Brian Scott Dutcher Sr., a 34-year-old father of five from Sebewaing, died in 2002, about a week after the radiologist who read the initial CT scan of his brain missed signs of a massive infection — multiple ringlike lesions suggestive of abscesses. Rather than treating him, Dutcher was released from Scheurer Hospital in Pigeon and told to take Tylenol for his headache, his family said.
Cheryl Jensen, 76, of Bethlehem, New Hampshire, had breast cancer that a radiologist missed on repeated mammograms. By the time it was discovered, Jensen said her cancer had advanced to stage 3 and spread to five lymph nodes. She can no longer work or do many of the activities she loved before her delayed diagnosis, she told the Free Press.
Dutcher and Jensen have one man in common: Dr. Mark F. Guilfoyle, a diagnostic radiologist who got his medical degree in 1984 from Michigan State University and has practiced for 35 years both in Michigan and New Hampshire.
Back in Michigan after discipline in seven states
Guilfoyle, 68, of Commerce Township, interpreted Dutcher’s brain CT scan and Jensen’s mammograms, reporting that the radiological images were normal when they were not.
Guilfoyle has been the subject of at least 13 malpractice lawsuits, 12 of which were settled out of court; one was dismissed. The bulk of the malpractice cases are tied to his failure to spot evidence of breast cancer on the mammograms of as many as two dozen women dating to 2015-17, when he worked in New Hampshire.
He has been disciplined by the medical boards in seven of the eight states where he is licensed to practice medicine, including Michigan. The state of New Hampshire's Board of Medicine fined him $750 and restricted his license so he can no longer read mammograms in that state.
He moved back to Michigan and has worked as a diagnostic radiologist at Garden City Hospital since March 2021, said Jason Gregoire, his New Hampshire-based attorney.
'How many were there who didn't know?'
That Guilfoyle continues to work in Michigan infuriates Cindy Freeman, Dutcher’s sister.
“I don't understand how he’s still practicing medicine. After the first couple of lawsuits, somebody should have took his medical license,” said Freeman, 53, of Flint Township.
“How the hell did this man ever become a doctor? … How many more (medical errors) were there even before my brother? How many were there who didn't know? Or maybe who just didn't sue?”
Nadia Fadel-Bazzi, a spokesperson for Garden City Hospital, would not tell the Free Press whether hospital leaders knew about Guilfoyle's history prior to granting him privileges to practice there, nor would she comment on whether they are confident that Guilfoyle is able to accurately interpret radiological scans.
“Garden City Hospital is a Leapfrog Safety Grade ‘A’ recipient, with systems in place to ensure the safety and wellbeing of all our patients," Fadel-Bazzi said in an email message to the Free Press. "Although this physician has privileges at Garden City Hospital, he is not an employee and does not read mammograms.
“I am not at liberty to say anything further.”
They 'screwed up and killed my brother'
Dutcher could have survived if he had been treated with antibiotics and steroids when he first went to Scheurer Hospital on Jan. 26, 2002, complaining of a severe headache, said Freeman, who is a licensed practical nurse.
Instead, he was told his brain scan was normal and was sent home. There, his symptoms progressed, and by Feb. 2, Freeman’s niece and daughter found him unconscious in his apartment in Sebewaing, a village on Saginaw Bay in Michigan's Thumb.
Court documents say he was frothing at the mouth when paramedics rushed him back to Scheurer Hospital. He was then taken to Ascension St. Mary’s Hospital in Saginaw, Freeman said, a level II trauma center better equipped to handle the severity of his illness.
“I actually beat the ambulance there,” Freeman said. “I stayed that whole weekend at the hospital with him. He was unconscious, and I wasn't allowed to really talk a lot to him. He wasn’t allowed to have a lot of stimulation because of the swelling on his brain.
“He had so much swelling. They were worried that stimulation would make it swell more at that time. They just wanted him to rest.”
Dutcher had brain surgery to relieve the pressure.
“The neurosurgeon talked to me and my brother Ken,” Freeman said. “He showed us the CAT scan they did at St. Mary's. He had 10 lesions on his brain.
“We commented that he had a CAT scan the week previous at Scheurer Hospital. That neurosurgeon looked at me and said: ‘I will go to court on this. There's no way 10 lesions grew in a week. They would have been on the first CAT scan.’
“They had to take the front right lobe of his brain out, trying to help with the swelling, and then they sent that piece of the brain that he took out to test it. He had a streptococcus infection on his brain caused from a bad wisdom tooth. The infection from the wisdom tooth went to his brain.
“Had they treated the lesions and infection the first time he went to Scheuer Hospital, and if they would have put him on IV antibiotics, it wouldn't have gotten as bad. His brain wouldn’t have swollen like that.
“(They) screwed up and killed my brother.”
'I made a mistake'
Two years after Dutcher’s death, Guilfoyle admitted his error when he testified in a deposition in the malpractice case, which was filed in U.S. District Court in Detroit.
“I made a mistake,” Guilfoyle said.
On Dutcher’s radiology report from Jan. 26, 2002, he had written: “Normal CT of the brain,” court documents show.
But when Guilfoyle reviewed the images again in February 2004 for his deposition in the malpractice case, he testified that he saw: “Several hypodense rings scattered within the cerebral hemispheres” indicative of abscesses.
The CT scan showed Dutcher likely had an “infection of the brain matter with some type of microorganism that has formed a small pus collection” that could be life-threatening if left untreated, Guilfoyle said.
Ultimately, the malpractice case was settled out of court and details of the settlement are confidential.
One of the saddest things, Freeman said, was that her father blamed himself for her brother’s death.
“My dad felt guilty because he knew that Brian had been complaining about a tooth. So my dad, of course, felt like it was his fault,” she said. “He lost a son. When they turned the (life support) machines off, he said: ‘Parents aren't supposed to outlive their kids.’ ”
And Freeman lost a brother, a man who worked for years at the Tower Automotive plant in town, who loved his children and enjoyed fishing, both commercially and for fun.
Another lawsuit filed and then dropped
In 2006, another family sued for medical malpractice, naming Guilfoyle along with two other doctors and Huron Medical Center in Bad Axe. That's where George Szymanski, of Port Austin, underwent cardiac testing on Nov. 23, 2004, because he'd been having chest pain and shortness of breath.
Court documents filed in Huron County Circuit Court suggest the results of Szymanski's cardiac imaging tests were "grossly abnormal" and showed a defect in the wall of his heart, along with insufficient blood flow.
The 63-year-old farmer was told, however, that the results of his tests were normal. He was sent home with no restrictions. Six days later, Szymanski died of cardiac arrest while working in the fields on his farm.
It's unclear what role Guilfoyle played in Szymanski's care or in evaluating his condition when he underwent testing at Huron Medical Center. Guilfoyle and the two other physicians named in the lawsuit were dropped from the case in 2007, and a settlement was reached with Huron Medical Center.
"Dr. Guilfoyle had nothing to do with the patient’s injuries," Gregoire, Guilfoyle's attorney, told the Free Press in an email message. He noted that Guilfoyle personally made no payments or settlements in the case. "He was named as a defendant because he was one of many providers that showed up in the patient’s medical records."
In correspondence with the Free Press, Gregoire also noted, "To be clear, if you re-read my initial email, I did not say he had no involvement in Mr. Szymanski’s care."
Szymanski’s family declined to be interviewed by the Free Press.
In 2015, Guilfoyle moved to New Hampshire to take a job with Dartmouth Health (then known as Dartmouth-Hitchcock Health). There, he was tasked with reading and interpreting radiological images for three small, affiliated hospitals in the rural northern part of the state: Weeks Medical Center in Lancaster, Upper Connecticut Valley Hospital in Colebrook and Androscoggin Valley Hospital in Berlin.
Cheryl Jensen, an automotive journalist who loved hiking, snowshoeing and cross-country skiing in the state's White Mountains, had yearly mammograms at Weeks Medical Center in 2015, 2016 and 2017.
"When I went back through all of my past mammograms, I saw Guilfoyle, Guilfoyle, Guilfoyle," named as the radiologist who analyzed the tests, she said. "And every time, I got a letter: normal, normal, normal."
Except they weren't. In late January 2018, another physician from Dartmouth Health called to tell Jensen about a review of her previous mammography screenings — and said something suspicious was found.
That led to a diagnosis of stage 3 invasive lobular carcinoma that had metastasized to several lymph nodes.
"I did what they call cut, poison, burn," Jensen said. "That’s surgery, chemo and radiation, and that was a year out of my life. I could have traveled then. I was much stronger. I lost several years of my good life because of this.
"And I wasn't the only one," Jensen said. "The lawyer who was representing me never really told me how many women were involved" in malpractice lawsuits against Guilfoyle in New Hampshire tied to misread mammograms that he reported as normal but actually showed evidence of breast cancer.
Concern about an irregularity in one of Guilfoyle's mammogram interpretations first arose in 2017, said Audra Burns, a spokesperson for Dartmouth Health.
The hospital system "acted immediately and decisively," she said. Guilfoyle was placed on administrative leave as the health system "reexamined every single mammogram Dr. Guilfoyle had read in his capacity. During the reexamination of Dr. Guilfoyle’s mammography cases, Dartmouth Health proactively reached out to patients identified to be at potential risk to bring them in for further testing and any necessary treatment."
Jensen was among them.
"If they hadn't done that (review), where would I be today? I’d be dead," Jensen said. "These things are nothing to fool around with."
$4.6 million paid in malpractice settlement
Dartmouth Health would not disclose the number of mammograms it reviewed, nor would Burns say how many women were found to have cancer who'd been initially told their test results were normal.
The Boston Globe, however, reported that Dartmouth Health reviewed 5,500 mammograms and breast ultrasounds Guilfoyle interpreted from 2015-17 as part of the investigation. Twenty-four women were found to have breast cancer after being initially told their mammograms were normal, and 11 of them sued.
Malpractice settlements totaling $4.6 million were paid to those women in 2020, according to the Georgia Composite Medical Board, which reports medical malpractice court judgments and arbitration awards that exceed $100,000 within the last 10 years of doctors licensed in that state.
There is no public record of the medical malpractice lawsuits or settlements tied to Guilfoyle in New Hampshire because the state keeps information about such cases confidential.
“If it’s truly medical malpractice, those are sealed cases,” a court clerk for the New Hampshire Judicial Branch told the Free Press. “You will not be able to get any information on them. Unfortunately, that just doesn't happen in New Hampshire.”
Guilfoyle and Dartmouth Health signed a separation agreement that took effect on Sept. 1, 2018, Burns said.
"We reported the matter to the New Hampshire Board of Medicine, as required, and we cooperated throughout the Board’s investigation process," she said.
'How can I ... trust the results of another mammogram?'
The New Hampshire medical board reprimanded Guilfoyle, issued an administrative fine of $750 and agreed to a settlement that would allow him to keep his medical license in that state, but with a restriction that he could no longer read or interpret mammograms there.
The board also wrote that: “No concerns have been raised about Dr. Guilfoyle’s interpretation of, or ability to provide, any other type of radiologic services or studies.”
Jensen was incensed, saying the penalty amounted to little more than a slap on the wrist.
"Guilfoyle shouldn't be reading anything. Nothing," she said. "Why isn’t he thrown out of medicine? He shouldn't be allowed to practice, period."
In a letter to the New Hampshire Board of Medicine, Jensen wrote: "If my cancer had been diagnosed at Stage I, not Stage IIIA with lymph node involvement, my treatment might have been very different and without such negative long-term consequences. Why would Dartmouth-Hitchcock have hired this guy and then also not supervised him appropriately? How can I be expected to ever trust the results of another mammogram?
"... Mark Guilfoyle ruined what’s left of my life. He should not be allowed to do this to anyone else."
Jensen said she was forced into retirement before she was ready because the pace of medical appointments and the unwelcome side effects of cancer treatment made it impossible for her to continue working. She had 123 cancer-related medical appointments in 2018.
She has lost the strength and stamina to hike, snowshoe and ski, as well.
"It's taken a lot out of me," she said. "It's really robbed me of quality of life."
As for her prognosis, Jensen refuses to use the term cancer-free.
"I know enough about medicine to know that is BS," she said. "I just don’t know what’s going to happen down the line."
Doctor: Malpractice cases 'ruining medicine'
Guilfoyle declined to be interviewed by the Free Press.
A colleague at Garden City Hospital, Dr. Alysse Cohen, also a diagnostic radiologist, said Guilfoyle doesn't deserve the scrutiny he has gotten.
“Mammograms are very hard to read," she said. "In radiology, specifically, it is all about the art of interpretation. One person, one radiologist, could see something and a different radiologist could see something completely different looking at the exact same images, and it's all based on what you think. There's no right or wrong to most of it.
"I guarantee you, if any radiologist reviewed 5,000 cases of another radiologist’s work, they would find an equal number of misses. A second opinion is always going to find more.
"We're human, right? We miss stuff," she said.
A study published in the medical journal RadioGraphics found errors and discrepancies in radiology occur on average in about 3% to 5% of cases.
If Guilfoyle missed evidence of cancer on the mammograms of 24 women out of 5,500 in New Hampshire, Cohen said that's still well below the accepted 3% to 5% error rate threshold.
Malpractice lawsuits, she said, are "ruining medicine."
“Almost all medical lawsuits get settled outside of court, whether there's fault or not because nobody wants to pay for lawyer fees," Cohen said. "That's why they settle everything out of court whether or not the doctor is guilty, whether or not they did anything wrong.”
“This is across the whole country, it’s not just my hospital. It is everywhere. Doctors are so afraid of being sued, they literally cannot do their job correctly or safely."A 2016 American Medical Association analysis found that 34% of physicians have faced at least one malpractice lawsuit in their careers. That number rises the longer a doctor practices.
Among physicians ages 55 and older, like Guilfoyle, nearly half have been sued. That compares with 8.2% of doctors younger than 40.
"Because of all these lawsuits and stuff, we're losing a lot of good radiologists," Cohen said. "And we're already in a super all-time shortage. ... So the ones we do have are more overworked, have to go faster, have to read more cases. And if you're going faster and reading more cases, you're going to miss more things. So then the problem just keeps getting worse and worse.
“I feel terrible for Mark because he's a good guy. He's a really good guy. He's been through a lot. I personally don't think he deserves this."
A $250 fine in Michigan
Guilfoyle's license to practice medicine in Michigan is valid through July 2024.
The Michigan Department of Licensing and Regulatory Affairs fined Guilfoyle $250 in 2020 for violating the public health code in New Hampshire.
Though Guilfoyle pledged to no longer read or interpret mammograms, Michigan regulators did not outright bar him from doing so as New Hampshire's Board of Medicine did.
Regardless, "he has not read a mammogram in any state since July 2017," his attorney, Gregoire, said. "He voluntarily stopped reading mammograms the day Dartmouth Hitchcock notified him he was being placed on administrative leave while they conducted an internal review of his mammogram readings.
"Even though the Michigan reciprocal discipline order does not technically prevent him from reading mammograms, Dr. Guilfoyle signed an affidavit in connection with this settlement attesting to the fact that he voluntarily agrees to no longer read mammograms in the future."
LARA spokesman Jeff Wattrick said the agency "took regulatory action consistent with the state of New Hampshire and other states where Dr. Guilfoyle is licensed."
"As it does in all cases, LARA made its regulatory action publicly accessible on its website so that Michigan citizens can make informed choices about their health care providers. .... The order does not prevent Mr. Guilfoyle from interpreting mammograms in Michigan. However, he represented to the department and board that he no longer does that in his practice, so if it was determined that such representation was false, that could have licensing implications."
Wattrick urged anyone with information regarding a violation of the Public Health Code to file a complaint with LARA.
Freeman says that's not enough.
She knows telling her brother’s story won’t bring him back, but she hopes it will lead to action that prevents Guilfoyle from continuing to practice medicine.
“I wish I could make him stop,” she said.
Contact Kristen Jordan Shamus: firstname.lastname@example.org. Follow her on Twitter @kristenshamus.
This article originally appeared on USA TODAY: Doctor with history of misdiagnosis still practicing in Michigan