See No Evil

[AF M4]

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[orbitsurgMD]

So a quandary has arisen at my clinic.

We have a one-year wonder GMO who functions as a SME at my base. He's sort of a mascot for his squadron, and is generally popular with his squadron, patients, and the line. For the first year or so that he was on base, we had no problems.

Over the last couple of months though, he's created at least three medical incidents that have the hairs on the back of my neck standing up. All three involve him making solo attempts at medical and sometimes surgical procedures that he has little to no training in and is not credentialed for. In one such incident the patient suffered what is likely to be permanent but luckily not disabling nerve damage.

When I confronted him about these things and the danger of what he was doing, he shrugged and blew me off. When I brought the matter up to the SGH, he was appropriately angry and immediately called the GMO for an explanation. The GMO apologized and confessed to his unfamiliarity with the procedures, then said that he thought that he was credentialled to attempt them but hadn't actually checked.

Today I found out that he took a crack at another one, and the patient is now in the hospital due to a post-operative infection. After screaming expletives at him for a good five minutes and nearly punching his face in, he again shrugged it off and tried to rationalize what he did. The SGH also chewed on him again, but has not done anything to his privileges. I have pulled him from the clinic schedule; however since the GMO was doing these procedures off the grid (i.e., outside of the clinic) in the first place, this is hardly going to prevent him from doing more experiments. In fact, the last time I saw him he was happily tossing back a few at the bar, laughing with one of the guys who is now injured because of him.

I've got a very bad feeling that things are spiralling out of control with this guy, and the next time he tries something it will be downrange where there's no one to protect patients from him. I've already attempted the conventional avenues; now what?

What exactly is your responsibility, here? Are you formally supposed to be supervising this doctor? Are you being asked to assume care of patients he has seen and you think he has harmed by his alleged negligence?

I understand your concern, but if you are not the person who has any formal responsibility to supervise this individual's work, then it seems to me you have done all you should do, which is to express your concern to someone who does have supervisory authority. You have expressed your concern to those in charge that the doctor in question is exceeding the limits of his training, experience and privileges. Making a personal campaign of objection, when taken too far can easily become an issue of slander and a liability for you.

I understand in the light of Ft. Hood that perceived inaction by supervisors may have consequences to many not yet involved, and that can be true. If you think the supervisor is not taking appropriate action, go to the MTF CO and ask for formal clarification to everyone what can and cannot be done under the privileges of the clinic.

 

[AF M4]

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[IgD]

From the description it sounded like a problem with outpatient surgical procedures. I think ideally any concerns should come from the specialty clinic that have seen the patient for the complication.

The surgeon could counsel the GMO directly and if that didn't work go over his head. I was with a Marine unit. If there were issues like this, it would go to the Division, Wing, Group or possibly the MEF Surgeon who was the top of the food chain.

The surgeon could also go to the hospital commander. I suspect the hospital commander would then go to the Division, Wing, Group or MEF Surgeon and ask for a review.

 

[NavyFP]

This does need to go up the medical chain. His credentials need to be pulled.

 

[orbitsurgMD]

This does need to go up the medical chain. His credentials need to be pulled.

That would seem to be part of the problem: per the OP, the GMO wasn't credentialed to be doing these procedures in the first place. It is hard to take away what was never given.

The Medical Director needs to get involved and review the incidents in question.
If it is true that the GMO was told not to do certain procedures while under the authority of the clinic, and he did them anyway, then this is a disciplinary matter. If he was doing the procedures in a setting outside the clinic, and he has more than one chain of command, then it is up to the responsible chain of command to issue limits on his activities and to seek guidance from appropriate professionals if they are not properly equipped to interpret the facts of the case.

 

[AF M4]

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[IgD]

I think you've got to look at it from a professional development perspective too. Part of medical education is learning limits. It's hard to know what you can do and can't do with only one year of training. Hopefully the GMO would be someone who could benefit from mentoring.

I was curious too, I wonder if he had a physician mentor somewhere that was encouraging him to do these procedures...

 

[NavyFP]

That would seem to be part of the problem: per the OP, the GMO wasn't credentialed to be doing these procedures in the first place. It is hard to take away what was never given.

The Medical Director needs to get involved and review the incidents in question.
If it is true that the GMO was told not to do certain procedures while under the authority of the clinic, and he did them anyway, then this is a disciplinary matter. If he was doing the procedures in a setting outside the clinic, and he has more than one chain of command, then it is up to the responsible chain of command to issue limits on his acticvities and to seek guidance from appropriate professionals if they are not properly equipped to interpret the facts of the case.

I mean all of his priviledges. He should not be allowed to perform patient care, period. There is also the possibility of UCMJ action for dereliction of duty.

 

[orbitsurgMD]

I mean all of his priviledges. He should not be allowed to perform patient care, period. There is also the possibility of UCMJ action for dereliction of duty.

As none of us posting have all of the facts, I am not ready to agree with that recommendation. It is not quite clear that any specific limits were established as to what the GMO in question was told, was privileged to do or was told to do or not do, before or after these incidents occurred.

Remember also that complications are not necessarily the result of negligence, although they certainly can be, and not being trained to do certain procedures places an unusual burden on the performing physician, particularly one acting alone in a presumably elective setting, of explaining why the patient was not referred to a physician who was trained to do the procedures.

Reckless indifference to one's own limitations in training and experience is always a bad thing. Poor judgment in understanding and acknowledging one's professional limitations is another.

The entire enterprise of having GMOs creates risks that should not be present: asking incompletely trained physicians to effectively practice independently and to know things they may never have had the chance to learn in what would be a continuum of residency training under better circumstances. Asking them to police themselves and to limit their own clinical scope is no better. Just as bad is the institutional fraud of "core privileges" established for GMOs who may not have any experience, or certainly not enough experience to do things they are being asked to do. I place the blame squarely on the medical departments of each of the services for that: it is organized, deliberate professional wrongdoing. The fact that they have done so for a long time, or that they can get so many people in the medical corps to collude with it does not make the practice one bit better or more appropriate. It really is a sign of widespread organizational corruption in the military medical departments.

 

[AF M4]

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[AF M4]

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[IgD]

As none of us posting have all of the facts, I am not ready to agree with that recommendation. It is not quite clear that any specific limits were established as to what the GMO in question was told, was privileged to do or was told to do or not do, before or after these incidents occurred.

Exactly. I recommend caution to avoid an unnecessary witch-hunt.

 

[IgD]

This of course exacerbates the problem with GMOs in general, as young officers see their more senior counterparts giving the finger to the hard work of gaining and maintaining clinical knowledge and then still being rewarded with promotions and cush administrative positions. It is difficult to keep from being corrupted in such an environment or to take patient care seriously when there is no punishment for neglecting it completely.

Well I found the same to be true for the MTF environment. The docs there were very comfortable, dumped a lot of work on the GMOs and didn't want to support the operational community.

 

[Gastrapathy]

Good on you for having the courage to protect our patients.

This can be a very long process and could get acrimonious. Take a minute and create some notes for yourself (dates, events, involved parties and when you notified various people). So, six months from now, you can remain clear on the details and not get "caught in a lie" (that was, in fact, a trivial honest mistake). Save any relevant email. Keep any notes on patient encounters you have with someone he saw precise and sterile (nothing editorial).

Finally, if, at the end of the day it is swept under the rug, you will face a difficult decision. I can't presume to advise you how to proceed at that point.

If he loses his privileges, he will have to report that on every application he fills out for the rest of his career in and out of the .mil. It is a severe and meaningful punishment.

 

[orbitsurgMD]

Good on you for having the courage to protect our patients.

This can be a very long process and could get acrimonious. Take a minute and create some notes for yourself (dates, events, involved parties and when you notified various people). So, six months from now, you can remain clear on the details and not get "caught in a lie" (that was, in fact, a trivial honest mistake). Save any relevant email. Keep any notes on patient encounters you have with someone he saw precise and sterile (nothing editorial).

Finally, if, at the end of the day it is swept under the rug, you will face a difficult decision. I can't presume to advise you how to proceed at that point.

If he loses his privileges, he will have to report that on every application he fills out for the rest of his career in and out of the .mil. It is a severe and meaningful punishment.

If the services gave a damn about quality or protecting the patient in the first place, there would be no GMOs. The canard of quality assurance, and worse, the use of adverse privileging action on an individual who should not and if had a choice likely would not be working independently as a "one-year wonder" is utterly condemnable.

The military medical services are to be condemned twice for this kind of thing: first for having GMOs at all and second, for creating the fraud of quality assurance when they subvert it's very foundations by withholding physician training.

This kind of thing has gone on forever. It is outright condemnable, as are the leaders and senior medical people who promote or acquiesce to it.

 

[Gastrapathy]

If the services gave a damn about quality or protecting the patient in the first place, there would be no GMOs. The canard of quality assurance, and worse, the use of adverse privileging action on an individual who should not and if had a choice likely would not be working independently as a "one-year wonder" is utterly condemnable.

The military medical services are to be condemned twice for this kind of thing: first for having GMOs at all and second, for creating the fraud of quality assurance when they subvert it's very foundations by withholding physician training.

This kind of thing has gone on forever. It is outright condemnable, as are the leaders and senior medical people who promote or acquiesce to it.

Its not that simple. Having a basic grasp of your limitations isn't something you magically figure out as an R2. You never would have done a procedure that you weren't credentialed for during internship, so why is it ok as a GMO?

I agree that we should protect GMOs (particularly deployed GMOs) who make mistakes. But, some conduct goes beyond that. The guy was warned and kept misbehaving. To me, that suggests an underlying problem that is better addressed sooner than later. You don't get a free pass.

This is totally different than the GMO who misdiagnoses acute leukemia as msk back pain or that sort of thing. This is someone deliberately going beyond his scope of care and justifying it by saying he thought he was credentialed. I don't care if you are an MS1 or a 25 year attending. That is unacceptable conduct.

I'm not sure how I feel about GMOs but it is fair for there to be some standard of conduct.

 

[Gastrapathy]

Exactly. I recommend caution to avoid an unnecessary witch-hunt.

None of us are there or will ever know the particulars. Obviously, we only have M4s account but that doesn't mean he's wrong. Ultimately, this is a decision that M4 needs to make. When does an unnecessary witch hunt become an appropriate response to repeated malpractice?

Its this attitude of avoiding conflict at all costs that is why the military can be a haven for incompetent physicians.

 

[orbitsurgMD]

Its not that simple. Having a basic grasp of your limitations isn't something you magically figure out as an R2.

Perhaps, so why assume it to be the case for an R1? There may be a lot of procedures one might capably learn to do as an R1, along with non-procedural activities and treatment plans. Having done them in a teaching hospital setting, with senior residents and attending faculty available and expected to be assisting when necessary and supervising regardless should not imply that one is then ready to do such things by oneself and without any supervision. I might have done a dozen or more appendectomies as an R1 as primary surgeon, but that doesn't mean I ought to be doing them by myself. The GMO "core privilege" process implies just that, and it is inappropriate wholly and on its face.

you weren't credentialed for during internship, so why is it ok as a GMO?

Exactly. And that goes for more than just procedures. Why is a GMO allowed to sign off on an outpatient treatment plan when a R2 in primary care clinics would be under a chart review, at a minimum?

I agree that we should protect GMOs (particularly deployed GMOs) who make mistakes.

What the services should really do is train their junior physicians, just like any respectable civilian institution would do, as a resident physician.

But, some conduct goes beyond that. The guy was warned and kept misbehaving. To me, that suggests an underlying problem that is better addressed sooner than later. You don't get a free pass.

Isn't that what supervisors in residencies are supposed to do? If a R2 in a FP residency decided on his own to start doing procedures he wasn't yet trained to do, someone would stop him. If he persisted after being told to stop, he would be disciplined, even fired.

This is totally different than the GMO who misdiagnoses acute leukemia as msk back pain or that sort of thing. This is someone deliberately going beyond his scope of care and justifying it by saying he thought he was credentialed. I don't care if you are an MS1 or a 25 year attending. That is unacceptable conduct.

Look, if the guy is a sociopath who operates on patients without proper training, tells them he is qualified when he is not, disobeys direct orders not to perform procedures he isn't qualified to do, then he needs to be stopped. But it has to be crystal clear to everyone what is and is not allowed. If a R1 did 100 outpatient vasectomies in his urology clinic month of his GS internship, and on the core privileges page he initialed there is nothing about doing vasectomies and likewise nothing about not doing vasectomies, the command has a job set out for it to show why he shouldn't be allowed to do that procedure. I am not saying they don't have the authority to prohibit vasectomies by non-board-eligible practitioners, but a compelling case on defense of the doctor doing procedures could be made that he wasn't unqualified, at least by the military's own sloppy standards that permit independent practice by one-year-trained GMOs. It seems they want things both ways here.

I'm not sure how I feel about GMOs but it is fair for there to be some standard of conduct.

Unlike you, I have no doubts at all. It is a terrible idea and a wrongful practice. Period.

 

[AF M4]

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[orbitsurgMD]

Yes, I certainly want to avoid an unnecessary witch hunt. Further news is that when justifying his decision to proceed with the operation, the GMO referenced three board-certified physicians who he claimed had shown him how to do similar procedures, so he thought he was capable of acting independently. All of these physicians PCS'd to different bases over the summer but are friendly with both myself and the SGH.

So it was easy enough to contact them to verify the story, and all reported that while they had done minor procedures with the GMO (mole removals, etc.), neither had done anything approaching the scope of the GMO's procedure. Only one had done the actual procedure in the past couple of years, the other two routinely referred it out to a specialist because of the difficulty and risks of complications. They were all quite irritated that their names had been invoked in this manner.

Unfortunately for the GMO, things are starting to pile up.

So it appears that this GMO doesn't have the experience or the judgment to
know what is an acceptable limit to his procedural scope. Having done one or two of a similar procedure with another surgeon is not a reassuring, nor possibly reasonable basis to perform that procedure without supervision.

I can understand the surgeons' irritation at being associated with this inquiry, but as they were not consulting and not supervising, they really have nothing to do with these alleged malpractice events.

My question is why did he bother doing these procedures at all? Sure, if one had an interest, doing a surgery might be tempting, but he gains no credit toward training by what he does unsupervised as a GMO; he gets nothing extra in compensation for doing procedures; the only reason I can see is that he was pressured, either socially or professionally, to accommodate a service member who didn't want to travel or wait for an appointment elsewhere.

It seems to me that this clinic has rules about what can or can't be done that are enforced only when someone actually does something that gets negative attention. I wonder had there never been a complication of his cases, would anyone have bothered to say anything?

 

[IgD]

So it was easy enough to contact them to verify the story, and all reported that while they had done minor procedures with the GMO (mole removals, etc.), neither had done anything approaching the scope of the GMO's procedure. Only one had done the actual procedure in the past couple of years, the other two routinely referred it out to a specialist because of the difficulty and risks of complications. They were all quite irritated that their names had been invoked in this manner.

I would want to know why he did the procedure. Did he have a sincere belief that it was appropriate and he could help the patient? Did he get proper consent? The alternative explanation was he was lying about it and had some kind of sinister motive.

As I recall somewhere in this forum is a thread where a GMO amputated someone's leg on a deployment successfully. Should he lose his privileges?

I'd like to think this was a moment in medical education. Young physician overstepped his bounds, counseled, learned something from it and that is the end of it. I think in the civilian world when someone loses their privileges it's because of either a cardinal sin or a chronic pervasive pattern that couldn't be remediated. Does the situation reach that threshold is the big question.

 

[Perrotfish]

Slightly tangential, but how exactly does one get credentialed to do a procedure? What is the credentialing body? Is it possible to become credentialed in procedures that are not part of your residency training, or to become credentialed in individual procedures despite not having completed residency training?

 

[IgD]

Slightly tangential, but how exactly does one get credentialed to do a procedure? What is the credentialing body? Is it possible to become credentialed in procedures that are not part of your residency training, or to become credentialed in individual procedures despite not having completed residency training?

Generally speaking you've got to apply for credentials. There is a check sheet where you request the privileges. Each specialty has its own set of checks. So for psych there is inpatient, outpatient, ECT, child psych, psychoanalysis and special addiction treatment with suboxone. The credentialing body would decide what is necessary to get the credentials. So for ECT they may require formal training or not. I would be curious what it says for surgery whether there is a check for each type of procedure or whether its just a broad statement. A GMO probably has a broad statement about providing operational and in garrison care.

 

[orbitsurgMD]

Slightly tangential, but how exactly does one get credentialed to do a procedure? What is the credentialing body? Is it possible to become credentialed in procedures that are not part of your residency training, or to become credentialed in individual procedures despite not having completed residency training?

Generally, one gets privileges granted by the facility. A standing committee is responsible for reviewing requests for privileges. (The military uses centralized credentialing.) Usually one has to present documentation of general training in a specialty--a letter of board-eligibility from one's PD or a board certification certificate. Then one has to submit case lists of procedures you have done. One also submits a list of procedures one wishes to do (although in practice, most facilities have a pre-written list based on the specialty, and one can add procedures to that list if they wish.) One can be queried as to the experience one has with unusual procedures, if privileges to do those are requested. And a facility may decline to grant some requests for any reason, but usually it is because the facility perceives the procedure to be one for which they cannot provide adequate support, such as anesthesia or perfusion or some other service.

Getting privileges beyond the scope of a specialty may require having done documented training in that procedure and submitting a case list to support your experience claim. Fellowship experience is one type of supplementary formal training.

 

[AF M4]

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[backrow]

I'm just going to go out on a limb here, but should this really be discussed in a forum such as this?

I realize it's a bit anonymous, but I would bet any lawyer worth his money would be able to figure out who/when/where this discussion is about. (granted they'd have to find it first) Doesn't sound like lawyers are likely here anyway

Anyway, I just wanted to throw that out there

 

[pgg]

As I recall somewhere in this forum is a thread where a GMO amputated someone's leg on a deployment successfully. Should he lose his privileges?

You're probably thinking of me, except I amputated a hand, it was a local national for whom medevac was denied, the next ring flight was days away, I was the only doctor around, and I thought (and 6 years later I still think) his alternative was to walk home and die.

That thread's around here somewhere. We certainly subjected him to some unnecessary risks out of ignorance, risks that didn't really fully click in my brain until I was well into residency, plus probably some risks I still don't appreciate because I'm not a surgeon, but cutting off the hand and improvising a stump was the right decision. I did a few other sketchy things during brief periods of truly unsupported deployment circumstances, but I did them with cold fear not dreams of glory in my heart.

Back in Camp Lejeune I was so conservative that I was accused once or twice of being lazy with my inappropriate consults.

Other GMOs did all sorts of things I wouldn't touch in their battalion aid stations. I don't know if it was boredom (even I would get excited about chopping out a 1 cm lipoma after weeks of URIs and ammo driver physicals) or if they were pressured into doing that stuff.

 

[AF M4]

I'm just going to go out on a limb here, but should this really be discussed in a forum such as this?

I realize it's a bit anonymous, but I would bet any lawyer worth his money would be able to figure out who/when/where this discussion is about. (granted they'd have to find it first) Doesn't sound like lawyers are likely here anyway

Anyway, I just wanted to throw that out there

Possibly, and a good thought. And for the record, I changed all of the identifying details of the case before I presented it and have maintained generalities throughout.

My intent was to work through a thorny professional issue with colleagues who understand the military medical system, and the discussion has been mature and thoughtful.

 

[Perrotfish]

Generally, one gets privileges granted by the facility. A standing committee is responsible for reviewing requests for privileges. (The military uses centralized credentialing.) Usually one has to present documentation of general training in a specialty--a letter of board-eligibility from one's PD or a board certification certificate. Then one has to submit case lists of procedures you have done. One also submits a list of procedures one wishes to do (although in practice, most facilities have a pre-written list based on the specialty, and one can add procedures to that list if they wish.) One can be queried as to the experience one has with unusual procedures, if privileges to do those are requested. And a facility may decline to grant some requests for any reason, but usually it is because the facility perceives the procedure to be one for which they cannot provide adequate support, such as anesthesia or perfusion or some other service.

Getting privileges beyond the scope of a specialty may require having done documented training in that procedure and submitting a case list to support your experience claim. Fellowship experience is one type of supplementary formal training.

So I guess my question is, is there any formal process I can go through to get credentialed in an individual procedure short of going through a full residency/fellowship program? For example suppose I am a GMO and I see a lot ofMarines who want vasectomies. I am near an FM clinic that performs vasectomies where I can both observe and first assist the procedure, and I can by some magic actually find enough time to go there when they have vasectomy clinic. How do I get credentialed to do this procedure without completing a residency?

 

[backrow]

So I guess my question is, is there any formal process I can go through to get credentialed in an individual procedure short of going through a full residency/fellowship program? For example suppose I am a GMO and I see a lot ofMarines who want vasectomies. I am near an FM clinic that performs vasectomies where I can both observe and first assist the procedure, and I can by some magic actually find enough time to go there when they have vasectomy clinic. How do I get credentialed to do this procedure without completing a residency?

At NMC Portsmouth it was well known that as an intern if you completed something like 20 vasectomies you could get an addendum stating you were competent to perform vasectomies. I think maybe one intern in my class got anywhere near enough to get the letter (can't recall if they actually did or not though)

In general all Navy GMO's are considered to be competent in the removal of moles/pilar cysts/epidermal inclusion cysts/etc. I would probably include small lipomas in that. I have even seen consults sent back to the clinic when a GMO thought a dermatologist should be the one to take off a probable basal cell on the forehead. The consult was refused by the referral office and consult doc and sent back to the clinic.

 

[orbitsurgMD]

So I guess my question is, is there any formal process I can go through to get credentialed in an individual procedure short of going through a full residency/fellowship program? For example suppose I am a GMO and I see a lot ofMarines who want vasectomies. I am near an FM clinic that performs vasectomies where I can both observe and first assist the procedure, and I can by some magic actually find enough time to go there when they have vasectomy clinic. How do I get credentialed to do this procedure without completing a residency?

I think that is going to depend on your facility and whatever instructions are applicable to credentialing in surgical procedures at that location.

The facility may or may not want to support you. Doing procedures requires manpower and materials. Also, doing procedures may or may not create a conflict with the nearby facility that does them also. On one hand, they may be swamped and welcome your interest and willingness to share in case load, and may offer you supervised training and approval. On the other hand, they may want to reserve cases for themselves to support resident training or to boost their RVUs for budgetary reasons.

In any event, you will need to document a case load to show you have actually done these procedures. They might place limits on when you will be allowed and on what conditions, say no working alone until you have 100 documented supervised cases over, say, a year, then they may say you can have provisional privileges for 200 cases as long as someone board-certified reviews your treatment charts and provides a letter to the medical director.

 

[DrMetal]

So a quandary has arisen at my clinic.

multiple times on different customers, an outpatient surgical procedure, in an otherwise healthy (probably male-dominated) squadron . . .that can only mean one procedure! (I just crossed and locked my legs).

Kudos to you for having the courage to do the right thing. Hold the superior officer accountable, threaten to go higher if you really wanna get involved. Maybe even threaten to contact a local media outlet. I had an old CO that used to say, "If you feel right about something, start a shtstorm so thick that people wont be able to see the light of day."

(echo what backrow said above, might wanna take this PM with the handful of guys that are giving you good advice). Please include me, even though I'm a lowly medical student, I could use the entertainment (not to mention an educating lesson, seriously).

 

[AF M4]

multiple times on different customers, an outpatient surgical procedure, in an otherwise healthy (probably male-dominated) squadron . . .that can only mean one procedure! (I just crossed and locked my legs).

Kudos to you for having the courage to do the right thing. Hold the superior officer accountable, threaten to go higher if you really wanna get involved. Maybe even threaten to contact a local media outlet. I had an old CO that used to say, "If you feel right about something, start a shtstorm so thick that people wont be able to see the light of day."

(echo what backrow said above, might wanna take this PM with the handful of guys that are giving you good advice). Please include me, even though I'm a lowly medical student, I could use the entertainment (not to mention an educating lesson, seriously).

Yes, that sounds good. Thanks for all the help guys. I'm going to go ahead and erase most of my stuff to cover things in the event that someone decides to play detective. Could everyone who quoted large portions of the story do the same?

Thanks to everyone who posted.

 

[orbitsurgMD]

multiple times on different customers, an outpatient surgical procedure, in an otherwise healthy (probably male-dominated) squadron . . .that can only mean one procedure! (I just crossed and locked my legs).

Kudos to you for having the courage to do the right thing. Hold the superior officer accountable, threaten to go higher if you really wanna get involved. Maybe even threaten to contact a local media outlet. I had an old CO that used to say, "If you feel right about something, start a shtstorm so thick that people wont be able to see the light of day."

(echo what backrow said above, might wanna take this PM with the handful of guys that are giving you good advice). Please include me, even though I'm a lowly medical student, I could use the entertainment (not to mention an educating lesson, seriously).

Be careful what you do in the thrall of your wanting to do what you think is "the right thing." I strongly suggest you get the advice of a senior person not involved in your clinic (who is not useless military dead wood) who has worked in clinics before and may have been involved in privileging actions before.

The military has an automatic, aggressive and sometimes very damaging approach to privileging action. Raising a sh:tstorm should not be your first approach and possibly anyone's approach, here. What you do in the name of what you think is the right thing might destroy someone's career. Maybe that is justifiable but maybe not (read: probably not, unless there are more significant facts you have not revealed, and not just one or two more cases with complications.) What will follow if he is placed before a process panel is a quasi-legal administrative proceeding. He will likely hire counsel, which will be a significant albeit necessary personal expense, and if he gets someone to testify on his behalf--possibly a real expert not under the thumb of your military branch-- which he would be allowed to do as part of his defense, he may be exonerated, despite your certainty at this point. You will then have made real enemies. He might have reason to seek redress against you and the other members of your command for libel and wrongs under UCMJ Section 138. You don't just get to walk away from this whole thing. That will follow you for a long time.

I am not telling you to do nothing, here, but if you go out on a witch hunt, you just might find yourself the hunted.