The Billig case, which first came to public attention more than a year ago, already has prompted all three services with medical corps--the Navy, Army and Air Force--to tighten disciplinary and quality-assurance programs. A crackdown has resulted in 66 military physicians--including 28 in the Navy--being stripped of their practice privileges and reported to civilian license officials in a 14-month period. A total of 101 military doctors have been slapped with less serious restrictions growing out of incompetency cases.
Yet the Times inquiry found no evidence that the equivalent of a Billig case exists at the three Navy hospitals in Southern California. In fact, only two physicians' names appeared in more than one of the cases studied; those two doctors--who each was linked to two cases--were only minor figures in each.
Instead, the problems with Navy medicine--and armed forces medicine in general, apparently--are that it is a worldwide bureaucracy in which patients often are forced to endure care in which they seldom see the same physician more than once; find their records in constant disarray--with harried doctors and paramedical personnel often too busy to carefully review a new case, and crowd into overburdened specialty clinics. (Vice Adm. Lewis H. Seaton, the Navy's surgeon general, said there are only enough surgeons and other specialists to deal with the equivalent of the number of active-duty personnel, who account for 25% of the patients at Navy hospitals.)
The Navy's problems--at the three hospitals in question and in Navy medicine in general--are typified in the cases of Mathew Titus, 3 1/2, and Philip Cote, 68, two people at different ends of life's spectrum, living in places far apart and who have not met. Mathew suffers from the aftereffects of botched heart surgery at San Diego and Cote has massive, terminal lung cancer that Navy doctors in San Diego and Camp Pendleton failed to diagnose for 10 months.
Southern California Navy medicine is atypical, even by military standards. Because of growing concentrations of Navy ships and personnel in San Diego and Long Beach, the large Marine detachment at Camp Pendleton and the clustering--by Navy estimates--of as many as 750,000 military retirees in this part of the state, the three Navy hospitals serve a patient load that is made up of 44% active-duty personnel, 32% dependents and the rest retired.
The system is huge, by any measure. Military medical operations have a budget of $9.6 billion, including $2.1 billion for the Navy, alone. With 170,000 health workers--13,000 of whom are doctors--military medical facilities have as many physicians as New Jersey, Massachusetts or Michigan. On any day, 23,500 people are patients in the 168 military hospitals--31 of which are Navy.
Navy medical care provides for the needs of 250,000 inpatients, 13 million outpatients, 34,000 newborns and 150,000 surgeries a year.
Overwhelmed by Caseload
In Southern California, the problems imposed by the sheer volume of care are particularly overwhelming and will get worse, top Navy officers agree. For example, in 1978, five ships were assigned to Long Beach; 35 are there now and the number is to reach 55 by the end of the decade.
The San Diego hospital staggers under an average load of 723,000 outpatient visits a year--64,200 a month these days, with 2,350 a month admitted. But to deal with this demand, San Diego has 287 staff doctors and 210 physicians still in training. To cope adequately, said Capt. Harold Koenig, the hospital commander, San Diego would require a staff as large as the entire Navy Medical Department and a physical plant with at least four or five times the 615 beds the hospital has.
"And you couldn't run such a hospital," Koenig said.
"There seems to be a constant repetition of the same kind of case," said Sheldon Deutsch, a prominent San Diego medical malpractice attorney who defended dozens of Navy cases while he served as an assistant U.S. attorney in San Francisco and San Diego until resigning 12 years ago. Litigation against Navy hospitals now accounts for the largest single share of Deutsch's practice. Navy medicine, Deutsch said, often becomes nothing more than a disjointed series of fruitless encounters between patients and either corpsmen or nurses who often are put in situations in which they must diagnose cases they cannot understand.
Dozen Cases Uncovered
Under these circumstances, even the most serious illnesses and most ominous danger signs often are missed because normal medical logic--in which the most serious possible diagnoses are ruled out \o7 first\f7 --is not followed. A dozen such cases were uncovered in the Times inquiry, typified by that of Mary Garcia, 28, the wife of a Navy enlisted man, who went four times to the emergency room at San Diego Naval Hospital and once to its internal medicine clinic early last year complaining of high fever, diarrhea, a bad cough and dizziness.