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Spotlight follow-up

N.H. doctor allegedly misread mammograms, ultrasounds of two dozen women later diagnosed with breast cancer

Some victims have criticized the N.H. Board of Medicine for failing to revoke the license of Dr. Mark Guilfoyle, formerly of Dartmouth Health, and none of his 13 malpractice settlements are posted on the board website

Cheryl Jensen of Bethlehem N.H., said that mammogram misreading by radiologist Dr. Mark Guilfoyle “ruined the rest of my life,” giving her breast cancer time to spread before it was diagnosed.Rose Lincoln for The Boston Globe

Patricia Eddy had always believed in early detection of breast cancer, and she was relieved when her mammograms in 2015, 2016, and 2017 revealed nothing suspicious. It wasn’t until later that she learned the alarming truth: Those three annual screening tests had shown signs of cancer, she said, but her New Hampshire radiologist, Dr. Mark Guilfoyle, had missed them every time.

In her shock and fear and then her fury, she had plenty of company among the doctor’s patients, the Boston Globe Spotlight Team has found. In a two-year span while working in the state’s sparsely populated North Country, Guilfoyle failed to spot signs of breast cancer in the mammograms or breast ultrasounds of two dozen women, according to a top clinician at Dartmouth Health, which hired Guilfoyle in 2015 to provide radiology services at three small, rural hospitals.

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Dr. Mark Guilfoyle was hired by Dartmouth Health to provide radiology services at three small, rural hospitals in northern New Hampshire in 2015.

In 2020, 11 of those women settled malpractice claims alleging that Guilfoyle’s negligence resulted in delayed diagnoses of their breast cancer, with potentially life-threatening repercussions, and ultimately received a payout totaling $4.6 million. There is no mention of any of these settled claims or of two earlier ones in his career for alleged diagnosis errors in Guilfoyle’s physician profile on the website of the New Hampshire Board of Medicine.

Eddy, who underwent a double mastectomy, is outraged by what she sees as kid-glove treatment of Guilfoyle by the board. The agency reprimanded him, fined him $750, and forbade him from reading mammograms. But it let him keep his medical license, so he could continue interpreting other X-rays and radiological images, which he does now in Michigan.

“Personally, I don’t think he should be reading anything,” said Eddy, 66, a special education consultant in Lancaster, N.H., who said the board should have revoked his license. “You’ve got this doctor who was harming innocent patients with his ineptness, and they’re doing nothing about it.”

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Through his attorney, Guilfoyle declined to respond to requests for comment. His lawyer, Jason Gregoire, of Portsmouth, N.H., said that the 2019 agreement Guilfoyle reached with the board “speaks for itself.”

A spokesperson for Michigan’s department of licensing and regulatory affairs told the Globe that Guilfoyle’s current Michigan license does not bar him from reading mammograms there, but his lawyer said the doctor has not read a mammogram since he left Dartmouth.

The exposure of potentially life-threatening errors and criticism of the New Hampshire medical board come at a time of heightened scrutiny. A Spotlight Team investigation found that another physician in that state, Dr. Yvon Baribeau, appeared to have a pristine record on the board’s website despite 21 medical malpractice settlements and at least one major disciplinary action at Catholic Medical Center, where he worked for nearly three decades.

In contrast, the website of the medical board in Massachusetts, where the cardiothoracic surgeon was also licensed, reported 20 of his 21 New Hampshire malpractice settlements. New Hampshire Attorney General John Formella is currently reviewing the practices of that state’s board of medicine.

The Globe investigation also found that CMC ignored repeated warning signs about Baribeau, an issue currently under review by an outside firm hired by the hospital.

Unlike CMC, Dartmouth Health, which is affiliated with Dartmouth’s Geisel School of Medicine, appeared to play a proactive role in uncovering and addressing Guilfoyle’s many mistakes. Dr. Rebecca Zuurbier, then director of breast imaging at Dartmouth Hitchcock Medical Center, raised concerns about Guilfoyle’s work in 2017, she told the Globe, and led an exhaustive review of every mammogram and breast ultrasound the radiologist had interpreted from more than 5,500 patient visits.

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“There were 24 patients with known missed breast cancers,” said Zuurbier.

“Dartmouth Health acted immediately and decisively when it was determined that there was an alleged irregularity in one of his mammogram readings,” Dartmouth spokesperson Audra Burns told the Globe. Dartmouth put Guilfoyle on administrative leave in 2017, contacted patients “identified to be at potential risk” to give them further testing and treatment if necessary, and signed a separation agreement with Guilfoyle in 2018, Burns said. She added that an internal review found his other radiology work met expected standards.

Dartmouth also alerted the medical board, as required by state law, prompting the agency to investigate “allegations of professional misconduct,” according to the board’s Sept. 10, 2019, settlement agreement with the radiologist.

But the board fell woefully short by not revoking his license, said some former patients.

Cheryl Jensen, a 76-year-old retired journalist from Bethlehem, N.H., said Guilfoyle “ruined the rest of my life” by misreading her mammograms and thus giving her breast cancer time to spread to her lymph nodes before it was diagnosed in early 2018. She had to undergo surgery, chemotherapy, and radiation.

“For me, the main issue is the Medical Board. Its lack of action and transparency,” said Jensen in an e-mail. She wrote the agency in 2020 urging it to reopen its investigation and revoke Guilfoyle’s license, but received a reply saying “the Board considers that matter to have been fully investigated.”

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Jensen told the Globe, “He got a slap on the wrist, and I got a slap in the face from that Board.”

Eddy had written the agency a wrenching letter in August 2017, detailing her grueling experiences with breast cancer and treatment and asking why Guilfoyle was still practicing medicine. More than eight months later, the board responded with a letter saying her complaint had not led to “formal disciplinary action.” It wasn’t until more than two years after Eddy’s letter that the board reached its settlement with Guilfoyle, following Dartmouth’s 2018 reporting of the doctor’s surrender of clinical privileges.

Patricia Eddy of Lancaster, N.H., wrote the New Hampshire Board of Medicine a wrenching letter in August 2017, detailing her grueling experiences with breast cancer and treatment and asking why Guilfoyle was still practicing medicine. Patricia Eddy

In other states, some radiologists have faced more stringent sanctions. Last year in Virginia, the board of medicine revoked radiologist Michael Bigg’s license for alleged failures in diagnosis and treatment of 18 patients, including misreading mammograms.

Dr. Emily Baker, president of the New Hampshire medical board and an obstetrician and gynecologist at Dartmouth Health, told the Globe via e-mail that she was not authorized to speak for the agency. Lindsey Courtney, executive director of the state’s Office of Professional Licensure and Certification, which oversees the administration of New Hampshire licensing and regulatory boards, e-mailed that she was not authorized to speak for the board, either. “To the extent the board took disciplinary action, the reasons and rationale are captured in the orders,” she said.

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Eddy and Jensen had their mammograms at Weeks Medical Center in Lancaster, N.H. Both later hired Holly Haines, a plaintiffs’ lawyer in Manchester, N.H., but declined to say whether they were among the 11 patients who settled malpractice claims with Dartmouth, as did the attorney. Haines’s firm, Abramson, Brown & Dugan, typically consents to confidentiality agreements with hospitals and doctors if clients reach out-of-court settlements, barring information about them from being made public.

The issues involving Guilfoyle surfaced last month when Haines appeared before a legislative committee examining the medical board’s role, which was convened in the wake of the Spotlight stories. The committee was debating, among other things, whether the board should post public information about doctors’ malpractice settlements and hospital disciplinary actions online.

As the Spotlight Team previously reported, New Hampshire patients have no simple way to learn important information about a physician’s past because the state’s medical board is one of the least transparent in the country. Unlike those in many other states, it does not make public a doctor’s malpractice settlements, hospital disciplinary actions, or criminal convictions, the Globe found.

New Hampshire’s board was also identified by Public Citizen, a nonprofit advocacy group, as having the lowest rate of serious disciplinary actions against physicians of any state between 2017 and 2019, the years it studied.

Guilfoyle had settled two medical malpractice claims in Michigan before coming to New Hampshire in 2015, according to court and licensing records. That makes a total of 13 known malpractice claims ending in settlements.

Thirteen is an extraordinarily high number of malpractice settlements for a physician in any specialty, said Robert Oshel, an expert on malpractice and medical discipline issues. Only about 0.03 percent of all US doctors have had 13 or more malpractice payments since 1990, said Oshel, a former official at the National Practitioner Data Bank, which provides information on such payments to state medical boards.

The $4.6 million malpractice payment made to Guilfoyle’s Dartmouth patients is listed in his online physician profile posted by the medical board in Georgia, where the radiologist is also licensed. Dartmouth reported a lump-sum payment for all 11 claimaints to the National Practitioner Data Bank, according to licensing records obtained by the Globe, so it looks like just one malpractice award on the Georgia board’s website.

Guilfoyle is licensed in eight states, including Idaho, Iowa, Kentucky, Vermont, and Washington. But in a sign of how states vary in what physician information they make public, only Georgia listed the $4.6 million malpractice payment.

Lori Nerbonne, a nurse who cofounded the patient advocacy group New England Patient Voices, said she wants the New Hampshire board to post all doctors’ medical malpractice settlements. “It’s yet another dimension that patients can take into consideration and it does nothing to harm ‘good doctors,’ Nerbonne said via e-mail. “The Board should be more focused on protecting the public.”

Guilfoyle’s many errors stand out even as researchers and clinicians stress that mammogram interpretation can be highly challenging. Screening mammograms miss about one in eight breast cancers, according to the American Cancer Society. And delayed breast cancer diagnoses are a common reason for malpractice claims against radiologists, reports show.

The missed cancers are not always the doctors’ fault, however. Small masses can be hard to spot because of numerous factors, including the density and complexity of breast tissue and the availability of a patient’s earlier comparison mammograms, said Zuurbier, who has long served as an expert witness in malpractice cases for both plaintiffs and defendants.

“I liken it to looking at a Jackson Pollock painting, with all the splashes and splotches and dots,” Zuurbier said. “If someone puts one new dot in, are you going to pick that up? I can go back later and find that new dot, though it’s sometimes difficult. But there are basic things you learn that you shouldn’t miss.”

With Guilfoyle, Zuurbier said, “he had a lot of big misses.”

The delayed cancer diagnoses have left lasting physical and emotional effects, said Eddy, whose black Toyota has a license plate that says “SURVIVA.” She said she was so disgusted by the leniency of the medical board that she couldn’t bear to read the 2019 settlement with Guilfoyle in its entirety until this month.

“What I wanted right from the get-go, I wanted his license,” she said. “I was advocating for myself but I was advocating for every other woman out there who was going to get a mammogram.”

Staff reporter Deirdre Fernandes contributed to this report


Jonathan Saltzman can be reached at jonathan.saltzman@globe.com. Rebecca Ostriker can be reached at rebecca.ostriker@globe.com. Follow her @GlobeOstriker. Liz Kowalczyk can be reached at lizbeth.kowalczyk@globe.com.