When Anthony Garcia applied for a medical license in Illinois in 2003, Creighton University officials indicated he had “satisfactorily completed” one year of pathology training at the school.
That despite the fact that Creighton had moved to terminate him in 2001 less than 11 months into his troubled residency. Had Creighton indicated to the State of Illinois that Garcia had failed to complete a year of residency, that likely would have raised a “red flag” for his license application, according to Illinois' medical licensing authority.
“There is nothing on here that suggests there was a problem,” Susan Hofer, a spokeswoman for the Illinois Department of Financial & Professional Regulation, said of the documentation Creighton submitted.
Illinois suspended Garcia's medical license recently in the aftermath of the doctor's arrest in a pair of double homicides: the 2008 deaths of 11-year-old Thomas Hunter and Shirlee Sherman, and the May deaths of Dr. Roger Brumback and his wife, Mary. Police have said the four killings were motivated by a simmering grudge Garcia held against Creighton pathologists Brumback and Dr. William Hunter, Thomas' father, for firing Garcia in 2001.
Questions have now been raised on how Garcia was able to obtain a physician's license in Illinois, particularly given that he was subsequently rejected for licenses in at least three other states. While many of the questions have focused on Illinois' actions, it also appears Creighton contributed to Garcia's ability to gain the license in at least two ways.
Not only did the university indicate that Garcia had satisfactorily completed one year of residency, the school did not report its termination of Garcia to the State of Nebraska. Had it done so, state officials likely would have revoked the temporary permit issued to Garcia to practice medicine as a Creighton resident.
The state would also have notified two national practitioner databases about the permit termination, an action that could have created a red flag for Garcia's subsequent Illinois license application.
Creighton officials declined last week to answer questions for this article, citing the current police investigation into Garcia.
“At this time, we simply can't elaborate — even generally — about our process for releasing resident information to state licensing boards due to the ongoing investigation and to protect the integrity of the case,” said Jennifer Homann, a Creighton spokeswoman.
But she said Creighton follows accepted standards in graduate medical education in what it reports to state licensing boards.
For many residency programs, it appears standard to provide limited information on past residents when state licensing boards seek to verify their training.
Garcia, a California native and a 1999 graduate of the University of Utah's medical school, began a pathology residency at Creighton in July 2000. Indications are that his time at the school and affiliated teaching hospital was tumultuous.
A Creighton faculty member has said that Garcia's work in the lab and classroom was inadequate and that he was often rude and insolent. The last straw was an incident on May 17, 2001, in which Garcia was accused of attempting to sabotage another resident who was taking a high-stakes national exam.
Creighton officials decided the incident constituted unprofessional behavior and, on May 22, 2001, asked Garcia to resign or face termination proceedings. On June 26, an appeals committee unanimously supported the termination. Hunter, the pathology residency director, and Brumback, the department chairman, argued for Garcia's termination.
Garcia appealed to the dean of the medical school, who upheld the termination on July 12.
Yet Hunter and Brumback later signed documents requested from state licensing boards in Illinois, Indiana and California, verifying that Garcia's residency lasted one full year, from July 1, 2000, to June 30, 2001.
The fact that Garcia's appeals extended his tenure at Creighton past June 30 might explain why the university gave him credit for completing a full year.
Remaining unclear is what definition the school used in determining that his training had been completed “satisfactorily” — the term Hunter and Brumback used in the three verification letters.
Garcia also had abbreviated stays in two other residencies. He resigned six months into his residency at a New York hospital in 1999 after yelling at a radiology technician. The University of Illinois-Chicago ended his contract in 2004 after 19 months because of several long absences from the program, apparently because of health problems, and his failure to communicate with the staff about the absences.
Garcia applied for full medical licenses in Illinois, California, twice in Indiana, and Louisiana. Only Illinois granted him a license.
When he applied for a license in Indiana in 2008, officials from the residency programs in Omaha, New York and Chicago provided verification letters that gave only the length of time of his service.
But Illinois does not routinely take one step that some state licensing authorities do: ask applicants to sign a release authorizing residency programs to provide more information on the applicants' residencies.
When Indiana obtained such a signed release from Garcia in 2012, Brumback disclosed that Garcia had been fired from the Creighton program. It has been speculated that the letter in late 2012 might be the motive for Garcia allegedly killing Brumback.
Hofer, the spokeswoman for the Illinois licensing authority, said the state sometimes asks license candidates to sign such releases. But she said it's not standard and is usually requested only when other red flags have been raised on a candidate.
The state didn't see red flags with Garcia in 2003, she said. According to the records provided by Creighton and the University of Illinois, Garcia met the state's requirements for licensure because he had satisfactorily completed at least two years of residency.
He subsequently used his Illinois license to work at two clinics in Chicago, from 2009 to 2012.
Garcia's firing also could have come to the attention of Illinois if Creighton had reported it to the State of Nebraska, which had granted him a temporary permit to practice medicine as a Creighton resident.
Under state law, when a health care facility takes an action “adversely affecting the privileges or membership” of a credential holder due to alleged “unprofessional conduct,” the facility must report the action to the state within 30 days.
Helen Meeks, administrator of the licensure unit in the Nebraska Department of Health and Human Services, said she could not comment on particulars of Garcia's case because the state has no official information on what happened during Garcia's residency.
She said, however, that the firing of a resident for unprofessional conduct in general should be reported to the state.
“They are required to report that to us,” she said.
Once a health care facility reports the firing or suspension of a permit holder, the state would treat it as a complaint, which could lead to disciplinary action. If the permit holder is disciplined, the state would typically report that to two national databases. One is operated by the federal government and the other by a consortium of state medical licensing boards.
In some instances, the federal government requires hospitals to report adverse actions against a staff member directly to the federal databank. However, that direct reporting requirement does not apply in the case of medical residents.
Hofer said Illinois checked both national databanks before issuing a license to Garcia.
Illinois officials have faced criticism for issuing Garcia a license, particularly given the fact that he was rejected by at least three other states.
Hofer said those other states had more information to go on than Illinois, the first state in which Garcia sought a full license. By the time Garcia applied for his license in Indiana in 2008, he disclosed his firing by Creighton — something he did not do on his Illinois application.
He also disclosed to Indiana the incident in New York, a residency he had completely left off his Illinois application.
Hofer said she could not say for sure how Illinois would have responded to Garcia's license request had his residency problems been disclosed a decade ago.
But there's no question his application would have been subjected to far more scrutiny. Today, in all likelihood, he would have been called to appear before the board.
“People have said 'Why did you issue him a license when no one else did?' ” she said. “We knew a lot more (about Garcia) in 2012 than we did in 2001.”