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  Anthony actually thought the trip went well. He presented a paper on a bizarre patient he had treated, a man he said had tried to commit “suicide by scissors.” The patient had driven the scissors’ blade tips into both his eyes. Anthony had worked on him for more than nine hours and had saved not only the patient but his eyesight. Anthony’s paper on the procedure was well received, and he was elated.

  But in June 1991, Anthony’s evaluation at Thomas Jefferson was so negative that once again he failed to be invited back for the second year of a residency program. That made him ineligible to sit for the American Board of Otolaryngology examinations. Once again, he had failed to complete a program. He was an M.D., but it was unlikely he would get hospital privileges—a kiss of death for a physician.

  Residents are expected to achieve at least a grade of 4 on a 1 to 5 scale evaluating their skill in otolaryngology. The records of his evaluation by teaching doctors gavel scores of 1 to 2.5. They commented on his performance in brutally frank terms. One termed him a “medico sociopath,” while another wrote “major questions regarding integrity raised by a large number of resident peers.” Many of the physicians who worked with Anthony found that he had a severe deficit in basic knowledge of the speciality of otolaryngology.

  For all of his boasting about his own brilliance and skill, when Anthony took the preparation test for the Board Certification test, he scored abysmally low. His raw score was in the 20th percentile, and was only in the 7th percentile for a resident in his year of standing, and in the 3rd percentile of his “year group.” Ninety-seven percent of his fellow residents in their senior year of otolaryngology scored higher than he did.

  But his peers were his harshest judges. Anthony was dead-on when he complained that nobody liked him or listened to him. “Simply put,” one resident wrote, “he is unreliable, poorly informed, dishonest and dangerous…do not rehire…the responsibility is too great, the risks innumerable…I fear that lives are truly at stake…”

  Other evaluations were just as damning: “I found many errors in patient care…His response was that ‘It could happen to anybody’…A major problem with Tony is that he will not change his behavior, even if he is directly confronted with a problem…I feel that he has no detectable positive attributes as a physician.”

  “I find him to be dishonest, manipulative and conniving. He has demonstrated a lack of fundamental medical knowledge…his dishonesty and lack of medical knowledge combined with his arrogance make him dangerous.”

  Anthony Pignataro was finished with residencies. He vowed that he would never go through another two-year program.

  “He believed in his mind that he had completed the process,” Debbie said. “We moved back to Buffalo, and he prepared to hang his shingle as an expert in otolaryngology in West Seneca.”

  Despite her doubts, and without full knowledge of why her husband had not been asked to return to the Thomas Jefferson program, Debbie Pignataro tried very hard to believe that their future had begun. Even though life hadn’t happened quite the way she pictured it, she had long since grown accustomed to accepting life the way it was.

  Part Three

  Private Practice

  4

  It was wonderful to be back in Buffalo. It was home, where everyone was wrapped up in ice hockey with the Buffalo Sabres, baseball with the Buffalo Bisons, and football with the National Football League’s multichampion Buffalo Bills, where O.J. Simpson was once a revered hero. Debbie and Anthony watched the thousands of tiny white lights illuminate the Peace Bridge to Fort Erie, Ontario, and they ate the best pizza in the world, Buffalo wings, and “beef-on-a-wick,” the thinly sliced roast beef on a Kimmelwick roll that was Buffalo cuisine. The air smelled of honeysuckle and the salty spray of Lake Erie.

  Debbie felt as if she had finally come out of a long dark tunnel. She didn’t have to pack up the kids and move any longer, and she could be close to her mother and brother. Anthony assured her again and again that he didn’t need any more of the controlling, prejudiced, two-year residencies. After all, he’d spent almost five years trying to fit into their stupid, confining little boxes, and he knew more than the lot of them. He was ready to treat patients in his own practice. Debbie wanted to believe him; the stress of his repeated failures in his two-year programs was almost too much to bear—for either of them.

  Anthony didn’t want to join a group practice or a health maintenance organization (HMO)—if, indeed, he was eligible. And there was his own research.

  “I needed to pursue my own ideas,” he recalled. I needed the freedom to go to the lab at my own discretion. I could not be held down by the demands of a group, where the youngest physician members obtain the least amount of personal time.”

  Once again, Debbie and Anthony were living with his parents—but that was all right; they would soon have their own home. Ralph Pignataro had always helped and mentored his son, and he was still there for him. If he was disappointed by Anthony’s scholastic and residency-program failures, he didn’t speak of it.

  After a few weeks, the younger Pignataros moved into a small two-bedroom apartment of their own. They planned to build a starter house to live in while they paid off some of their debts and saved up enough to open their own clinic.

  Anthony’s father and his best friend owned several acres of land in West Seneca, not far from Dr. Ralph’s home. It was zoned for residential building, and the older men envisioned streets lined with new home construction as Buffalo’s burgeoning population spread to the western suburbs.

  Anthony and his brother Steve were given one lot along the otherwise empty street. They borrowed money to start construction on a duplex. Steven would live on one side of the three-story duplex, and Anthony and his family on the other. Although they would contract most of the actual labor out, they would oversee the building. Anthony and his brothers had worked summers in construction when they were teenagers, and they understood the principles of building.

  It wasn’t a good summer. Buffalo is usually hot and sunny all summer, but in 1991, rain came down in torrents, making the project take longer and longer as the brothers slogged through a sea of mud. They finally set their moving-in date for February 1992.

  It wasn’t a good omen when Debbie and Anthony stopped to check their new house three days before their moving date and found that someone—probably teenagers—had broken in through a basement window. Since their place was the only home on the long street, it was a natural target for someone looking for a spot to have a beer bust. Empty bottles littered the interior. Their unwelcome visitors had vandalized the house, smearing linoleum glue on the walls, cabinets, and carpets. Debbie sobbed. They had been so close to having a home of their own, and she knew that their insurance wouldn’t cover their losses. They would have to tear up the brand-new carpet and replace it.

  Anthony was enraged, and rightly so. He slept on a cot in the empty house every night to be sure that no one broke in again.

  Finally, in March, after living for nine months in a cramped apartment, and for years without a real home of their own, they moved in. It was lonely for Debbie at first. There were no neighbors to have coffee with, and no grocery stores close by. But they were close to her in-laws, and she and Lena were by now good friends. Caroline Rago wasn’t far away, either, although Anthony wasn’t enthusiastic about Debbie spending much time with her family. Caroline had to work, and her visits were limited to weekends.

  They settled in. Anthony was now completely free to work on his plans to be granted hospital privileges, where he would meet future patients. He applied to several hospitals in western New York, telling them that he was eligible to sit for the otolaryngology boards. But it was simple enough for the hospitals to verify this—and most of them did check and found it wasn’t true. Anthony had never been notified that he had achieved this eligibility, and he was bluffing.

  Anthony found a way in, at least temporarily. An elderly physician in Warsaw, New York, was recovering from a coronary bypass and als
o had diabetes and hardening of the arteries. He needed help with his small country practice. The older doctor, a native of India, offered Anthony a job assisting him for two or three days a week. It meant an income to add to Debbie’s, and that was important. Anthony applied for loans to remodel an office he leased in West Seneca for his primary practice.

  Largely because he was helping a well-known local doctor, Anthony was given conditional privileges at the Wyoming County Community Hospital in Warsaw, almost forty miles east of Buffalo.

  Debbie set up Anthony’s office books and did all the paperwork for his fledgling practice. There were considerable expenses in setting up a solo practice. Beyond the office and examining room furniture and equipment, there was malpractice insurance, and leasing fees for the equipment Anthony could not afford to buy outright. In time, he would need to hire office personnel and medical assistants. Debbie was doing everything she could to help him get started. For the moment, they were on a shoestring budget.

  Anthony planned an operating room in the basement of his building. That might take a while longer, but he wanted to get to a place where he was autonomous and would never again have to depend on anyone but himself. If he had his own operating room, it wouldn’t matter if hospitals didn’t accept him. Of course, he didn’t include his father as someone he didn’t want to depend on. His father’s approval and support were vital to him.

  Even in the beginning, Anthony designated Wednesdays as special days set aside for his “current research endeavor.” His ultimate goal had always been plastic surgery. As he had said, it was “the perfect match of his intellect and his artistry.”

  For now, he treated patients with ear, nose, and throat problems, and most of the time, he seemed to be competent. At last, the Pignataros were enjoying a comfortable, if not luxuriant, lifestyle.

  Ralph was 5 and in kindergarten. Without discussing it with Debbie, Anthony bought a German shepherd puppy, which he named Polo. Ralph had been named for his grandfather, and Debbie had chosen the name Lauren because she liked it. Polo’s name was Anthony’s little joke because of the “Ralph-Lauren” combination: a dog named for a men’s cologne. The dog grew to be huge—too big for Debbie to handle—but Anthony pointed out that Polo was a good protector for their household.

  “Anthony always had a dog when he was a kid,” Debbie said. “But he was so mean to Polo. He didn’t train him, and when Polo did something to irritate him, Anthony would hit him or kick him.”

  Polo remained loyal to Anthony, and Ralph loved the big dog.

  Anthony was determined to be board-certified, if only for economic reasons. Patients with any savvy knew enough about specialists to ask that vital question. Reference services were more likely to recommend board-certified physicians. He attended a few seminars, and he read medical journals with articles about plastic surgery. He usually traveled to seminars on his own because Debbie was so busy with Ralph and Lauren. He was piling up hours of study, although some of the conferences he attended were too experimental to qualify as continuing medical education (CME) courses.

  Part of Anthony’s Wednesday research was grotesque. He worked on female cadavers as he experimented with underwires beneath the skin to maintain breast implants. He even thought he might be able to bypass implants entirely. He wanted to come up with techniques he could use when he was doing breast plastic surgery—something that would make him appeal to the mass of prospective patients who were looking for plastic surgeons.

  But perhaps more than anything, Dr. Anthony Pignataro wanted to be famous, renowned for his brilliance and innovative thinking. He still thought of himself as a “modern-day Galileo,” a man of such vision that he saw far beyond the ordinary man’s imagination.

  Most of his research didn’t concern life-threatening illnesses. Rather, he was almost entirely focused on ways to improve the physical appearance of his future patients. The way he looked mattered so much to Anthony that he assumed everyone was as self-focused.

  In the meantime, Anthony’s practice was growing, but his conditional privileges at the Wyoming County Community Hospital ran out in September 1994. The official reason was that he was still not eligible to take the otolaryngology board exams. However, there may have been another reason.

  One of the most delicate procedures in otolaryngology is surgery in the frontal sinus area. Only a paper-thin layer of bone separates the sinus area at the top of the nose from the brain itself, and any surgeon operating there must have a steady and educated hand.

  On August 3, 1994, Anthony operated on a deviated septum (the center cartilage in the nose) in a 30-year-old man. He clumsily entered the outer layer of the brain, a critical mishap that greatly increased the patient’s susceptibility for brain abscess, meningitis, and nerve damage. In this case, the patient’s brain fluid actually leaked into the nasal passages, but Anthony told no one and sent the patient home from day surgery.

  A senior otolaryngologist who studied the case reported that there were serious questions, of both “omission” and “commission,” about Anthony’s surgical technique. The specialist questioned whether Anthony had the credentials to continue doing endoscopic sinus surgery.

  The following day, Anthony’s hospital privileges were canceled. He was fortunate that the young man with the deviated septum didn’t develop deadly meningitis.

  In 1992, Anthony had fortuitously added a second hospital that gave him temporary operating privileges, Our Lady of Victory Hospital. But in February 1993, Anthony operated on a seventy-one-year-old patient who agreed to elective surgery to remove a laryngeal tumor for biopsy. It was, in some aspects, a routine procedure, but any time a patient is operated on deep in the throat, his main route to get oxygen to the lungs can be compromised. Sensitive tissue can swell or hemorrhage.

  Anthony’s patient died.

  A hospital board reviewed the operation and immediately restricted his privileges. After that, he was not allowed to do elective procedures involving the airway after 1:00 P.M., and before that hour, he had to be monitored. The chief of surgery and chief of otolaryngology met with Anthony to explain that it was extremely important not to disturb laryngeal tumors any more than necessary, and that he should have been prepared for swelling and excessive bleeding at the site of surgery.

  Anthony was indignant that they should lecture him as if he were a mere intern.

  Anthony’s privileges at Our Lady of Victory expired in September 1993, and the hospital did not renew them.

  Anthony no longer had any hospital where he was welcome to operate or treat patients. He applied for privileges in otolaryngology and plastic surgery in Irving, New York, and at Buffalo Mercy Hospital. He wasn’t accepted because he had no proof to back up his statement that he was board-certified in those specialties.

  Anthony suspected that one of the department chairmen at Thomas Jefferson Hospital in Philadelphia might be blocking him by failing to endorse him as a doctor of good moral character worthy of taking the board exams. He fought back by suing his last training hospital and the chairman.

  Thomas Jefferson submitted the names of seven ear, nose, and throat specialists to serve as arbitrators. Any one of them was competent to evaluate Anthony’s level of skill in this speciality.

  Characteristically, Anthony balked. He came back with his own list of three otolaryngologists. That was no problem for Thomas Jefferson Hospital; they agreed to let the matter be decided by the very first doctor on Anthony’s list.

  Although Anthony was intelligent enough, he was ultimately self-defeating. In his rage at anyone who had the temerity to block him from doing what he wanted, he often failed to reason things out carefully. He apparently expected the past to disappear into a kind of mist where no one remembered details.

  “Dr. H.,” the physician whom Anthony himself had chosen, set about gathering statements that were either for or against the subject. He interviewed specialists who had worked with Anthony Pignataro. Usually physicians tend to close ranks and protect each oth
er. So many things can go wrong in diagnosis, treatment, and surgery that they are hesitant to point fingers at other doctors, knowing that they too could make mistakes. Not this time.

  In the end, Dr. H.’s report was scathing. The doctors who had worked with Anthony in Philadelphia recalled that he was lazy and slipshod when he came into the residency, and that he never improved while he was there. “He would routinely show up late for rounds, claiming he had done work he had not done, say he had seen intensive care unit (ICU) patients that he had not seen, fabricate laboratory data, fabricate physical examination data, fabricate information about postoperative patients that he had not seen. This was routine…”

  Anthony scoffed at his evaluation. “If I had been such a bad doctor…practicing for four years…If I were as bad as I’m made out to appear, I’m sure that something would have happened by now.”

  As indeed it had. More than one “something” had happened. He had simply forgotten the dead biopsy patient and the young man whose brain had been pierced by an errant blade.

  Dr. H. said that no one at Thomas Jefferson should be compelled to recommend that Anthony take the otolaryngology board exam. He concurred that Pignataro was in no way qualified for either skill or good moral character. Stung, Anthony challenged the findings of the arbitrator he himself had chosen, and he requested a review in federal court.

  In May 1995, Anthony withdrew his lawsuit, and it was dismissed.

  Actually, he cared very little about the practice of otolaryngology. It was only a stepping-stone for him on his way to plastic surgery. He had had minimal formal training in that delicate art, although he still attended every conference he could afford where plastic surgeons gathered. He leaned toward techniques that were more experimental than accredited. Aware that there was a lot of competition in plastic surgery, Anthony focused on procedures that were new and dramatic, something that would attract patients to him.