Dr. Javaid Anwar, president of the Nevada Board of Medical Examiners, didn't rush to let the public know that Dr. Dipak Desai is a longtime friend and business associate.
Nor was Anwar, whose board licenses and investigates complaints against doctors, in a hurry to divulge he had referred patients to Desai and last year attended a Desai daughter's wedding.
Or that he, along with Dr. Ikran Khan, a health care adviser to Gov. Jim Gibbons, had performed consulting work for Desai last year, judging the quality of physicians Desai employed.
Some physicians Desai employed at the Endoscopy Clinic of Southern Nevada are now under investigation for health care practices that may have infected six individuals with hepatitis C and put at least another 40,000 people at risk for potentially fatal blood-borne diseases.
It wasn't until Friday, 16 days after officials announced that patients who visited Desai's center between March 2004 and Jan. 11 should be tested for HIV and hepatitis, that Anwar recused himself from any action involving the clinic to avoid public perceptions of bias or impropriety.
That was well after Anwar suggested to news media that only nurses were involved in the "breach of protocol" at Desai's clinic.
And Anwar's recusal came after he played a key role in ensuring Desai's medical license remains in good standing. That allowed him to continue practicing medicine despite officials saying it was "common practice" for medical personnel at his clinic to reuse syringes and medications, a practice epidemiologists have likened to Russian roulette.
That arrangement was brokered by Anwar and medical board Executive Director Tony Clark. Announced March 7, it allowed Desai to make a nonbinding promise to not practice medicine in Nevada and keep his license, leaving the door open for him to practice elsewhere.
Clark is working on similar deals for an unspecified number of doctors at the clinic.
RESTORING PUBLIC CONFIDENCE
That Desai still has a medical license is proof, according to Dr. James Tate, a trauma surgeon at University Medical Center, that Desai's network of influential relationships, extending to the highest levels of state government, continues to play out.
And it plays out despite the fact that Anwar and fellow board members Sohail Anjum and Daniel McBride recused themselves Friday from taking actions dealing with their friends or business associates tied to the health crisis.
"He's (Desai) tied in everywhere," said Tate, president of the national Association of Black Physicians. "The more you look at this mess, the more you realize that an independent investigation, probably by an agency from out of state, has to be done in order to restore public confidence in our health care system.
"And part of the investigation now has to include looking into Anwar and Khan, since they are in positions of authority and have seen the quality of work of Desai's physicians. What did they know and when did they know it?"
Assembly Speaker Barbara Buckley, D-Las Vegas, said she's troubled by the deal letting Desai keep his license.
"They announced it like he had surrendered his license," Buckley said. "Everybody thought he had turned it in the way the nurse anesthetists from his clinic did" when they surrendered their licenses to the state nursing board.
"I find it unbelievable that we're not going to revoke his license. This wasn't a mistake, a one-time deal by an over tired physician. It was a conscious disregard for safety. If we can't get a summary suspension of a license after what's happened here, when can we?"
Khan told the Review-Journal he hasn't spoken to Gibbons about Desai, who was a member of Gibbons' transition team on health care, so he doesn't have to recuse himself from looking into the health crisis.
But Daniel Burton, a Gibbons spokesman, said Khan "may have" talked to the governor about Desai and the evolving crisis.
"What is Khan telling the governor about this?" Tate asked. "You don't see the governor or anybody on the board asking for Desai's license."
GOVERNOR APPOINTS BOARD
Whether the medical board can carry out an unbiased investigation is questionable.
The board consists of six physicians and three members representing the public, all appointed by the governor. They hand out discipline for offenses ranging from malpractice to bad billing.
Clark acknowledges Desai has long had friends at the state agency. Desai was on the board from 1993 to 2001, including a stint as chairman of its investigative committee.
He also has had strong ties at the state Board of Health, where his friend and business associate at his clinic, Dr. Vishvinder Sharma, was a board member. He stepped down as investigations into his clinic work with Desai stepped up.
Assemblywoman Sheila Leslie, D-Reno, chair of the Legislative Committee on Health Care and a longtime critic of the state medical board, said her committee on March 24 will "look at changes to licensing boards to develop a better process to follow up on complaints and to implement effective discipline."
Both Leslie and Buckley are irritated with Anwar over his removal of complete reports on malpractice by doctors from the board's Web site.
"He said nobody from the public wants it and they can get it by telephone if they want it," Buckley said. "It appears as though he doesn't want people to get the information about doctors they need."
Leslie said she was stunned when she asked Clark shortly after the crisis began whether he could attend a meeting about the investigation. While others said they would do whatever was necessary to be there, Clark said he would be vacationing in Hawaii.
"There just doesn't seem to be a sense of urgency there when we may be facing the biggest crisis in health care in the country's history," Leslie said.
Clark told the Review-Journal he would have someone else at the meeting. "There's really nothing I can add anyway," he said.
How the board has reacted to the Desai probe seems inappropriate to Tate and Dr. Sidney Wolfe of Public Citizen, a public advocacy group begun by Ralph Nader.
"The conflicts of interest are incredibly glaring," said Wolfe, who believes there "is more than enough evidence" to suspend Desai's license.
As he defended the doctors at Desai's clinic to the public during the first days of the crisis, Anwar never divulged that he and Khan worked for Desai in 2007.
Both he and Khan have refused to say how much they were paid to judge the work of Desai's physicians.
Khan also attended the recent wedding of a Desai daughter.
Anwar also never told the public that he "sometimes" referred patients to Desai over more than two decades.
Anwar spoke about his association with Desai only after being confronted with evidence of their association.
Until Friday, Anwar said that if he thought he might have a conflict of interest he would ask the state attorney general's office for an opinion.
NO EMERGENCY MEETING
During a March 6 meeting of the health care committee, Leslie and Buckley pushed the medical board to take action against the license of Desai and other physicians at the Endoscopy Center of Southern Nevada. Until then, Clark and Anwar publicly said there was nothing they could do except assemble evidence for a process that Clark acknowledges often drags on for two years.
Both said they wanted to ensure due process for doctors.
According to Clark, the decision to broker the license deal with Desai was made after Anwar suggested action should be taken to react to the wishes of the committee and the public. Clark said the agreement was made without consulting the board, which he noted is legal.
No emergency medical board meeting has been called to address the crisis.
Clark said he talked with Abe Vigil, an attorney for Desai. Clark said Anwar "may have talked with him (Desai). I'm not sure. I think he might have."
Anwar has not returned calls since March 6, the day before the nonbinding promise he and Clark brokered with Desai was announced.
"Dr. Desai can actually start practicing in Nevada again anytime he wants," Clark acknowledged.
Had Desai's license been suspended that wouldn't be the case. Suspension information would be entered in the National Practitioner Data Bank and be available to licensing agencies and health care organizations in every state.
Few organizations would hire a physician who has lost his license through what is called a summary or emergency suspension.
"Should Desai abide by his promise not to practice in Nevada, he would have little difficulty getting a license elsewhere," Clark said.
Desai's only blemish on his Nevada license came in 1996, when the board fined him $2,500 for falsely advertising that all of his clinic physicians were board certified.
Records in New York and Maine show Desai has inactive licenses there, but authorities in those states said he could make them active if his license isn't tarnished.
He could also quickly get temporary licenses in many states to fill in for ill or vacationing physicians.
"One of the physicians at his (Desai's) clinic is doing that right now, working out of state," Clark said. "He has to make a living."
'ONE OF THE FIVE WORST BOARDS'
Nevada's medical board has long come under fire for lax discipline, earning Public Citizen's ranking of "one of the five worst boards in the nation."
From 2004 through 2006, Public Citizen noted, the board took serious actions against only 1.68 doctors per 1,000. The national average is 3.18.
In 2006, the board took 20 disciplinary actions against the state's 4,000-plus physicians, revoking three licenses.
Wolfe said Nevada's board too often relies on fines and public reprimands for behavior that should be treated with probation, suspension or revocation of their license.
Clark said Wolfe doesn't understand Nevada's challenges: "We're still the fastest-growing state in the nation as far as I know. If we start stringing up 16 doctors a day the way Wolfe wants, you can't expect we're going to have any medical care."
He said the fact that Nevada has few doctors means "accommodations" must be made for physicians with some deficiencies.
"We try to help a doctor get over deficiencies through education," Clark said. "Not serious cases, of course."
Whether the malpractice case brought against Dr. Frank Anthony Shallenberger by the board could be considered serious is debatable. In September 2007, the board found that the Carson City doctor failed to diagnose an elderly patient with the cancer that ultimately killed him in 2003.
Shallenberger, who also practices homeopathic medicine, treated the 76-year-old man with rectal bleeding for hemorrhoids. He told him to use suppositories and take baths in witch hazel. Evidence showed Shallenberger never ordered tests that could have detected the cancer.
The medical board gave Shallenberger a public reprimand, ordered him to pay its $6,500 in investigation costs and made him take 16 hours of classes in cancer screening.
"I thought the board dealt with me fairly," Shallenberger said. "They always do."
Dr. Vernon Smith, a Washington, D.C., physician who served on a committee of the National Medical Association that studied medical boards, said they often just become "a group of political appointees" who want to protect the turf of physicians.
He said medical board members should not be appointed by governors who are rewarding political work. He favors filling boards with representatives of medical schools or other professional organizations that recognize achievement.
To James Tate, the UMC surgeon, the wedding of politics and medicine on the board has meant that black physicians aren't appointed to the board. Blacks are appointed to non-physician positions representing the public, he said.
Because of the role political influence plays on board appointments and actions, Tate sees no way the public can trust the board to do the right thing.
"Can you imagine a medical board not seeing the need to suspend a license of a doctor who has put thousands of lives at risk?" Tate said. "So what if he says he's not going to practice in Nevada? Don't we care about people in other states?"
Contact reporter Paul Harasim at pharasim @reviewjournal.com or (702) 387-2908.