The pain from the pinched nerve in the back of Jeff Glidewell's neck had become unbearable. Every time he would turn his head a certain way, or drive over bumps in the road, he felt as if jolts of electricity were running through his body.
Glidewell, now 54, had been living on disability because of an accident a decade earlier. As the pain grew worse, it became clear his only choice was neurosurgery. He searched Google to find a doctor near his home in suburban Dallas who would accept his Medicare Advantage insurance.
Duntsch seemed impressive, at least on the surface. His CV boasted that he'd earned an M.D. and a Ph.D. from a top spinal surgery program. Glidewell found four- and five-star reviews of Duntsch on Healthgrades and more praise seemingly from patients on Duntsch's Facebook page.
On a link for something called "Best Docs Network," Glidewell found a slickly produced video showing Duntsch in his white coat, talking to a happy patient and wearing a surgical mask in an operating room.
There was no way Glidewell could have known from Duntsch's carefully curated internet presence or any other information than publicly available that to be Duntsch's patient was to be in mortal danger.
In the roughly two years that Duntsch, a blue-eyed, smooth-talking former college football player had practiced medicine in Dallas, he had operated on 37 patients. Almost all, 33 to be exact, had been injured during or after these procedures, suffering almost unheard-of complications.
Some had permanent nerve damage. Several woke up from surgery unable to move from the neck down or feel one side of their bodies. Two died in the hospital, including a 55-year-old schoolteacher undergoing what was supposed to be straightforward day surgery.
Multiple layers of safeguards are supposed to protect patients from doctors who are incompetent or dangerous or to provide them with redress if they are harmed. Duntsch illustrates how easily these defenses can fail, even in egregious cases.
Neurosurgeons are worth millions in revenue for hospitals, so Duntsch was able to get operating privileges at a string of Dallas-area institutions. Once his ineptitude became clear, most chose to spare themselves the hassle and legal exposure of firing him outright and instead let him resign, reputation intact.
At least two facilities that quietly dumped Duntsch failed to report him to a database run by the U.S. Department of Health and Human Services that are supposed to act as a clearinghouse for information on problem practitioners, warning potential employers about their histories.
"It seems to be the custom and practice," said Kay Van Wey, a Dallas plaintiff's attorney who came to represent 14 of Duntsch's patients. "Kick the can down the road and protect yourself first, and protect the doctor second and make it be somebody else's problem."