuring competency and professionalism through state medical licensing. JAMA 2015; 313(18): 1791-2.
  2. State Board of Registration for the Healing Arts v. Adem, No. 12-0526 HA (Sept. 24, 2013). https://archive.org/details/medical-board-dysregulation Accessed November 24, 2015.
  3. State Board of Registration for the Healing Arts v. Adem, No. 12-0526 HA (Apr. 17, 2014). https://archive.org/details/MO-Healing-Arts-v-Adem Accessed November 24, 2015.
  4. State Board of Registration for the Healing Arts v. Adem, 2010-002086 (Nov. 24, 2014). https://archive.org/details/SBRHA-v-Adem Accessed November 24, 2015.
  5. Smith SC, Jr., Feldman TE, Hirshfeld JW, Jr., et al. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention–summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 2006; 113(1): 156-75.
  6. Antoine Adem, M.D v. Jefferson Memorial Hospital Association, (Nov. 13, 2012). http://mo.findacase.com/research/wfrmDocViewer.aspx/xq/fac.20121113_0002014.EMO.htm/qx Accessed November 24, 2015.
  7. Nishioka T, Amanullah AM, Luo H, et al. Clinical validation of intravascular ultrasound imaging for assessment of coronary stenosis severity: comparison with stress myocardial perfusion imaging. J Am Coll Cardiol 1999; 33(7): 1870-8.
  8. State Board of Registration for the Healing Arts v. Adem, No. 12-0526 HA, 10 (Sept. 24, 2013). https://archive.org/details/medical-board-dysregulation Accessed November 24, 2015.
  9. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004; 13 Suppl 1: i85-90.
  10. State Board of Registration for the Healing Arts v. Adem, No. 12-0526 HA, 10, 11 (Sept. 24, 2013). https://archive.org/details/medical-board-dysregulation Accessed September 29, 2015.
  11. Johnson DA, Chaudhry  HJ. Medical Licensing and Discipline in America. Lanham, MD: Lexington Books; 2012.
  12. discipline. (n.d.). Online Etymology Dictionary. Retrieved November 24, 2015, from Dictionary.com website: http://dictionary.reference.com/browse/discipline.
  13. Berwick DM. Postgraduate education of physicians: professional self-regulation and external accountability. JAMA 2015; 313(18): 1803-4.
  14. Healing Arts News, (Apr. 1, 2015). http://pr.mo.gov/boards/healingarts/newsletters/2015-04-01.pdf Accessed November 24, 2015. 29(1): 1-20.
Novel insight into the quality of medical regulation by the State Board of Registration for the Healing Arts