Every July 17, Patricia A. Smith marks her son's birthday by placing roses on his grave.
The Dundalk woman blames the death of her firstborn son 13 years ago on her obstetrician, Dr. Ghevont W. Wartanian. She says Wartanian, who practices at Harbor Hospital in Baltimore, failed to detect signs of fetal distress late in her pregnancy.
"It was just a horrible, horrible experience," said Smith, who eventually received a $150,000 out-of-court settlement from the doctor's insurer.
Smith is one of 18 women who have sued Wartanian in the past 20 years for malpractice - an extraordinary record for any doctor, national experts say. While some suits proved without merit, nine resulted in payments totaling well over $2 million.
Yet, the 55-year-old obstetrician-gynecologist has never faced state disciplinary action; neither has his license to practice medicine been restricted, according to a review of state records.
Wartanian's history illustrates fundamental flaws in the way Maryland regulates and disciplines its doctors, critics say, particularly physicians with recurring malpractice suits - known in the medical field as "highfliers."
Maryland's doctors largely regulate themselves, records and interviews show. In this state, physicians decide whether to review a colleague's skills and whether the results warrant disciplinary action.
In addition, the state board responsible for licensing and disciplining doctors - the Maryland Board of Physician Quality Assurance - has ignored a provision in state law meant to bring extra scrutiny to doctors who have faced multiple malpractice suits. The law requires that doctors who have three or more malpractice claims filed against them within a five-year period be reported to the regulatory board.
The scope of Maryland's failures of oversight is impossible to gauge with precision because the board's records on malpractice suits are incomplete and difficult to access. But available records indicate that Wartanian is near the top of the state's 10,127 practicing physicians in eliciting such suits.
The chairman of the American College of Obstetricians and Gynecologists' professional liability committee says a pattern of lawsuits such as the one compiled by Wartanian is extraordinary.
"I don't believe I've ever seen anything close to this," said Dr. Willette L. LeHew of Norfolk, Va., after reviewing a summary of Wartanian's malpractice suits. "This is an extremely unusual number of cases for one physician to have."
The ob-gyn college is a national organization representing nearly 40,000 physicians who provide health care for women. Its research indicates that, on average, an ob-gyn can expect to be sued 2.53 times during his or her career - a number that Wartanian has exceeded several times over.
While some Maryland doctors with long histories of malpractice complaints have eventually lost their licenses, others - like Wartanian - have never been disciplined. And it can take a lot of lawsuits and time before state regulators act.
For example, it took almost a decade of efforts by the state board before it yanked the license of a Baltimore plastic surgeon who racked up 25 malpractice suits and lost his credentials at a number of area hospitals, records show.
All states wrestle with the problem of how best to monitor physician quality to protect the public. State regulators often have to deal with issues of substance abuse, sexual misconduct and criminal behavior, but their hardest task is determining whether doctors fail to meet accepted standards in treating patients.
Some do it better than others.
In contrast with the Maryland system, Ohio uses a computer program to identify physicians with malpractice histories that fall well outside the norms for others practicing in the same field. That state consistently ranks as one of the toughest in the nation in terms of its rate of disciplinary actions taken against doctors.
Some states also provide far more information to the public about the track record of physicians than does Maryland, where residents can find out little beyond whether a doctor has ever been disciplined by the state's regulatory board. In Massachusetts, for example, the state medical board's Web site lists cases in which doctors have paid to resolve malpractice suits - along with case numbers and information on malpractice suits that are pending.
The Sun began examining Wartanian's record after a Baltimore attorney cited him as a glaring example of the failings of the state's disciplinary system.
The malpractice suits against Wartanian were filed by women such as Patricia L. Davis of Sparrows Point in Baltimore County. She nearly died of complications after what is widely considered a routine surgical procedure, according to lawsuit records. A jury awarded her and her husband $1.5 million, although the amount was later reduced to about $926,000.