Dr. Vicki Georges Hufnagel says she remembers the moment vividly, even though it was a decade ago. As a resident physician training in obstetrics and gynecology, she was assigned to assist in a hysterectomy on a nun.
But something about it bothered her. Questioning the patient, she learned the 26-year-old nun planned to leave her vocation to marry and hoped to raise a family.
Over the opposition of senior doctors, Hufnagel says, she forced cancellation of the hysterectomy--removal of the uterus--and substituted less extensive surgery.
The incident, she says, began her transformation into a revolutionary crusading for women's health. She has spent the last 10 years working to educate both women and their physicians about unnecessary and unjustified hysterectomies. In July, New American Library published her book, "No More Hysterectomies," an angry broadside that argues that 90% of the operations are unnecessary and that hysterectomy is completely appropriate only to treat cancer.
"I'm angry because often I feel alone in my struggle to effect change within the 'good old boy' medical system," she writes in the book's opening chapter. "For the last century there has been an unspoken conspiracy against the uterus. It's time to break free of the myths."
Publication of the book comes, however, as Hufnagel herself faces a broad array of legal and ethical challenges, including charges that she performed her own hysterectomy-substitute procedures unnecessarily. It is a melodrama of soap-opera proportions.
Accused of Negligence, Incompetence
Court and official documents depict her not as a crusader but as a physician accused of gross negligence and incompetence. In a still-pending license revocation case filed last year by the California Board of Medical Quality Assurance, Antonio Merino, a deputy state attorney general, summed up the board's case against her by saying, "Dr. Hufnagel is a fraud and a liar."
"Dr. Hufnagel passes herself off to prospective patients, current patients and to the (administrative law judge assigned to hear the revocation case) as being innovative, a front-runner, the developer of new procedures, a crusader and a protector of women," the brief by Merino concludes. "She purports to be like Galileo. She is none of these."
Among the complex of controversies, Hufnagel:
- Is accused by the BMQA, the state agency that regulates doctors, of botching the care of 11 patients, including at least five on whom she allegedly performed her own procedures unnecessarily.
- Is accused by the BMQA of submitting false and fraudulent bills in the cases, charging as much as $21,175 for surgery ostensibly intended to involve far less drastic procedures than hysterectomy. In California, a complete hysterectomy costs an average of $6,500, according to the Metropolitan Life Insurance Co.
- Is embroiled in a complex series of lawsuits with Cedars-Sinai Medical Center in which she charges she was dismissed from the hospital, where she underwent most of her residency training, because of what she contends was a sexual affair with the chairman of the department of obstetrics and gynecology.
- Faces at least nine malpractice suits charging her with mistreating women who sought her help for a variety of reproductive health problems. All of these suits figure in the license-revocation case.
- Has used a medical resume that contains three apparently questionable entries, according to a legal brief filed in her revocation action and an independent check of her credentials by The Times.
Hufnagel declined to comment on the controversies directly, saying that to do so would be inappropriate because of ongoing legal proceedings. But in two separate interviews, she called herself the victim of a conspiracy by other physicians who, she contends, see her and her ideas as a threat to the medical establishment.
"If you have a conspiracy and people are doing things to you," she said, "the first thing they want (is to have you) wear down, become emotional and not deal with things logically.
Addressing 'Social Issues'
"My situation politically is my situation politically. The issues I'm trying to address are social issues, which are on a different sphere politically. The fact that I have 50 knives in my back and I'm still out there trying to help women should be seen as positive, not as a completely negative thing. I haven't the money or the power of the people I'm fighting. Not even close."
But, she added: "I'm out to change medicine for women. I'm not going to play (by) the same tactics they play. I'm sincere in what I'm doing. I will be completely vindicated. I did no wrong. I did no harm. I practice what I preach."
Dr. Robert Gans, a physician-attorney who formerly worked for the BMQA and now maintains a private legal practice in which he represents Hufnagel, contended that Hufnagel is "a superb surgeon," but he declined to discuss details of specific allegations against her.
Hufnagel has attracted at least one powerful political ally, State Sen. Diane Watson, D-Los Angeles, who successfully sponsored a state hysterectomy informed-consent law last year at Hufnagel's behest.
'Impressed' With Hufnagel
"I am convinced that women suffer unnecessary hysterectomies," Watson said. "I was very much impressed with Dr. Vicki Hufnagel. I testified (at a hearing in the license revocation case) about what I have learned from her about hysterectomies and the fact that I felt she was ethical. I'm not a medical doctor, but I just know I was compelled by her data and by her research."
Hufnagel was born in Chula Vista in 1949 and raised in Riverside. She graduated in 1976 from UC San Francisco Medical School and did her internship and residency at Cedars-Sinai, followed by a second residency at the Albert Einstein College of Medicine in New York. She was married twice, both of which ended in divorce. She and her third husband, Robert Schuster, have a 2 1/2-year-old daughter and live on the Westside.
Hysterectomy, the second most common operation performed in the United States each year after Caesarean section childbirth, has been a highly visible target of feminist health care advocates for at least a decade. Allegations of excessive hysterectomy rates began surfacing between 1970 and 1975 as physicians started to question the appropriateness of the operation as a means of routine sterilization for women. While many hysterectomies are still performed for that purpose, use of it as a means of contraception has long been in decline.
Six years ago, when the hysterectomy controversy was still at its peak, the Ralph Nader-affiliated Health Research Group contended that 27% of American women can expect to undergo the operation by the time they are 45 and 50% by age 65. A separate 1987 review by Hufnagel and a U.S. government statistician estimated that 37% of American women can expect to have the procedure during their lifetimes. Hufnagel's statistical analysis also found rates tumbled from 8.6 hysterectomies per 1,000 women over 15 in 1975 to about 7 per 1,000 in 1984.
Yet the absolute number of hysterectomies is continuing to rise because the Baby Boom's life cycle has increased the number of women in high-risk age groups.
In her book, Hufnagel emphasizes a hysterectomy-avoidance technique called "Female Reconstructive Surgery," which she developed, which she practices through the Institute for Reproductive Health, her Westside clinic, and which she has been pushing on the talk show circuit the last few weeks in a promotion tour organized by her publisher and publicist. "Female Reconstructive Surgery," Hufnagel says, includes a variety of techniques that stress preservation and conservation of a woman's reproductive organs as opposed to removing them. But prominent obstetrics and gynecology specialists in California questioned by The Times said that Hufnagel's treatment includes little that is not commonly offered by a broad array of well-qualified specialists. One doctor said all of the techniques in question have been widely available for as long as 50 years.
In interviews, Hufnagel backed away from characterizing her techniques as unique. Her concept, she said, "is not an original idea. Is (Female Reconstructive Surgery) special? No. What is special is trying to put it all together, get laws, get informed consent and make a conscious awareness so (abuse of women through unnecessary hysterectomy) doesn't continue insidiously throughout our history."
The controversy over the originality of her therapy is exacerbated by the separate state medical board allegations.
In one case, identified as that of a 34-year-old woman who had suffered a spontaneous abortion, Hufnagel is accused of reporting she found fetal tissue in the patient's uterus when none was present, worsening a perforation in her uterus, billing for an ovarian biopsy she never performed and performing surgery to support the uterus even though the surgery was not necessary to correct an inflammation that could have been treated otherwise.
Evidence submitted at her license revocation hearing includes internal insurance company documents in which Hufnagel's billings are characterized as grossly excessive. The bills include such charges as $250 to videotape surgical procedures, $200 for single topical applications of vaginal medicine and between several hundred and several thousand dollars for procedures that appear to be charged both singly and collectively on the same bill. Records in the case indicate insurance carriers routinely disallowed large proportions of Hufnagel's bills, paying as little as 20% of what she demanded.
Schuster, who is also Hufnagel's business manager but no longer controls billing, disputed contentions that her billings were improper. "There was no fraud. There was no intent at fraud," he said. "There are some people out there who are trying to get Vicki." Schuster said he mistakenly entered some incorrect codes on bills that mistakenly led insurance firms to conclude Hufnagel performed procedures she had not actually done. Hufnagel herself declined to discuss the billing allegations, but she said she now follows different procedures.
The license revocation case is scheduled for final oral arguments this month and a decision is due in October.
The malpractice cases against Hufnagel parallel those that brought about the license revocation action. All nine malpractice actions involve patients mentioned in the state complaint. All but one are still pending. The ninth was resolved in Hufnagel's favor a few weeks ago.
In her series of lawsuits against Cedars-Sinai filed in the last three years, Hufnagel is embroiled in litigation over her banishment from the medical staff in March, 1984. According to court documents and Hufnagel in an interview, she was officially terminated on various grounds of questionable performance.
But in her suits, seeking reinstatement and monetary damages, she contends that as a resident at Cedars-Sinai she entered into a sexual relationship with Dr. Maclyn Wade, the chairman of the hospital's obstetrics and gynecology department, and that when she broke off the relationship several years later as an attending physician, he had her thrown off the hospital medical staff.
Hufnagel's suits on the issue, however, contain apparent contradictions on whether she submitted to Wade's alleged sexual advances. In a complaint filed against Wade in 1985, Hufnagel contends Wade exacted his alleged professional retribution after she resisted his overtures. But in a 1987 lawsuit against Cedars-Sinai, she charges she and Wade were personally or sexually involved from 1976 to 1983 and that his alleged actions occurred only after she broke if off. Hufnagel said in the interview the apparent conflicts in the two accounts come from differences in the way her various attorneys interpreted her account of the episodes.
In court documents, Hufnagel also asserts that Wade turned her in to the BMQA and even called a television talk show producer to try to head off her booking at a time she says she was attempting to establish herself as a "television personality." She further claims that doctors at Cedars-Sinai tried to intervene in her attempts to gain medical staff membership at four other area medical centers and characterized her as "a butcher" and "an incompetent" to patients and other physicians. She is, she said, currently on the staff only at Beverly Hills Medical Center.
She further charges in the court complaint that Wade routinely promoted and extended professional favors to physicians in his department "on the basis of sexual and other favors."
The Times, however, has found that Hufnagel was called to the attention of the state medical board by at least some sources with no apparent connection to Cedars-Sinai, including insurance companies and doctors acting as consultants to insurance companies.
A spokeswoman for Cedars-Sinai said the hospital would not comment on any aspect of the legal disputes with Hufnagel. Wade did not return calls from The Times.
Merino and other state officials declined to be interviewed on any aspect of the Hufnagel case, citing its still pending nature.
Hufnagel has also introduced into her prolonged litigation with Cedars-Sinai a separate legal dispute with a former boyfriend, restaurateur James Factor, operator of the now defunct Beverly Hills spa cuisine eatery 400 North Canon. In court documents, Factor claims he bankrolled Hufnagel's practice with a $650,000 personal loan she failed to repay. She filed a counterclaim contending he manipulated the finances of her clinic, leaving essentially no proceeds after a one-year gross of $1 million, and then had the counterclaim added to the Cedars-Sinai action, charging he conspired with doctors there.
The background is tangled by apparent misrepresentations in Hufnagel's medical credentials.
Documents in her license revocation case charge Hufnagel falsely represented herself as an American College of Obstetricians and Gynecologists member and a Berkeley graduate at a hearing in the case in July. Hufnagel's resume provided to The Times by her administrative assistant states she is a junior fellow of ACOG, the leading professional organization in its field. The group ousted her last December because she failed to take or pass an examination to certify basic competency in her specialty, a spokesman said.
The resume also indicates she attended UC Berkeley continuously from 1971 to 1973, a claim a university spokesperson said conflicts with Berkeley records that indicate Hufnagel attended only on two comparatively brief occasions during that period and received no degree.
In addition, her resume says she held a National Institutes of Health fellowship in reproductive genetics at UC San Francisco in 1980. However, a UCSF spokesperson said Hufnagel resigned after completing only three months of the scheduled two-year program.
Hufnagel said the resume provided to The Times was released in error and contained incorrect information as a result of typographical errors and flawed computer storage. She said she did not intend to imply she was graduated from Berkeley and that, in fact, she has no undergraduate degree. She said she gained admission to medical school on the basis of her total number of undergraduate credits.
She said she left the fellowship prematurely because of a romantic involvement. And she denied making false statements at the hearing.
A publicity spokeswoman for New American Library said the firm would not comment on Hufnagel's licensure and legal troubles and the questions about her credentials. The book lists free-lance journalist Susan Golant as a co-author.
Hufnagel, 39, has remained stoic through it all. She maintains she has been victimized by a male-dominated medical care system unable to change and unwilling to recognize a basic conflict between contemporary science as it pertains to the female reproductive system and the system's own entrenched, masculine beliefs.
"The situation that occurred to me personally," she said, "is so intertwined and intrigued and with such characters and such stories (that) it's the kind of thing you would (look at and) go, 'This can't be happening!' If you read the charges (against me), you could (ask the) question yourself, 'What is this document doing in this court?' "
Hufnagel said she was determined not to allow her legal difficulties to detract from what she said are the central issues in her crusade against unnecessary hysterectomies and insensitive reproductive health care for women.
"When you're a pioneer and you're speaking out on an issue there is a tendency not to look at the issue (but to) attack the person personally," she said. "There is also a tendency (to want to) keep things as they are."
Hufnagel relies on surgical techniques like myomectomy, in which tumors or other abnormalities are removed from the uterus but with the uterus itself left intact. She also performs a wide array of procedures to repair tissues supporting the uterus, vagina, bladder and rectum. She specializes in other techniques, both involving traditional surgery and use of lasers, to treat a variety of other problems that have often in the past resulted in hysterectomy.
Top experts in obstetrics and gynecology, however, contended that Hufnagel's claim that her "Female Reconstructive Surgery" is a newly developed or unique approach cannot be substantiated.
A 'New Label'
Dr. Benson Harer, chairman of the California district of the American College of Obstetricians and Gynecologists, said he has reviewed Hufnagel's procedures in some detail. "What she does is simply use a number of techniques that have been available for many years and puts them together under a new label," said Harer, who practices in San Bernardino. Dr. Edward Quilligan, vice chancellor of the UC Irvine College of Medicine and a nationally known expert on women's health care, said that Hufnagel's program is "not new at all."
Dr. Joseph Gambone, a UCLA hysterectomy expert, said there is little doubt that hysterectomy rates are still excessive. "I think it is generally acknowledged in the medical community that there are probably too many hysterectomies being done. The problem is defining which ones are the unnecessary ones."
He said research he did in San Diego, in which extensive reviews were conducted of the medical reasoning behind several hundred hysterectomies, suggested that about 33% of the procedures were performed when the uterus removed was either completely normal or had abnormalities too minor to justify surgery.
Hufnagel is undeterred by the continuing controversy. "If I have to go through this, I'm going to go through it because I'm not going to watch it (the imposition of unnecessary hysterectomy) happen any more because it could happen to me and it could happen to my daughter.
"(What I'm engaged in) isn't 'promote Hufnagel.' This is 'Change medicine.' Against all odds. And I can tell you, I've been against all odds."