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Tuesday, November 28, 2000

Tragic Consequences

By Thomas J. Cole
Journal Investigative Reporter


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    Marilyn Hey seemed to lead a charmed life growing up in Baldwin City, Kan. She belonged to one of the oldest and most prosperous families in town. She was a popular girl, elected queen of the town's annual Maple Leaf Festival. She was smart, graduating first in her high school class of 41 students. By then, according to a childhood friend, she had set her sights on a career in medicine.
    In the next decade, she would excel in college and medical school and marry a fellow medical student, Paul Duncan. Her plans seemed to be well on their way to fulfillment.
    But somewhere along the way, the promise of Marilyn Duncan's childhood gave way to something else.
    The University of New Mexico in 1997 suspended the hospital privileges of Duncan, who had risen to become chief of the pediatric oncology division.
    UNM took the action after learning that children with acute lymphoblastic leukemia did not receive the most up-to-date treatments.
    Prior to her leaving the school, some of Duncan's colleagues in the pediatric oncology division thought she had become tired, sad, distant. One used the term "burnout phenomenon."
    Several co-workers began to question her medical decisions in caring for children with cancer. They confronted her and went to her boss with a plea that she be barred from seeing patients.
    Resign, co-workers told Duncan.
    Duncan did eventually retire.
    She has insisted she did no wrong, but she voluntarily gave up her license to practice medicine in August 1998 amid an investigation of her treatment of children with acute lymphoblastic leukemia.
    Duncan, 57, and her husband declined to be interviewed for these stories.
   
Promising start
    Like many people who choose medicine with its demands and responsibilities Duncan was a star.
    She enrolled at Baker University in her hometown, where she pledged a sorority and worked in the dean's office. After a year, she transferred to the University of Washington.
    She earned a degree in zoology, then completed medical school at the same university. She received an award for clinical proficiency and humanitarian concern.
    On a sweltering summer day in 1970, she returned to her hometown and married Paul Duncan at the First United Methodist Church.
    Fresh from medical school, the newlyweds set out for Anchorage to work at the Alaska Native Medical Center, operated by the Public Health Service. They moved to New Mexico in 1972, where Marilyn Duncan completed a residency in pediatrics. She followed that with a more specialized fellowship in pediatric hematology/oncology at UNM and a second fellowship in oncology in England.
    UNM hired her as a temporary instructor in 1974 and made her an assistant professor in 1977.
    Her husband, Paul, established an adult oncology practice in Albuquerque.
    In a 1990 interview in the Journal's SAGE magazine, Duncan said her husband's work spurred her interest in cancer treatment. She said she focused on cancers in children because of tradition. Pediatrics was considered an appropriate specialty for women when Duncan was in medical school.
    Their careers firmly launched, the Duncans had the first of their two children, a girl, in about 1980. A boy was born in 1982.
    The following year, Duncan underwent surgery, then radiation, for breast cancer. The couple later built a home in Albuquerque's North Valley.
    "Overall, I am living a hectic but satisfying lifestyle that is quite happy," Duncan wrote in a 1986 survey for her 25th high school reunion.
    "She always seemed very much in control" of her life, said Linda Lederer, a friend who grew up with Duncan in Baldwin City and now lives in Albuquerque. As a doctor, Lederer said, Marilyn inspired confidence.
    "I would trust her with my family and children," Lederer said.
    But on the job, stress was mounting.
   
Growing challenges
    In 1986, Duncan was made an associate professor. The following year, UNM split its pediatric hematology/oncology program into two divisions and Duncan became acting director of pediatric oncology.
    It was a tall order for a working mother. She told SAGE in 1990, "Obviously, taking care of patients, my kids and my home does decrease my productivity and affects my momentum." She said her mother-in-law helped care for her children.
    As the only full-time doctor in pediatric oncology in 1988, she had some issues she wanted addressed.
    "We need to have enough personnel to continue providing 'state-of-the-art' clinical care, as well as move ahead to accomplish university academic expectations for teaching and research," she wrote in a letter to her boss accepting the job of director of pediatric oncology.
    "I feel strongly that staffing patterns and program expectations must recognize and allow for ongoing mental-health support to oncology team members."
    The letter continued, "This field is emotionally demanding (and draining) since many, but not all, children will be cured of their cancers."
    The stresses of the job still were on her mind in 1990 when she was interviewed by SAGE.
    "The doctors in oncology who burn out can't give up control," Duncan told the magazine. "They take it all too personally. I'm sad when a child dies, but having done the best I can for the family, I don't take it as a personal failure."
    She told SAGE the most useful mechanism for coping with the intensity of her work was to let families take as much responsibility as possible for their children.
    Duncan's demand for help was met in 1989 when UNM hired Brian Corden, who had been working at Johns Hopkins University in Baltimore.
    Duncan appeared to like her work, Corden recalled in a lawsuit deposition nearly a decade later.
    "She did not appear to be bored," he said. "She did not appear to be burned out."
    But Corden and Duncan clashed in both personality and in their approach to taking care of children. He left in 1991 to take a job in Atlanta.
    In a recent interview, Corden said that Duncan "was sort of a sad person." He also said Duncan was a good doctor but a "control freak" in terms of her work.
    "Duncan was just a very, I think, self-centered and egotistical person who would not consider that anybody else had any knowledge that was worth anything," he said.
    When Corden left, Duncan again was the only full-time pediatric oncologist at the university. Records show she was responsible for the care of 352 patients in the year that began July 1, 1993. The pediatric oncology unit had 1,349 clinic visits and children spent 48 days in the hospital. A couple of other physicians worked part time with Duncan.
    Away from the hospital, Duncan was frequently on call to respond to emergencies.
    Some co-workers began to feel something was amiss.
   
Concerned co-workers
    Cathy Chavez, a registered nurse in the pediatric oncology division, said that beginning in 1993 she sometimes felt uncomfortable with Duncan's medical decisions.
    "It didn't always seem like she was a strong person," Chavez said in a deposition given in a lawsuit brought against UNM by families of some of Duncan's patients. "She seemed tired and she seemed weak."
    Chavez said Duncan was rude to some families and sometimes would not return their telephone calls.
    Yolanda Vinajeras, a social worker in the pediatric oncology division, said in a deposition that Duncan worked long hours and often was at the hospital late into the night.
    "I think Dr. Duncan was very fragile," she said. "She looked tired. ... It seemed that she didn't have the energy at times."
    Duncan did not always take families' concerns about their children seriously, Mary Leasure, a nurse in the pediatric oncology division, said in a deposition.
    "There was more than one occasion that I can think of where it was just by the grace of God in my opinion that the patients lived through the night or through the situation," Leasure said. "The main problem I saw was that Dr. Duncan quit thinking of patients as people. It was reflected in a disassociated disregard of patients and their families."
    Marlene Aubert, whose son was successfully treated for leukemia at UNM Hospital, said Duncan seemed a bit irritated when she tried to talk to her.
    She described the doctor as stoic, detached and unsmiling.
    "I always felt that she was hurrying out of the room," Aubert said in an interview.
    Others who dealt with Duncan professionally were complimentary.
    Duncan was a prominent member of the Pediatric Oncology Group, a cooperative of hospitals and physicians that designs and tests protocols to treat childhood cancers.
    Sharon Murphy, chairwoman of the group, said Duncan ran the group's hospital-review committee in "impeccable fashion."
   
Fading reputation
    Duncan was promoted in 1995 to professor in the Department of Pediatrics. That same year, UNM hired another pediatric oncologist, Stuart Winter.
    But by the following spring, Duncan's life was unraveling.
    Workers in the pediatric oncology division went to Duncan's boss, Pediatrics Department chairwoman Shirley Murphy, with concerns about the doctor, according to nurse Chavez.
    Documents show that Murphy, who declined to be interviewed, suggested Duncan take a sabbatical in the summer of 1996.
    Chavez also testified in her deposition about receiving two telephone calls from Duncan's husband.
    "He said he wanted to know what was going on at the university," the nurse said. "Just kind of seemed like he was concerned about how she was doing."
    Chavez said she and Paul Duncan talked about Marilyn Duncan's work hours.
    "He said that he would like to see her home more," she said. "I said she should be home more."
    The nurse said Paul Duncan seemed surprised when she told him about a meeting in February 1997 during which Chavez and others in the pediatric oncology division told Marilyn Duncan that she should quit her job.
    "I asked him if he knew she was on leave, and he said no," she said, adding she got the impression Paul Duncan believed his wife had simply been going to work every day like normal.
    Also in February 1997, Winter confronted Duncan about two cases in which he believed she had made bad decisions in response to serious medical problems.
    "I am both confused and concerned about your medical judgment in these two instances," Winter wrote to Duncan. "We all make mistakes; these were unacceptable."
    Jami Frost, a pediatric oncologist who had recently been hired by UNM, wrote to school officials about a meeting of the pediatric oncology staff on Feb. 7, 1997.
    "All members were in complete agreement that Dr. Duncan does not appear to have the ability to manage patients safely," her memo read. "All agreed that immediate action should be taken to remove Dr. Duncan of patient care responsibilities, and less urgently, to relieve her of administrative duties."
    Duncan was placed on leave a few days later. Soon afterward, her co-workers confronted her at a meeting.
    "She was informed by the individuals present that, in their considered opinions, she had treated patients carelessly; she was no longer to be trusted," Duncan's co-workers wrote in a joint letter to John Johnson, the acting chairman of the Pediatrics Department.
    The letter said Duncan was told she "could still save her soul" by quitting her job.
    A fellow doctor said Duncan suffered from a "burnout phenomenon" in late 1996 and early 1997.
    "I did not feel that, at that point, her decision-making was always, shall I say, uninfluenced by the perceived work load," Donald Pinkerton, a part-time doctor in the pediatric oncology division who had worked with Duncan for several years, said in a deposition.
    Duncan has said she saw a psychiatrist in February 1997 at the request of supervisors Murphy and Johnson. She said she has never undergone psychiatric treatment.
    After investigating her work, UNM officials suspended her hospital privileges in December 1997. She appealed the loss of privileges but dropped the appeal in 1998.
    An agreement between Duncan and UNM prevents the university from using the withdrawal in defense of claims or lawsuits brought against UNM as a result of the doctor's care of patients.
    Duncan gave up her medical license in an Aug. 28, 1998, agreement with the state Board of Medical Examiners, but she admitted no wrongdoing.
    Duncan "desires to settle her differences with the board and agrees to voluntarily surrender her New Mexico license to practice medicine and not reapply for a New Mexico license to practice medicine," the document said.