Star surgeon is scrutinized on concurrent procedures

“He’s God,” Nadler, a 67-year-old retired restaurateur, recalled thinking when he met the doctor.

But after his June 2015 surgery for an enlarged prostate, Nadler began to wonder whether someone other than his famous urologist did the operation. Nadler barely saw Samadi that day and mostly remembered the doctor’s young assistants, he said. His urinary problems didn’t improve. Worse, he said, his libido vanished. Finally, this January he confronted the surgeon in Samadi’s posh Madison Avenue office: Did you do the operation or did someone else?

A lot of people are asking the same question. Samadi’s handling of his immense patient volume has become an extraordinary flashpoint in the growing national controversy over simultaneous surgery — the practice of one surgeon managing two or more procedures in the same time period. Samadi, chairman of urology at Lenox Hill, is under investigation by New York state regulators for allegedly improperly double-booking surgeries. Current and former medical personnel there have told regulators and the Globe that Samadi, while working on one case, routinely hands off simultaneous operations to unsupervised residents who are still learning how to do surgery. His residents have also complained to an accrediting agency that he doesn’t properly train them.

A review of hospital data obtained by the Boston Globe Spotlight Team found that Samadi overlapped one case with another at some point in about 70 percent of his roughly 2,200 operations between mid-2013 and mid-2016. Hundreds of times, one operation overlapped completely with another. During Nadler’s case, which lasted more than two hours, Samadi had another operating room going for all but about 25 minutes.

Medicare rules allow teaching surgeons to bill for two operations simultaneously, but the physician must be present for all the “critical parts,” which, at a minimum, would require Samadi to shuttle between operating rooms. But most of Samadi’s overlapping cases occur when he is doing a robot-assisted operation, and he promises on his website that in such surgeries the “entire procedure is performed by Dr. Samadi.”

Samadi, 49, declined Globe requests for interviews but issued a statement through a hospital spokeswoman: “I am proud of and stand by my record of success and my reputation for excellence. I assure all my patients that I am there when my skills are promised and required. Every patient gets that same level of care by me and my team.”

Samadi said US privacy laws bar him from discussing individual patients, but he said “the welfare and quality of their lives are always my priority.”

Barbara Osborn, a spokeswoman for Northwell Health, parent company of Lenox Hill, acknowledged the investigation by the state Office of Professional Medical Conduct and said the hospital will cooperate.

“Dr. David Samadi is a distinguished member of Lenox Hill Hospital’s faculty and in good clinical standing,’’ she said. “The hospital regards Dr. Samadi as a high-quality surgeon with excellent clinical outcomes whose primary concern and priority has always been the well-being of his patients.”

She confirmed that the doctor uses two operating rooms at once and said patients are informed that residents might participate “under supervision by a physician.” She stressed, however, that Samadi “performs all of his robotic surgeries himself” and is present for the entirety of “major surgeries.” He complies with Medicare rules, she added.

The allegations against Samadi underscore the growing concern nationally over surgeons who boost their volume — and revenue — by overseeing two or more operating rooms at once. The practice was largely unknown to the public until late 2015, when the Spotlight Team published several stories about simultaneous operations at Massachusetts General Hospital and other US teaching hospitals. Since then, the Senate Finance Committee has urged hospitals to more strictly enforce Medicare rules limiting the practice. And the nation’s largest association of surgeons has revised its guidelines for such surgeries, saying patients need to be informed whenever doctors run more than one operating room at a time.

But concurrent surgery continues to stir controversy. In February, the chief executive of a large Seattle hospital system resigned after a Seattle Times report that neurosurgeons were asked to increase patient volume, in part by running concurrent operating rooms. Hospitals that permit double-booking say it can be an efficient way to deploy the talents of their most in-demand specialists.

In recent months, at least three medical studies have given conflicting results on the comparative safety of concurrent surgery. A study by a University of Toronto professor found a greater risk for complications, but studies by the University of California at San Francisco and by the Mayo Clinic found no increased risk.

Absent undisputed findings about medical risks, the key issue for critics of concurrent surgery is patient consent. About 95 percent of patients in a recent survey published by the Journal of the American College of Surgeons made it clear that, at a minimum, they want to be told if they will be sharing their surgeon with a second patient.

When Nadler confronted Samadi in January about whether Samadi did his operation, the surgeon replied: “That’s a horrible thing to say to your doctor,’’ according to Nadler’s wife, Lorraine, who accompanied him.

Peter Nadler said in an interview he never would have consented to surgery if he had known Samadi would have another operation going. It’s unclear whether Nadler’s erectile dysfunction is a result of the operation, but it is a known risk of prostate surgery.

“Who in their right mind would agree if the doctor said, ‘I’m going to do you, but I gotta do somebody else, too?’ ”
Nadler said. “My God, with my manhood?”

Samadi has long been controversial among his peers for what they consider conspicuous self-promotion, including regular appearances as a medical expert on Fox News and even a cameo on the TV show “Law & Order: Criminal Intent.” He ran advertisements in airline in-flight magazines claiming he had a 97 percent cancer cure rate and calling himself “the best in the world.”

But even Samadi’s critics acknowledge he is a skilled and hard-working surgeon. And Lenox Hill has rewarded him handsomely for his productivity, recently giving him a $2.9 million raise because he was “prolific,” Northwell Health’s board chairman told Crain’s New York Business last year. Samadi zealously keeps track of his robotic surgeries on a whiteboard in one of his operating rooms. A recent photograph showed the running total since July 2013 — 1,380 robotic cases — and included an admonition: “PLEASE DO NOT ERASE.”

But his practice of double-booking patients has alarmed and angered some medical staffers enough that, breaking with the tradition of professional reticence, they took their concerns to regulators and the Spotlight Team.

At least six medical personnel were contacted by New York regulators and told the Globe that urology residents do the vast majority of Samadi’s nonrobotic surgeries, including two-hour operations to trim away excess prostate tissue blocking urine flow. One of the six recounted being present when a resident performed virtually all of about 200 operations booked under Samadi’s name while Samadi did robotic surgery in another room. Sometimes, the staffer said, Samadi would call the resident on the phone or briefly pop in to see how the operation was going. All but one of the six individuals insisted they not be identified by the Spotlight Team because they feared retaliation.

A spokeswoman for the New York medical conduct office said the agency does not comment on whether it is investigating a physician unless it finds enough evidence to file misconduct charges. Osborn, the Lenox Hill spokeswoman, said state investigators have not shared details of their inquiry and that the hospital could not talk to the Spotlight Team about specific patient cases.

The Globe review found that on more than 400 occasions Samadi completely overlapped a robotic case and a nonrobotic case, according to multiple sets of hospital data obtained by the Globe that did not identify patients. The cases were of different duration and complexity.

The average length of the fully overlapped cases was roughly 45 minutes. Given that Samadi promises on his website to do his robotic operations entirely by himself, it’s unclear to peers in his field who spoke to the Globe how he could also be present in the other operating room for significant periods of time.

It’s also a radical departure from the way the hospital previously did urology surgery. Dr. John A. Fracchia, who headed Lenox Hill’s urology department from 1983 to 2008 and continues to operate there, said surgeons asked him several times as chairman to let them run two rooms simultaneously. He always said no.

“I think it’s wrong,” said Fracchia, after being contacted by the Globe and shown Samadi’s schedules. “It would be difficult for me to look at the operating room schedules on a daily basis, as the administration does, and not see that it’s impossible for somebody to be at two places at the same time.”

Fracchia said he was also interviewed by regulators.

If nothing else, Samadi’s surgical schedules indicate remarkably busy days of simultaneous operations. On at least 80 days since arriving at Lenox Hill from Mount Sinai Hospital in New York in mid-2013, he was listed as the primary surgeon for an average of nine cases. On five of those days, his cases totaled more than 20 hours when adding up his overlapping operations. He usually operates two or three days a week, according to the data shared with the Globe.

In October 2013, Samadi had seven operations scheduled in a single day — and anesthesia for the last two patients began at the same time, according to the hospital data. One of those patients was Stephen Markelson, a frail 79-year-old who had blood in his urine, an enlarged prostate, and other health problems.

“We thought we were so lucky in getting him,” recalled Markelson’s widow, Ann. “He was the head doctor at the time. He was a good-looking man with tremendous publicity.”

But Samadi was busy with a robotic case that completely overlapped Markelson’s, and a resident allegedly began and then had to halt Markelson’s surgery, according to interviews with medical personnel who were briefed on the case and spoke with state regulators. The resident declined to comment.

Ann Markelson said she had no idea Samadi had another operation going until she was informed by the Spotlight Team and that her husband never would have agreed to the procedure had he known. She was told the operation couldn’t be finished because of blood pressure problems. Several days after Markelson was discharged, he returned to the hospital with a massive amount of blood in his urine and had the operation redone by a different surgeon, according to patient records shared by the Markelson family and an interview with one of the six medical staffers contacted by state regulators. Stephen Markelson died several months after the prostate operations of unrelated causes.

“That’s completely unethical,” Ann Markelson said of the double-booking.

Markelson’s case is among those the New York office of medical conduct is investigating, according to medical personnel interviewed by the Globe. Consent forms signed by Markelson and Nadler for their operations made no mention that a concurrent surgery was planned, though Nadler’s form acknowledged possible participation of residents. Residents are surgical trainees who have completed medical school and care for patients under supervision of teaching physicians.

Robotic cases, Samadi’s specialty, leave little time for attending surgeons to leave the operating room, according to practitioners. The urologist sits at a computer console several feet from the patient, looking at a magnified, three-dimensional image of the surgical field while precisely manipulating robotic arms with miniature surgical instruments passing through keyhole incisions.

“I’m there the entire time,” said Dr. Robert Reiter, director of the Prostate Cancer Program at UCLA, who performs robotic surgery.

One of the medical personnel interviewed by state regulators said Samadi always shows up for the “time-out” at the start of the nonrobotic operation — a routine but mandatory pause to make sure the medical team has the right patient and correct surgical site.

But that typically takes less than a minute. After that, he goes to OR 25 to perform the robotic operation, according to the medical staffer, who described witnessing a resident assigned to work with Samadi operate alone in the nonrobotic room about 200 times.

Another medical staffer interviewed by state regulators described watching Samadi at the computer console about 10 times in 2013 for about a half-hour while Samadi did robotic surgery. Each time, the staffer said, a resident was performing a nonrobotic operation on a patient of Samadi’s in another room while Samadi stayed at the console.

The double-booking controversy, in some ways, reflects the exceptional drive of a surgeon who fled his native Iran as a teenager to escape the revolution and worked his way up to the pinnacle of American medicine as the chairman of urology at Lenox Hill Hospital.

Samadi has collected a huge roster of patients who are delighted with how he handled their prostate surgery. Men have plastered his LinkedIn profile and websites with testimonials: “Dr. Samadi is in a league of his own,’’ wrote one, who praised the personal attention he received. “You are the bomb!” wrote another.

But with his success came conflict: with some surgical residents who complained Samadi wasn’t teaching them robot-assisted surgery, with some fellow urologists put off by Samadi’s marketing claims, and with the larger medical community over his willingness to weigh in publicly on things he was not in position to know much about, such as Hillary Clinton’s health.

Last August, Samadi told Fox News host Sean Hannity that a photograph of Clinton stumbling on porch steps during her campaign in early 2016 indicated she might have serious neurological problems. The photograph of the Democratic presidential candidate being helped up the stairs by two Secret Service agents, Samadi said, spoke “a million words.’’

Afterward, Dr. Joseph Safdieh, a neurologist at Weill Cornell Medicine in Manhattan, tweeted that he was not a fan of Clinton, but he felt Samadi’s diagnosis showed the urologist was “an idiot.’’

“I would never go on TV to discuss prostate cancer,’’ Safdieh tweeted at Samadi. “You are a sell-out.”

Samadi did not respond but Safdieh said the urologist blocked him on Twitter.

Samadi also faced criticism from some peers for claiming in advertisements that he had “cured” 97 percent of his prostate cancer patients.

In early 2014 Dr. Henry Woo, a urologist in Australia, wrote on his blog that no prostate cancer doctor can boast a 97 percent cure rate “unless the subjects were all men with such low-volume indolent disease that they did not need surgery in the first place.’’

The American Urological Association eventually investigated Samadi’s advertising tactics based on complaints from other urologists, according to e-mails obtained by the Globe, and Samadi significantly scaled back claims on his website.

“The issues raised by the American Urological Association were addressed and resolved,” said Osborn, the Lenox Hill spokeswoman.

If state regulators interview current and former residents about Samadi’s surgical practices, they are likely to get an earful.

The Accreditation Council for Graduate Medical Education, or ACGME, recently downgraded Lenox Hill’s residency program after residents complained in an anonymous survey that Samadi wasn’t teaching them the intricacies of robotic surgery and instead had them do his conventional urology operations, according to medical personnel and a letter that was written by the accrediting agency and obtained by the Globe.

“This is one of the self-proclaimed experts in robotic surgery in the entire world,’’ said one of the staffers interviewed by medical regulators. “Why wouldn’t he teach them? The joke among the residents was that ‘he’s teaching Third World doctors how to do it, but he won’t teach us.’ ”

In recent years, Samadi has launched robotic prostate surgery institutes in the Dominican Republic and Cyprus.

A hospital spokeswoman said this week that it had “thoroughly reviewed recommendations” from ACGME, and in response, “enhanced and increased the training its surgical residents receive, including those involved in robotic cases.”

Jonathan Saltzman can be reached at jonathan.saltzman@globe.com. Jenn Abelson can be reached at jenn.abelson@globe.com. Follow her on Twitter @jennabelson. Gabriel Florit contributed to this report.