The Secret Truth About Boston Doctors

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Photo illustration by C.J. Burton

When retired police sergeant Charles Antonio went under the knife of Michael Medlock, he was confident the neurosurgeon would eliminate the numbness in his fingers and toes, alleviate the pain in his legs, and improve his faltering balance due to compression in his spinal cord. After all, like many of us, Antonio believed Massachusetts had some of the best doctors in the country. He’d scoured the Internet for any information he could discover about his surgeon, though in truth he couldn’t find much: merely that Medlock was chief of neurosurgery at the Partners-affiliated North Shore Medical Center–Salem Hospital and had worked at Mass General, one of the top-ranked hospitals in the world. Now, on a gurney rolling toward the operating room, Antonio felt butterflies in his stomach, but he was comforted by the knowledge that the man who would be carving into his neck was a well-credentialed and experienced pro.

But things didn’t go as planned. Within days of the operation in September 2015, Antonio began suffering what he now describes as “ungodly pain” in his neck and shoulders. Antonio says he returned to Medlock, who prescribed opioid painkillers, ran some tests, and sent him home. Then things got worse. Antonio started hallucinating and verbally abusing his wife, Linda. He flushed the painkillers down the toilet, saying, “I’m not getting hooked on these. I’ve seen people addicted to drugs and liquor.” Still, the pain continued and his balance worsened, and by late October his condition had deteriorated to the point that he had to be hospitalized at the same facility where Medlock had operated on him a month earlier.

While Antonio was in his hospital room, he and Linda said another physician walked in with an update. The doctor knew Antonio was fond of Medlock and announced that Medlock was considering operating on Antonio again. Then the doctor offered a subtle yet chilling warning: “If I were you, Charlie,” Antonio recalls him saying, “I would find a new friend.”

What neither of the Antonios knew, but court records showed, was that over the past several years, two of Medlock’s surgeries had left patients injured and led to medical malpractice settlements.

Not long after the warning, and for reasons Antonio is still unsure of, he was transferred to MGH for a rescue operation. According to Antonio’s allegations in a still-pending lawsuit that he filed one year later, when the neurosurgeons there opened his neck, they discovered a disaster zone. A raging infection had spread around the plate and screws that Medlock had installed. Even worse, when the MGH surgeons removed one of the screws, a geyser of blood erupted. A screw from the previous surgery was lodged in Antonio’s artery. To prevent Antonio from bleeding out and dying right there in the operating room, surgeons put a new screw back into the artery, where it remains to this day as a permanent plug. Then they sewed him up and sent him to the intensive care unit to fight for his life.

As Antonio slowly convalesced, and a halo stabilization device was pinned to his skull, he and his wife filed a medical malpractice lawsuit against Medlock, who has since denied the allegations. Then, last year, Antonio wrote a letter to the Massachusetts Board of Registration in Medicine, which is charged with overseeing doctors and protecting patients from substandard care. According to a letter Antonio received from the board, an official investigation had begun. Now, more than a year later, the medical board has reached no conclusion regarding the allegations against Medlock, who remains a licensed neurosurgeon free to practice anywhere in the state. There is no practical or simple way for the public to find out about any of this, including his surgery on Antonio.

As alarming as that may sound, Medlock’s situation is hardly exceptional. Rather, it’s the norm for Massachusetts doctors to continue treating patients despite repeated accidents or blunders. When physicians with histories of bad outcomes do face consequences, the sanctions tend to be temporary or easily circumvented. Doctors quietly leave one hospital, only to pop up at another. In severe cases, a doctor with a history of problems might leave Massachusetts altogether and reboot his or her career in another state. Meanwhile, studies have found that as few as 10 percent of medical errors are reported nationwide, and here in Massachusetts, the state medical board acts only in a small fraction of the cases that come before it. Last year, for instance, the board received 211 complaints alleging medical mistakes but disciplined only 17 doctors for providing substandard care.

The unexpected plot twist here is that Medlock is now a member of the state medical board. Even as he defends himself against the Antonio lawsuit and faces an ongoing investigation initiated by the very board he now sits on, he has been elevated to serve as one of the chief regulators charged with protecting Massachusetts patients from the kind of substandard care he stands accused of providing. Worse still, there’s evidence that Medlock’s appointment to the board by Governor Charlie Baker was not due to a desire to improve medicine in the state, but to sate the interests of the physicians’ lobby—interests Medlock is arguably defending from his seat on the board.

Not long ago, the Massachusetts medical board was widely considered one of the least effective watchdogs in the country. Its rate of discipline ranked fifth-lowest among all states, its transparency efforts put it at the back of the pack, and its critics credibly alleged that it served the interest groups it was meant to regulate. After a brief period of reform, two recent appointments, including Medlock’s, herald a turn toward the board’s darker past, one that forces us all to ask a very unhealthy question: Who will save us from our doctors?

After surgery that didn’t go as planned, Charles Antonio, once a semipro cyclist, can no longer ride the roads nor fully raise his arms. / Photo by Jonathan Kozowyk

The unfortunate truth is that accidents happen, even at the hands of Boston’s most brilliant physicians. Knives slip, diagnoses are bungled, and medications do unexpected things. In fact, by most estimates, preventable medical errors kill at least 100,000 Americans every year. For the past two decades, since the advent of the so-called “patient safety movement,” the medical profession has worked with some success to minimize these tragedies: Deadly hospital infections are down; the use of surgical checklists is up. But there is one frightening aspect of healthcare that seems stuck in the past: a pervasive culture of silence that keeps a small percentage of dangerous doctors on the payrolls of some of our most prestigious hospitals.

To start with, says Martin Makary, a renowned surgeon and hospital whistleblower, most surgeons know of at least one physician who is so dangerous that he or she shouldn’t be practicing. When Makary was a medical student at Harvard, for instance, he briefly worked alongside one of the Boston area’s most esteemed surgeons. Makary soon learned, however, that the doctor was known to his colleagues for routinely botching surgeries. They even had a nickname for him, “Dr. Hodad,” which stood for “Hands of Death and Destruction.” Yet no one stopped him. “What blew me away,” Makary now says, “is that so many people were aware, yet no one said anything, except to each other.”

Making matters worse, Makary says, healthcare providers, administrators, and regulators rarely feel empowered to flag and act against bad doctors. Residents and nurses, stuck in a military-type hierarchy, fear retribution if they speak up. “It would have been like a sergeant or a private telling the general the strategy was flawed,” Makary says, explaining why junior employees didn’t blow the whistle on Dr. Hodad. “It would have been extremely out of line.”

Even when hospitals do act, administrators’ efforts to rein in dangerous doctors tend to stop at their own walls. Ashish Jha, a physician and dean of global strategy at Harvard’s T.H. Chan School of Public Health, says hospitals have two choices when they encounter doctors who have screwed up a string of surgeries: terminate the doctor, who would then likely threaten to sue, leading to an ugly situation, or simply say, “‘You know…if you just step down quietly, we won’t go after you. Let’s just part ways.’ For the hospital, that’s much easier. It’s clean,” Jha explains. The legal device used in such situations is called a “separation agreement,” a confidential contract between hospital and doctor that has been used to evade accountability and transparency. That way, Jha says, the “next time the neurosurgeon applies for credentials and is asked, ‘Have you ever been terminated?’ he can truthfully say, ‘No.’”

Patients, of course, are the ones who ultimately bear the costs of hospitals’ secrecy. Take the case of Peter Black, neurosurgeon in chief at Brigham and Women’s and Boston Children’s hospitals during the early 2000s. In 2008, Brigham and Women’s restricted the types of procedures he could perform—considered a major disciplinary action that requires a report to the medical board. But BWH structured the restriction as a voluntary choice by Black (despite the fact that, as Black later testified in an unrelated federal lawsuit, he agreed to it under duress). This voluntary agreement freed BWH of its requirement to report its disciplinary action to the medical board and make the information public. (Brigham and Women’s said in a statement it could not release details of Black’s former employment, adding, “Patient safety is our first priority, and we take seriously our obligation to notify the Board of Medicine regarding any reportable disciplinary action.”)

Meanwhile, Black kept operating. In April 2009, according to a malpractice lawsuit, he performed a complex surgery at Children’s Hospital on an 18-month-old whose parents say they had no idea that Black’s surgical privileges had been restricted at Brigham and Women’s. The child suffered a stroke during or immediately after the procedure and is now permanently disabled. That month, Children’s neurosurgeon in chief, Michael Scott, wrote to Black “to express [his] serious concerns regarding the management” of the case and mandated that Black could no longer operate without first submitting his cases to Scott for review. (Black declined to comment through his lawyer. A Children’s spokesperson said, “Dr. Black is no longer with Boston Children’s. We don’t plan to comment further.”) According to the results of a public-records request at the Department of Public Health, no sanction against Black was ever reported by Children’s, which means that the board and the public were none the wiser.

Complicating matters for patients is the fact that the tools available to research doctors’ histories are incomplete, poorly advertised, and designed with privacy, rather than transparency, in mind. If you are like most Massachusetts healthcare consumers, you are probably unaware that every licensed doctor in the state has a Physician Profile on the board’s website. But don’t worry, you aren’t missing much. The profiles are supposed to list all malpractice payments and disciplinary actions, but often don’t.

The National Practitioner Data Bank is another hunk of fool’s gold. The most comprehensive repository of information about doctors in the country, the 1.4 million-report data set is supposed to list every malpractice payment and disciplinary action involving a doctor in the United States since 1990. Again, though, there are errors and omissions. In a perfect world, it could tell you if a specific doctor has had his or her license suspended or has an unusual rate of malpractice payments, and the types of procedures for which the claims were brought—except that all of the doctors are anonymous, identified only by a number. Several hours of research on the NPDB, however, revealed more than 200 Massachusetts doctors who have racked up at least five malpractice payments or disciplinary actions in the past 15 years without permanently losing their licenses (and no fewer than 36 who have tallied 10 or more). Many of them appear still to be in practice. These are the kinds of doctors most patients would like to avoid. The problem is, we have no idea who they are. So what’s a patient to do?

Medical malpractice attorney Andrew Meyer is often patients’ only recourse against
dangerous doctors. / Photo by Jonathan Kozowyk

Standing outside of Antonio’s hospital room at Mass General, a day after learning of the allegedly misplaced screw in her husband’s neck, Linda paused and took a deep breath before entering. She wanted so badly to act brave, but her mind was somewhere else. “There was equipment floor to ceiling,” she recalls, overwhelmed by the scene and the surreal sensation that the room seemed to be lengthening before her; she remembers spotting her husband amid the machines and flashing lights, as if he were at the end of a narrow corridor. With horror, she noticed the halo exoskeleton screwed into his skull. As she stepped closer, the nurse dialed back Antonio’s sedatives and he gradually regained consciousness. Leaning down toward her husband, Linda heard him whisper, “Call Alex,” referring to their friend, a lawyer. When she reached the friend, he immediately advised her to contact the only man he knew who could surely help: Andrew Meyer.

Meyer is not only Boston’s most prolific medical malpractice attorney, but he also has one of the best views of how the system that is supposed to protect patients from bad doctors consistently fails. Every month, his firm, Lubin & Meyer, fields hundreds of calls from people who believe they have been harmed by negligent care. Some of those people are mistaken (again, accidents happen), some may be right but don’t have a winnable case, and some, like the Antonios, have a claim that becomes the basis of a lawsuit. On November 18, 2015, in a phone call, Linda unloaded her story to Krysia Syska, a partner at Meyer’s firm who ultimately represented the Antonios. For the first time, Linda says, “somebody was listening.”

Meyer and his team see their work as the last line of defense against a sprawling, powerful, and indifferent regime. After all, Meyer says, the medical industry and state government have never adequately protected patients. “I say to my team all the time that we’re the consumer protection bureau,” he tells me. And he likes to make sure Charlie Baker knows about it. “When I see the governor,” Meyer says, “and he asks, ‘How’s business?’ I say, ‘The bad news for the patients of Massachusetts is that our business is very good.’”

Critics of medical malpractice litigation, including many patient-safety advocates, argue that lawsuits don’t make medicine any safer, can be distressing for the patients who file them, and are often gratuitously damaging to physicians. Even Meyer admits that malpractice lawsuits are an imperfect proxy for doctors’ performance and likens them to speeding tickets. “If you get one,” he says, “maybe that doesn’t mean anything. If you get two or three, maybe then it’s time to ask questions. But when you start getting four or five over a reasonable period of time, you’re probably driving too fast.” Malpractice attorneys have a name for doctors who are repeatedly sued: “frequent flyers.” Although attorneys and their clients can potentially reap financial gain by taking a physician to court, they can’t remove bad doctors from practice. That’s the responsibility of the medical board, which is charged with investigating, disciplining, and licensing doctors. The problem, Meyer says, is that it’s never been very good at the job.

Look, for instance, at the career of John Farricy, an obstetrician and one of the most frequent “frequent flyers” targeted by Meyer’s firm. Farricy has been known to the medical board for at least 30 years, since his first publicly disclosed malpractice payment in 1988. Since then, he has been the target of no fewer than 15 malpractice claims. Allegations in lawsuits against Farricy—some of which resulted in payments, and some of which were dismissed for failure to present sufficient evidence of negligence—run the gamut of OB/GYN complications from preventable birth defects to missed cancer diagnoses. As far back as 1994, he appeared in a Globe Spotlight report highlighting his multiple lawsuits related to brain-damaged babies. In defense, Farricy told me that malpractice claims were a “hazard of the business” and that his high rate was the consequence of running a busy practice in obstetrics, a specialty that served as a magnet for lawsuits up through the 1990s, he says, when most of his cases were settled.

But the lawsuits against Farricy didn’t stop in the 1990s. He settled one case against him (which doesn’t appear on his board profile) in 2010 and made a malpractice payment in another case in 2016. But the board has never taken serious action against him. The most it has ever done, according to board records, is send him letters stressing the importance of clearly communicating with patients before performing procedures. Today, Farricy’s license, issued by the board, is “active” and unrestricted, and he remains in practice in Worcester.

One of the board’s problems is workload. With more than 40,000 licensed physicians in Massachusetts, the watchdog fails to keep tabs on everyone. But the other charge leveled at the board—that it has long been too deferential to doctors and to the attorneys who represent them—is harder to explain away. One nightmare case goes back almost 20 years, but haunts Meyer to this day. In the fall of 2001, he received a call from an anguished father. Paul Hamburg, the associate director of an eating disorder program at Mass General, had repeatedly sexually abused the man’s daughter while she was under Hamburg’s care, according to a lawsuit filed in Suffolk Superior Court. Meyer says he notified the medical board to let officials know that Hamburg might pose a danger to others. Soon after, the board began an investigation and Hamburg’s colleagues rallied to his defense, praising him as an accomplished and respected psychiatrist and professor. Ultimately, the medical board put Hamburg on probation and required him to take 20 hours of courses about maintaining appropriate boundaries with patients and keeping proper records. Then he went back to work at MGH.

Meyer was furious, and horrified. “They never only do it once,” he told me.

Six years later, in October 2008, Meyer filed another complaint against Hamburg, this time on behalf of a young woman who alleged that Hamburg had manipulated her into a sexual relationship while treating her for an eating disorder. This time, Meyer contacted Hamburg’s lawyer, and within weeks Hamburg had voluntarily surrendered his medical license, according to medical board documents. The board took no further action and there is no record of the second complaint in readily accessible documents. Still, during the seven-year interval between Meyer’s interventions, Hamburg had been treating vulnerable women with the blessing of the medical board and under the banner of one of the world’s most prestigious hospitals.

After the Hamburg disgrace, and an unrelated embarrassing Globe exposé about the medical board, then-Governor Deval Patrick cleaned house. In 2012, he replaced five of the board’s seven members, clearing the way for Candace Sloane to become chairwoman. Sloane, known as an uncompromising patient-safety crusader, ushered in a period of reform. She improved transparency, took some frequent flyers out of commission, and developed a reputation for being far less cozy with healthcare interest groups and physicians’ attorneys than her predecessors. Then came the backlash. In recent years, two groups—the Massachusetts Medical Society, which is the state’s principal physicians’ lobby, and the defense bar, an ad hoc group composed of physicians’ defense attorneys—have waged a silent campaign to take back the board. The appointments of Medlock and another new member, Paul Gitlin, marked their first victories.

On Monday, December 4, 2017, Marylou Sudders, the state secretary of Health and Human Services, had plans to meet with Charlie Baker to discuss upcoming changes on the medical board. New seats would soon open up, and the governor had a chance to appoint replacements.

As the head of HHS, Sudders ran the process of picking and vetting candidates. But rather than conducting a rigorous search from within HHS, she essentially phoned a friend. According to HHS emails, on the Friday before her meeting with Baker, Sudders’s deputy chief of staff, Robert Jones, reached out to a lobbyist at the Massachusetts Medical Society. Jones knew the society planned to suggest potential candidates and asked if the group could provide recommendations immediately. Three days later, the lobbyist responded with two names: Michael Medlock and Paul Gitlin.

A vast, multifaceted organization, the Massachusetts Medical Society wears many hats, including publisher of the prestigious New England Journal of Medicine. But as the state’s most powerful physicians’ lobby, the organization has a history of locking horns with Sloane and is on record opposing some of her pro-patient reforms. Now that seats on Sloane’s board were opening up, the group suggested a pair of allies who were friendly to their cause. Sixty days later, Baker, whose office didn’t respond to detailed questions, granted their wish.

In hindsight, the Gitlin pick should have raised red flags from the start as a potential conflict of interest. Not only had Gitlin previously served as chairman of the medical board at a time when its members were known to be especially pliant, but he was also an active physicians’ attorney himself. Making matters more complicated, Baker appointed him to serve as a non-physician “public member” of the board. Massachusetts law says that public members of boards cannot have had substantial business relationships (defined as more than 2 percent of their practice) with professionals licensed by that board within the past five years. As an attorney, though, Gitlin had represented numerous doctors before the board, as recently as late 2017, according to a government official familiar with the board’s functioning. Some close observers of the board were stunned to see Gitlin appointed. “Here he was,” says the government official, “one month representing doctors as an attorney, and then the next month he was on the board representing the public.” Still, Gitlin says he has significantly scaled back his practice in recent years and that his relationships with such clients have not exceeded that 2 percent threshold.

Meanwhile, the problems with Medlock’s appointment didn’t surface until HHS issued a press release in February 2018 naming him to the medical board. It painted Medlock as an esteemed practicing neurosurgeon at North Shore Medical Center–Salem Hospital and Mass General. But that wasn’t exactly true. At the time of Medlock’s appointment, he was unaffiliated, having split with North Shore Medical Center and MGH almost a year earlier.

The press release and Medlock’s résumé also overstated some of his credentials. Both documents listed him as an “assistant visiting surgeon” at MGH, even though he hadn’t held that title since 2005. (Medlock says, “My résumé was not clear on this change in title.”) Medlock’s résumé and the state’s official press release also listed him as the president of the Massachusetts Society of Neurosurgeons, which sounds important, but isn’t. The group has no office, no website, and no paying members. Its last listed address was Medlock’s house. Once a small lobbying outfit closely aligned with the Massachusetts Medical Society, “it may not be functional anymore,” admits Stephen Johnson, a former president of the organization. Finally, on the application Medlock submitted to the government to join the board, he omitted a malpractice lawsuit that had been settled for $1 million, as the application required him to do, government documents indicate. (Medlock says, “I did not read the document to require providing this information and did not intentionally omit anything.”)

When asked about the false statements in the press release, HHS spokespeople at first said they were simply clerical errors, but when pressed they changed their story and said they’d known all along that Medlock was no longer working at the hospitals. But their own emails suggest otherwise. HHS documents dated January 2018 affirmatively list Medlock as a surgeon at North Shore and at Mass General. The barest amount of due diligence on Medlock surely would have revealed this wasn’t true.

When Medlock and Gitlin took their seats on the medical board in February 2018, they joined a body firmly under chairwoman Candace Sloane’s control. She had purged senior staffers from the pre-2012 days; brought in a widely respected prosecutor, George Zachos, from Attorney General Maura Healey’s office to serve as executive director; and reoriented the board’s priorities to make it tougher, more aggressive, and less collegial with the physicians’ attorneys who appeared before it. Physicians’ attorneys say that some staffers resented the changes, and members of the ad hoc defense bar stewed over their new pariah status. But by nearly all accounts, the board members themselves, largely committed to Sloane’s patients-first vision, were getting along quite well. That all changed when Medlock and Gitlin arrived.

Now there were two voluble dissenters among the board’s ranks and, for the first time in years, board meetings became contentious. Medlock, sources say, was often the chief instigator. He delivered speeches inveighing against the board’s decisions and “is sort of nonconformist with anything the board proposes,” says the government official familiar with the board’s functioning. “He is quite difficult to get along with. He’s a bit like a bull in a china shop.”

Medlock now sits on the board’s licensing committee, responsible for deciding who gets to practice medicine in Massachusetts. In this role, he has rebelled against some of Sloane’s strict standards. “His general position is to license anybody, that the board is being too picky with competence,” says a government official who asked not to be named for fear of reprisal. Medlock and Gitlin have often voted together when a controversial licensing issue comes before the board.

Medlock denies he has advocated for a departure from Sloane’s standards, saying, “My goal is to administer the laws and regulations of the commonwealth fairly and transparently in order to promote patient safety.” Meanwhile, attorneys who represent physicians in licensing matters feel the previous personnel had been overzealous and often overreacted to small bureaucratic issues. “I think in the last year,” says attorney Andy Hyams, “the licensing process has gotten much better.”

Gitlin has proven to be subtler than Medlock. When he arrived on the board, he began advocating for policies favored by his former colleagues on the defense bar. One pet issue is a device called a Letter of Agreement, a tool that once enabled the board to enter into confidential agreements with doctors instead of carrying out discipline in public view. Gitlin says these agreements were useful for discreetly dealing early on with physicians who have substance-abuse issues. But the board, under Sloane’s leadership, “discontinued this practice in 2012, because it is committed to greater transparency,” Zachos explained in an email. Gitlin says “a major reason” he accepted an appointment to the board was to protect patients, adding, “Each of my fellow board members and I share this purpose and our only disagreement is the best and most efficient way to protect the public.”

From the outside, defense attorneys have gleefully watched Medlock and Gitlin peck away at Sloane’s reforms. The way they see it, the two new board members are a corrective to the chairwoman’s reign of terror, during which the board ignored due process to zealously go after unfairly maligned doctors. They point to what they regard as abuses, such as the board’s practice of not always providing doctors with a copy of a complaint against them before subjecting them to an interview. “That’s so fundamental to due process,” Hyams says. In response, Zachos states that in some circumstances, such as when a complaint comes from an anonymous whistleblower, the board cannot share the complaint but does “provide the nature of the allegation.”

At the same time, a package of Sloane’s proposed pro-patient reforms, sent to HHS by the board, have not been made permanent, according to the current and former government officials. And HHS has continued to act in lockstep with the Massachusetts Medical Society and the defense bar by stalling their approval. “The board finalized everything, sent it up to the state, and it’s been in the cooler there,” says a current government official. Until these pending regulations pass, however, new leadership could abandon them overnight. With Sloane’s term on the board ending next year, that means time is of the essence.

Meanwhile, Antonio’s days in the Mass General ICU—head screwed into a halo, limbs hooked up to beeping machines—marked only the beginning of an arduous and incomplete recovery. His next stops included Spaulding Rehabilitation Hospital and a nursing home in Topsfield, where he spent months regaining, among other things, the ability to walk. Spaulding was also the place where Antonio took full stock of the damage done to his body. His original symptoms—tingling hands and feet, face-plant-inducing loss of balance—had not improved. Instead, his disability—once predominantly an issue of his lower body—is now most apparent in his arms. He can no longer raise his limbs by more than about 30 degrees on his own.

Antonio’s new disabilities have forced him and his wife to reimagine their retirement. Linda has given up travel. “I can’t leave him alone,” she says. Antonio, for his part, now lives a circumscribed life. Robbed of the dexterity in his hands, he won’t even go out to eat anymore. “It’s too embarrassing,” he says. Meanwhile, their lawsuit winds its way through the courts, as Medlock denies any wrongdoing. It makes them queasy to think that the doctor they blame for changing the course of their lives now sits on the medical board and holds responsibility for ensuring the same thing doesn’t happen to others. Still, Antonio tries not to be mad. “I don’t hate him,” he says. “I’m just disappointed in him.”

On a Tuesday afternoon in early April, Medlock rang me on my cell phone. I had left a message for him with a nurse at North Shore Community Health, where he now works prescribing medication to opioid addicts, and he was returning my call. He spoke quietly and cautiously in a nasal voice. I asked Medlock how he viewed his responsibility as a board member. “My role on the board is to protect the public interest, to make sure that people practice safe medicine in the commonwealth,” he said. When I mentioned I was particularly interested in patient safety, he replied, “It’s a very important topic. And we can always do it better.”

Source URL: https://www.bostonmagazine.com/news/2019/06/05/truth-about-boston-doctors/