Is surgeon innovative, or unfit?
By COLLINS CONNER
© St. Petersburg Times, published November 20, 2000
HUDSON -- After years of struggle to save his career and his clinic, Hudson physician Alfred Bonati will soon know the future of both.
Bonati, who has been fighting state regulators and dozens of malpractice claims, could learn today if his Gulf Coast Orthopedic Center will settle those claims and come out from under bankruptcy protection. He will learn early next year if he can keep his medical license.
Over the years, the legal and disciplinary cases have evolved into a minefield of accusations: that Bonati created credentials, hid money from creditors, overbilled insurance companies, kept one-size-fits-all medical records and performed repeated surgeries on people who didn't need them.
Despite those allegations, Bonati has kept the faith of thousands of patients who bring their aching backs to his mirrored office complex on U.S. 19 in Hudson and fill the company's Web site with testimonials to his care.
"He has kept me walking," said 71-year-old Walter Briggs of Port Richey. "Thank God for him."
At the urging of former Baltimore Colts great Tom Matte, the Retired Players Association of the National Football League began referring its members to the Bonati Institute. Willie Wood, a Green Bay Packers star in the Vince Lombardi era, was one of the referrals and told the Times he was very satisfied.
Bonati, 61, collects upward of $500,000 annually from his medical corporations, which could generate an estimated $31-million in business this year.
Bonati's supporters consider him a martyr to innovation, a man who uses lasers and his own patented tools to perform a less invasive method of back surgery than that used by most doctors.
But that's not the view of some patients suing Bonati, who say he mistook the source of their pain and operated on their perfectly normal backs, weakening their spines and creating the risk of future problems.
And it's not the view of the Florida Board of Medicine, which wants to shut down Bonati's practice. The state's medical experts said Bonati's serial surgeries, at best, fail to relieve pain and,at worst, leave patients cruelly impaired.
But during the June meeting of the Board of Medicine, Britt Thomas, the attorney for the state's Agency for Health Care Administration, warned board members that "a few" of their experts' conclusions "have not held up to a closer scrutiny and do not appear to be substantially borne out by the evidence."
Thomas' disclosure didn't dissuade the board.
Board member Zachariah P. Zachariah called Bonati "totally dishonest."
"He doctors his records to fit the diagnosis," Zachariah said.
"He is a major nemesis to the medical profession and a great danger to the citizens of Florida."
Bonati declined repeated interview requests from the Times.
Leading the field
By specializing in spine surgery, Bonati tapped into an inexhaustible patient pool: Backaches send more people to the doctor than anything but the common cold.
Unlike most other orthopedic surgeons, Bonati operates exclusively with arthroscopy and lasers -- producing incisions the size of a staple, minimal bleeding and little muscle trauma.
Bonati, who lives in St. Petersburg, considers himself a pioneer in the field; in his promotional materials, he says he developed his own microsurgery procedures and instruments. Simply put, he makes a tiny cut over an area of the spine, then uses miniaturized tools to remove tissue that may be causing pain.
Traditional back surgery involves a much larger incision, more drastic surgery, a longer recuperative period and a number of potential complications.
To spread the word about his special technique, Bonati has given speeches and conducted seminars, sometimes bringing doctors to Hudson to watch him work. He has additional offices in Arkansas, Orlando and Amsterdam,and he markets his practice by putting on workshops throughout the United States and by distributing a film and book about his work in Europe.
Bonati's career began with medical school in Spain. He then worked at five U.S. hospitals in five years without completing their training programs, a circumstance he blames on his misunderstanding of American training requirements. Reviews of his performance during those years range from compliments on his "exceptionally good, skillful hands in the O.R." to criticisms that he was "not at all promising" and that "he has tried to cover up mistakes."
He completed his residency in orthopedic surgery at the Bowman Gray School of Medicine of Wake Forest University in North Carolina, though he was twiceplaced on probation by the school.
In 1983, Bonati sought to become board certified in orthopedic surgery. Certification is a big deal to doctors; it means they are trained and tested in their specialty.
But Bonati flunked the exam. Regina Kehr, a volunteer who works at Gulf Coast, said Bonati blamed it on a simple language problem.
He later formed his own specialty board, the Arthroscopy Board of North America Inc., which then certified him in his field.
He also is certified by the American Board of Neurological and Orthopaedic Medicine and Surgery and by the American Academy of Minimally Invasive Spinal Medicine and Surgery.
None of the three organizations that certified Bonati is sanctioned by the American Board of Medical Specialties, the rating organization recognized by the American Medical Association.
Unsanctioned boards typically are created by non-conformists, said Dr. G. Paul DeRosa, executive director of the American Board of Orthopaedic Surgery, one of the 24 ABMS-sanctioned boards. "Since they are not courted by mainline physicians," he said, "they'll start their own group."
Doctors who claim membership in unsanctioned organizations "may be great guys who couldn't pass the exams," DeRosa said."But you need to know that over 85 percent of the orthopedic surgeons in this country are board certified.
The other 15 percent . . . most likely, they're fringe players."
Just 127 orthopedic surgeons are members of the American Board of Neurological and Orthopaedic Medicine, according to its Web site.
The Web site of the American Academy of Minimally Invasive Spinal Medicine and Surgery lists only 44 members worldwide, including five in Bonati's office.
By comparison, the ABMS-sanctioned board that didn't certify Bonati has 20,780 members.
Vastly different views
In 1992, when Bonati was attempting to buy a struggling Pinellas County hospital, the St. Petersburg Times published a story about his efforts and about lawsuits filed against him -- a story Bonati said derailed the hospital purchase and triggered the filing of dozens of malpractice claims.
And, in fact, the majority of the malpractice claims Bonati faces were filed after the newspaper's report was published. Bonati sued the Times for libel, but the lawsuit was dismissed in 1997 on technical grounds. Bonati then sued his libel attorneys for malpractice.
Bonati's Tallahassee attorney Cynthia Tunnicliff adds this explanation for her client's legal troubles: He is ahead of his time.
"I think it's the same with a lot of people who, throughout history, start doing something that is unique and different -- the established way of doing it is threatened by it."
But Miami orthopedic surgeon Alvin Stein, one of the state's experts, said Bonati repeatedly operated on normal spines.
Stein reviewed 16 of 21 complaints pending against Bonati at the state Department of Health.
Some of Bonati's surgical patients had disc bulges of 2-3mm, which Stein said is within the normal range.
Calling a 2mm bulge in a short, obese patient "pathological" was "absolutely criminal," Stein wrote, adding that "there is no justification for any surgical intervention."
Stein accused Bonati of "ping-ponging" patients from test to test, procedure to procedure, to jack up costs. The tests are performed at Bonati's companies, as are the surgeries and physical therapy sessions.
In one case, a patient underwent repeated operations and tests as well as an MRI of the thoracic spine, two MRIs of the lumbar spine, two MRIs of the cervical spine, two MRIs of the shoulder and an MRI of the brain.
"I cannot find the reason why this MRI of the brain was done," Stein wrote. "However, it was one part of the body that hadn't been MRI'd."
Stein claimed Bonati's patient records were "patently false" and "embellished" and "fabricated . . . from a computer. "Dr. Bonati seems to be fixated on every single condition in the neck or back being associated with a discal bulge that is associated with nerve root compression," Stein wrote in one report.
As a result, he wrote, Bonati tends "to fit everybody with one brush: everybody has a nerve root problem, everybody has a disc that needs a laser. . . ."
In one case, Stein said, Bonati "dysrupted" a disc, then performed repeated surgeries to correct the problem. "Once he dysrupted it himself, it was always going to be dysrupted," Stein wrote. How Bonati's surgery "could be of any value after the disc has already been dysrupted by his surgery is beyond my comprehension and is purely an unnecessary surgery fraudulently introduced into the patient."
Stein accused Bonati of billing patients for as many as four procedures during the same operation. He said billing for a general anesthetic, then a regional anesthetic during a single surgery was "truly fraudulent."
Tunnicliff called Stein's reports "very inflammatory" and very wrong.
Bonati did not subdivide surgeries to generate extra bills, she said; he merely described each procedure separately in his surgical notes. If Stein had reviewed Bonati's billing records, Tunnicliff said, he would have found appropriate charges.
She said none of the state's experts uses Bonati's procedure; therefore, none has the familiarity necessary to pass judgment.
Moreover, four patients named in the state complaints were satisfied with their care. They hadn't criticized Bonati; three complaints were filed by doctors hired by the patients' insurance companies.
Bonati has claimed that his regulatory problems were created by the insurance industry, arguing in a 1994 hearing that one state expert "has especially been used against me by the insurance industry to stop new development because it costs them money."
As for the claim that Bonati operated on normal spines, Tunnicliff said, "we have experts that say just the opposite."
Indeed, in 1995, the Board of Medicine dropped charges that Bonati exploited patients and delivered substandard care, after three board-certified orthopedic surgeons testified on his behalf, including the former orthopedics department chair at Bowman Gray, where Bonati served his residency. The board did cite Bonati for poor record keeping.
According to Ms. Tunnicliff, what registers as a 2mm bulge on an MRI may be larger than that, because MRIs are "taken when the patient is laying down, without any weight bearing" on the disc. Bonati finds problems that aren't visible on an MRI, she said, because he uses a scope to see the disc close up.
"Very few people are doing this," Tunnicliff said, mentioning two others in the field: Dr. John C. Chiu of Thousand Oaks, Calif., and Dr. Anthony Yeung of Phoenix.
Chiu and Yeung are certified by the same boards as Bonati, boards that are not sanctioned by the American Board of Medical Specialties. In fact, the two lead the American Academy of Minimally Invasive Spinal Medicine and Surgery, the 44-member group holding its first-ever World Congress in Las Vegas next month.
Back before the board
Despite Stein's critical findings, the state's case against Bonati had soft spots. Many of the 21 complaints date to the 1980s and early 1990s.
Some of the experts' criticisms could be considered violations of the state's medical practice act only under the strictest interpretation of the rules, said Bill Parizek, spokesman for the Florida Department of Health. Doctors can and do disagree on what constitutes appropriate patient care.
Rather than take the complaints to trial, the opposing attorneys negotiated a settlement: Bonati was to pay a $100,000 fine and have his work monitored by another physician for two years.
After hearing the proposed settlement of the 21 current complaints, board member Zachariah Zachariah erupted.
"I am appalled at the Department (of Health) as to why they could come up with such a lousy settlement," he said at the June meeting.
Unanimously, the board voted it down and agreed instead to try to yank Bonati's license to practice medicine.
The licensure hearing is scheduled in February.
This wasn't the first time a state case against Bonati ran into trouble.
Since 1989, 18 other complaints, organized into five separate actions, have been brought before the medical board.
The complaints ranged from false advertising to poor record keeping to administering a drug without determining if the patient was allergic to it.
Four complaints were dismissed, two ended with letters of concern and probation, one with a letter of guidance, and 11 with a reprimand.
Hanging over Bonati's head are at least 35 pending malpractice complaints that could result in damages totaling $130-million, according to court records.
The claims have been piling up since 1996, when one malpractice case ended with a jury award of over $3-million. As the jury was reaching its verdict, Bonati and Gulf Coast asked the bankruptcy court for protection from their creditors.
Six months later, a federal judge said the jury's award was "grossly excessive and without support in the evidence." He tossed out the verdict and ordered a new trial.
The trial has been on hold for four years while Gulf Coast has been under the protection of the bankruptcy court.
In that time, Gulf Coast has filed seven plans to reorganize its debt, none of which has been accepted.
Bonati, meanwhile, has been paid $420,000 a year by Gulf Coast and "tens of thousands of dollars . . . every month" by affiliated corporations, according to the U.S. trustee. Bonati's other companies include Medical Development Corp., which owns the Hudson surgical building, GCOC Physical Therapy and American Medical Care, an anesthesiology group.
For months, the trustee and the attorneys for Gulf Coast and its creditors have been trying to bring the bankruptcy case to a close.
One solution, suggested at a hearing last month, is a settlement: Gulf Coast would provide a sum of money to be divided among the creditors, including the former patients with malpractice claims.
If a settlement isn't reached, Gulf Coast, which could generate $12-million in business this year, could be liquidated and its assets sold to satisfy creditors.
The assets include the MRI building, the imaging equipment, office furniture, the money owed by patients for services rendered and more than $2-million in loans to Bonati and his other businesses.
The bankruptcy court also could find that Gulf Coast and the other Bonati companies, which together employ more than 50 people, act as a single entity, whose assets should be distributed to creditors.
Or, the judge could simply dismiss the case, which would throw the malpractice claims back to the civil courts for trial.
Last summer, Kevin O'Halloran, an examiner appointed by the bankruptcy court, combed through Gulf Coast's records.
In his August report, O'Halloran said he was "concerned" that:
Cash payments from Bonati's Amsterdam patients weren't showing up immediately in the books of Gulf Coast.
A company traceable to Bonati's good friend and promoter, the Rev. Sam Bailey of Mountain Home, Ark., was paid "considerable" amounts of money without court approval.
Bonati had made no effort to repay more than $1-million loaned to him by Gulf Coast before the bankruptcy filing.
Since the filing, Gulf Coast has made donations to the alumni fund of Bonati's alma mater and has paid for Bonati to drive a Lamborghini valued at $132,000.
All of these issues could come to the fore today at a 9 a.m. hearing before U.S. Bankruptcy Court Judge Alexander L. Paskay.
1969 -- Alfred Bonati, 30, graduates from the University of Seville medical school in Spain.
1977 -- Bonati begins his residency in orthopedic surgery at Bowman Gray School of Medicine in North Carolina.
1981 -- Bonati opens his Gulf Coast Orthopedic Center after obtaining his Florida medical license.
1983 -- Bonati flunks the certification exam of the American Board of Orthopaedic Surgery.
1988 -- He forms his own board, the Arthroscopy Board of North America, which certifies him as a specialist in the field.
1991 -- Bonati forms companies to market his surgical instruments and publishes a book: No More Back Pain.
1992 -- The St. Petersburg Times publishes a report about Bonati's effort to purchase the former Sun Bay Medical Center in St. Petersburg and recounts patient complaints against him. Bonati sues the newspaper for defamation.
1994 -- In its third case against Bonati since 1991, the Florida Board of Medicine issues a letter of concern and puts him on two years' probation.
1995 -- Bonati builds a following in Amsterdam after a film on his institute is shown on Dutch television.
1996 -- A federal jury awards a Hernando County woman $3.1-million in her malpractice lawsuit against Bonati. He and Gulf Coast Orthopedic Center seek protection in U.S. Bankruptcy Court. The jury award is later thrown out and a new trial is ordered. In the meantime, the Florida Board of Medicine hears two more cases against Bonati. One is thrown out, the other ends in a reprimand.
1997 -- Bonati's suit against the Times is dismissed on technical grounds. Meanwhile, patient Linda West touts Bonati in her hometown of Mountain Home, Ark., where Bonati opens an office and meets Annette and Sam Bailey, who become his good friends and promoters.
1999 -- The Retired Players Association of the National Football League adds Gulf Coast Orthopedic Center to its list of recommended treatment facilities for its members.
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