State Has Hard Time Keeping Up With Him : Doctor Trying to Escape His Past Finds New Problems Cropping Up

Less than four years ago, Dr. Ralph J. W. Small, an Orange County physician who performed cosmetic surgery, quietly moved his practice to the San Fernando Valley.

Small, who is an ear, nose and throat doctor, wanted to renew his medical career in a place where no one knew about his past, according to Richard Guluzza, his attorney.

That past included an involuntary manslaughter conviction in 1979 in connection with the death of a patient, a medical license temporarily suspended by the state Board of Medical Quality Assurance and at least two dozen malpractice lawsuits filed primarily by patients who claim that Small botched their cosmetic surgeries, according to court records.

Now the 36-year-old physician is facing new problems, which could result in the revocation of his license for violation of probation terms that allowed him to continue practicing medicine. Additionally, his case has raised questions about how closely the Board of Medical Quality Assurance monitors doctors who are under its supervision.

At the time of his involuntary manslaughter conviction, the board concluded that Small was guilty of gross negligence and incompetence for repeatedly placing patients at risk by performing cosmetic surgeries he was unqualified to do and then abandoning them, according to board documents.

Yet in a move that created controversy within the medical community, the board did not revoke Small’s license. Instead, it placed him on probation for 10 years and restricted his practice to ear, nose and throat medicine and then only under the supervision of another physician.

In explaining the board’s action, Robert Rowland, then executive director, promised that the probation would be so strict that it would be “extremely unlikely there could be a recurrence.”

Given a second chance, Small began practicing ear, nose and throat medicine at Lake View Medical Center in Lake View Terrace under the supervision of staff physicians in 1981. Small received high marks from his Lake View peers.

But at an administrative hearing held in May to determine the fate of Small’s license, the Board of Medical Quality Assurance alleged that the physician has broken numerous probation requirements, including advertising and practicing a medical specialty put off limits to him by the board, practicing medicine alone and maintaining a secret office.

A decision by the board is pending.

At the hearing, Marilyn Levin, the deputy state attorney general representing the board, portrayed Small as a physician who refused to live with the restraints the board had placed upon him. Shortly after arriving in the San Fernando Valley, Levin said, he opened an office and it took the board two years to catch on.

For his part, Small told the board that he is a victim of a regulatory system which, over the years, has provided him with conflicting instructions on how to obey the terms of his probation. It was not uncommon for the board’s medical consultants and investigators to contradict one another, testified Small, who declined to be interviewed by The Times.

Among the board’s most serious current charges is that Small was practicing medicine alone in a converted Northridge bungalow and was maintaining a secret office in Newhall since at least 1982.

Board officials said they only learned about the Newhall office in February, 1984, after the mother of a patient treated for acne there complained about Small.

State investigators who testified during the hearing said they had no record of the existence of the Newhall office. Frank Heckl, Small’s probation officer from the board’s Orange County office, said Small asked him if he could open a Newhall office in 1982 and was told no.

Small testified, however, that he told board representatives about the Newhall office from the start and that no one had objected.

Actually, Small’s Newhall address was not exactly a secret. A review of old telephone directories for the San Fernando and Santa Clarita valleys shows that Small has been advertising the Newhall office, which he shared with Dr. Edwin Juda, a dentist, since 1982.

When asked why it took so long for the board to discover the Newhall office, Vernon A. Leeper, the board’s enforcement program manager in Sacramento, conceded, “There was a period of time when we weren’t keeping good track of Dr. Small.”

In part, Leeper attributed the gap in supervision to Small’s case being transferred from the board’s Santa Ana office to Los Angeles in 1982. Leeper also blamed a severe manpower crunch, which allows for only six investigators to keep track of more than 400 doctors on probation throughout the state.

This was not the first time that the board learned about one of Small’s offices.

Once, when Heckl dropped in to visit Small at Lake View Medical Center, he was told that the physician was in his office across the street, Heckl testified. The board agreed to let Small keep the office after hospital physicians, including Jordan Crovatin, the head of emergency medicine, assured the board that Small would only greet patients and maintain files and a telephone there.

Opens Another Office

Small testified that he opened yet another office in a house in Northridge in January, 1984. He advertised his Northridge office in the Yellow Pages as the Vista Medical Group, which he characterizes as a walk-in emergency service. He still practices there.

Small said at the hearing that he moved to Northridge because he had been evicted from his Lake View Terrace office in late 1983. However, board correspondence indicates, Small was told that he could not practice medicine in Northridge if he did not find a board-approved physician to share his office and supervise him.

During the hearing, Small explained that he was having a difficult time finding a partner.

The Board of Medical Quality Assurance is also seeking revocation based on Small’s alleged lies to the board and criminal probation officers regarding his compliance with terms of his probation, a 1984 conviction of drunk driving and a 1983 conviction of resisting arrest.

The district attorney’s office has also reopened its files on Small. Late last year, the Superior Court in Santa Monica (Small’s case was transferred there from Orange County) froze Small’s criminal probation--it would have expired last January--while it waits for the medical board’s ruling.

Ad Proves Alluring

Small’s problems with the board go back to the 1970s when he was advertising his Doctor’s Plastic Surgery Medical Group in Santa Ana in newspapers, magazines and on the radio. In one of Small’s telephone book ads, a young naked woman with long flowing hair, hands crossed over her breasts, promised: “Beautiful Tomorrows Begin Today.”

The ads apparently helped generate a booming practice. In an affidavit, Small estimated that he had performed nearly 1,000 procedures.

On Nov. 22, 1978, Small performed a breast-implant surgery on Kim Plock, a 33-year-old mother of three. After he inserted the implants, Plock suffered cardiac and respiratory arrest and lapsed into a coma, according to board documents. Small kept his patient at the clinic for more than nine hours before sending her to a nearby hospital. She died five days later.

At the time, Small told police he did not transport his patient to the hospital immediately because he was using his own emergency equipment to revive her.

In 1979, after the board began its investigation, Small was charged by the Orange County district attorney with 41 criminal counts, including murder, assault, unlawful practice of medicine, grand theft and false advertising. In a plea bargain, Small pleaded no contest to involuntary manslaughter and was placed on probation for five years.

New Probe Limited

Contrasted with its first investigation, the scope of the board’s current examination of Small has been limited. The board, for example, is not certain how many types of medicine Small was practicing in his offices in Newhall or in Northridge. According to Leeper, investigators can only subpoena the records of patients who complain.

One of those who complained, Cleo Chavez of Arleta, said she wanted Small to tell her if she was allergic to her dog, according to her sworn declaration. During her first visit to Small’s Northridge office on April 17, 1984, she said she was given an allergy test and then Small asked her if she wanted a hearing test. Chavez said she reminded the physician that she had not complained about her hearing, but she acquiesced.

After another allergy test on a separate visit, Small told her to stop eating eggs, Chavez said in her declaration. Then several days later, Chavez said, Small’s clerk telephoned her to say that the physician wanted to give her an EKG and other tests in a hospital. She declined.

Chavez said Small billed Medicare for $843 for her two visits. She said Small also billed Medicare for $130 for the phone call inquiring if she would undergo hospital tests.

During the hearing, Small said he did not remember what treatment he gave Chavez.

The other complaint came from Kathryn Sanfilippo of Canyon Country, who tipped off the board in February, 1984, to the existence of Small’s Newhall location. In a letter to the board, she said she took her son to Small for dermatological services because Small was listed as a dermatological specialist in the Santa Clarita Valley Yellow Pages.

Called Dermatologist

Sanfilippo said that when she asked the receptionist if Small was a dermatologist, she said he was.

In connection with the Sanfilippo complaint, the board alleges that Small broke his probation by treating acne--not an ear, nose and throat (ENT) procedure--and by advertising that he was a dermatologist.

Guluzza, Small’s attorney, contends, however, that “there is no clear-cut line that divides dermatology from ENT” so his client has not done anything wrong.

Without the board’s knowledge, Small was advertising for other off-limits specialties--including plastic surgery.

In his first year in the San Fernando Valley, he used his middle name, listing himself as Joseph Small under the general physician and surgeon heading. Since 1983, Small has been listing himself in area Yellow Pages under the headings of dermatology, plastic surgery and pediatrics.

Others Doing Same Thing

Small testified that he did not restrict himself to the ENT heading because the telephone book solicitors told him that other ENT doctors were doing the same thing. When a patient called wanting a medical service he was prohibited from providing, he said, his receptionist would turn down the caller.

Today, Small apparently is practicing only in Northridge. According to Richard Pierce, administrator of Lake View Medical Center, Small left the hospital last year when he again began experiencing problems with the board. And Small has said he shut down his Newhall practice after the board renewed its investigation.