From the New York Times, I'm Sabrina.

Tavernisi, and this is the Daily.

A.

Times investigation has found that doctors are increasingly performing unnecessary medical procedures that generate huge profits while often harming patients. Today, my colleague Katie Thomas on the forces driving this emerging and troubling trend in american healthcare.

And the story of one family caught.

In the middle of it. It's Monday, February 19. So, Katie, tell me about this investigation.

So I am a healthcare reporter who writes about the kind of intersection of healthcare and money. And I was working with two other colleagues, Sarah Cliff and Jessica Silvergreenberg. And together the three of us had long been interested in are the medical procedures and the tests and other things that we get when we go to the doctor or into a hospital, are they always necessary? But what we were really interested in exploring was not just, are these procedures and are these tests, et cetera, are they necessary? But in some situations, could they actually be harmful to patients? And so that's what we decided to try and take a look at. And so we had gotten started in our reporting when we got a tip, and it was from a mom in Boise, Idaho, and her name was Lauren Lavelle. Hi. Nice to meet you. Hi, how are you? And my colleague Jessica Silvergreenberg, and I went to her house to meet with her.

And where does her story start?

I am a mom of two. I live in Boise. My daughter June is four, and I have a 17 month old, Flora.

Her story starts when Lauren gets pregnant with her daughter June.

So by the time we got pregnant with June, November of 2018, about eight months after we had the miscarriage, I think I was just more hesitant and nervous than anything.

Lauren and her husband had had trouble conceiving, and so they were so happy when they learned that they were going to have June. And like most first time parents, they were also a little bit nervous.

But being type a and super prepared, I did all my homework. We hired a doula. I wanted an epidural. Having AN ActuAl Childbirth absolutely was not for me.

And LAURen is very organized. She's always on top of everything, and she makes all sorts of plans, and she gets a lot of different providers lined up ahead of time.

I didn't know anything about breastfeeding, like.

Zero things, including one that she has hired to help her with breastfeeding. Where did you find out about her?

So I asked ArDUla for a list of recommendations, and she gave me a very short list. At the time, there were very few lactation consultants in the VAlley, and MElAnie was one of them.

She ended up deciding to work with melanie Henstrom, who is a local lactation consultant in Boise.

She sold this package at the time. I don't know if she still did, but it was like prenatal visit, breastfeeding class, and then she'll come to the hospital and help you Latch, and then she'll come to the house a couple of times after. And I thought, well, that sounds perfect. Great, I'm covered there.

So one week after her due date, she gives birth. And it was a difficult labor. It took 24 hours. LAURen was completely exhausted. But once JUne arrived, the family was very, very excited to have her.

And I remember JUne coming out and that Surreal feeling you have when you see your first baby for the first time. Like, oh, my. Like, there's a baby in the Room.

And JUne was a healthy baby, but she was having trouble breastfeeding.

She would not latch. Like, she wouldn't even attempt. She would scream. It was the only time she ever cried if you tried to make her to breastfeed.

So as her pediatrician was making the round, they noticed that JUne was having trouble and said that JUNe's TonGue is really tight.

We can clip it if you'd like.

And that they could clip it.

What does that mean exactly, Katie? Clipping her tongue?

What it means is that there's a SmAll PeRCeNtage of babies whose tongue is very tightly tethered to the bottom of their mouth. And for a very small percentage of babies, their tongue is almost tied so tightly down that they can't nurse well.

So it makes breastfeeding very difficult if a baby has a tongue like this.

Exactly. If you bottle feed your baby, the baby can basically adjust and make do. But if you want to breastfeed, some babies have trouble basically latching on to their mother when they don't have that tongue motion. And so some version of clipping these tongue ties has been done for centuries. Midwives have been doing it, pediatricians do it. And traditionally, what it's been is a very quick Snip right underneath the tongue just to loosen up the tongue. And traditionally, that procedure is extremely straightforward. There's little to no follow up care. And basically, the baby naturally heals as it learns to breastfeed.

And so we said, okay, they explained that it was completely painless.

They do it with Scissors.

She wouldn't even feel it. And all of that was true. They clipped it. I don't even think she woke up.

But in June's case, it didn't seem to help much. And she and Lauren were still having problems breastfeeding afterwards. So while she's still in the hospital. She calls up the lactation consultant that she had hired, melanie Henstrom, just to let her know what was going on. And from talking to her on the phone, Melanie said that the situation was actually much worse than Lauren had thought, and that Lauren's baby needed another tongue tie procedure. A deeper cut under the tongue.

How did she make this diagnosis, Katie? Was it over the phone? How did she know this?

Yes, Lauren told us that it was from a phone conversation. And in addition to that, she also warned her that know Lauren and her husband should really take this seriously and consider getting it done. Because if she doesn't get it fixed, it could lead to a whole host of problems, beyond just problems. Breastfeeding.

She'll have scoliosis, and she'll suffer from migraines, and she'll never eat, and she'll have a speech impediment. She won't sleep. I mean, just like the long list of things over the phone.

Then Lauren starts panicking.

I mean, first of all, I've never felt more terrible in my life than that first day or so after giving birth. Like, the comedown from the hormones, the drugs, all of it, the sleep deprivation. And then here was this baby we'd wanted. We were told we probably would never have after one miscarriage. And she's so perfect. Like, the most beautiful baby I'd ever seen. And you think that she has some deformity that's going to ruin her.

But Melanie says it's know she has a solution. And she tells Lauren that there's a dentist in town who can handle cases that are as severe as June's.

A dentist? Why a dentist?

Well, there's a procedure that's done in a dentist's office that's a laser surgery. And dentists use this high powered laser machine that can quickly cut the flesh that connects the lips and the cheeks to the gums. So according to Lauren, Melanie tells her that by chance, this dentist has an opening, because she said a family coming in from Oregon had just canceled their Saturday appointment.

So I thought, okay, wow, you know, people are coming in from Oregon to see him. So we talked about it. We both felt unsure, but we said, well, let's at least take the appointment, and then we can at least meet with the dentist, and also someone can look at our mouth.

And so Lauren agrees to go in and meet the.

Like, I think some people, when they hear this story, think, like, why would you believe, like, it just sounds so scammy. But to me, there's a lot of things that you hear in the hospital that sound insane. It's no different than someone saying, like, your baby's orange because their Billy Rubens, their lovers are too high. So we got to go put them under these lights. That sounds insane. That sounds more insane. Know, your baby's having a hard time eating because their tongue is too tight, and it needs to be like, that seems rational, actually.

And all of this seemed really weird to Lauren at the, you know, in the context of the hospital and having a baby. Lots of things about healthcare are weird. So one day, after they got back home from the hospital, Lauren, her husband, pack up the car and go to the office.

Early in the know, I was wearing my hospital diaper and an ice pack took the elevator up to his office. And what happened?

So Melanie greets them at the door. They sign some paperwork, and pretty soon, the dentist, Dr. Samuel Zink, arrives.

And then he very briefly looks in her mouth and is like, yeah, she's got whatever. However, he classified it grade four.

Whatever.

He says, class four. And she has a lip tie, which that had never been mentioned to us before. So it's very much, like, on the spot, like, this new piece of know.

Pretty quickly. The dentist diagnosed June as having a couple of ties. He confirmed that she had a tongue tie, and he said it was severe. He also said that she had tightness under her top lip, called a lip tie. And so the baby actually needed to get two cuts. And again, Lauren said that the dentist and the consultant told her how important it was for her to do this for her baby.

One of us know what happens if we don't do the like, what are our alternatives? And it was basically like, there's no alternative. Like, you have to do otherwise. Like, again, long, long.

So Lauren and her husband decided to do it. But before the procedure starts, Melanie actually stopped Lauren from coming into the room.

Melanie turned around and put a hand on my shoulder and said, oh, no. And I said, oh, am I not going with you? She goes, well, we can't tell you. You know, if you hear her cry, it'll impact your milk supply, like, adversely.

What do I know?

So I said, oh, okay. And she pulled out the white noise machine and said, what do you want to listen to? And I had no idea what she was talking about. I had no idea what it. And so then she just turned it on white noise and left.

What happens next is Melanie turns on a white noise machine in the room.

And that was the moment that I was like, get your baby and get out of here. And I didn't listen to it. It was like all of my mom intuition firing, being like, this isn't right. I don't know how to describe it, but, like, a full body. You have to get your baby and get out of here. And I just ignored it.

She said her maternal instincts really kicked in, and she just had this instinctive fear about the procedure and whether June would be okay. But the procedure itself was very quick. Within just a couple of minutes, Melanie returns with June.

And she was screaming, like, screaming and so worked up. This was, like, hysterical, inconsolable. And she was also choking on something, like gagging.

And June was so worked up. Lauren had only had her for a couple of days, but she said that this was on a different level than any other way she had ever seen June crying. And June just wouldn't stop crying. And she looked over to Melanie, and Lauren said that she remembered Melanie saying this was very typical. And so they pay the dentist, they pay $600 for the procedure, and then they go home. And what happens over the next several days? June did not get better, as Melanie had assured them. She was basically inconsolable, Lauren said, just crying hysterically. And Lauren and her know, they don't know how to comfort her. They're new parents. They've only had a baby. A couple of know, they're. They're almost beside themselves.

There was nothing we could do. And I remember finally, I said, this is not normal. We're going to the emergency room.

And they decide to go to the emergency room, where a doctor looks inside June's mouth and finds a large sore in her mouth that he says is probably causing her so much pain.

And so he know, it breaks my heart to see a sore that big in a baby this small. It was like the floodgates opened, and there was nothing but guilt and shame. Like, unmanageable guilt and shame. Like, what have we done? Who are these people? What have I done to my baby? Will she ever be the. Like, what did I do?

So at this point, Lauren is really understanding that her intuition about this surgery was probably right and that she and her husband may have really made a mistake with this. What does June's recovery look like?

So June never did end up breastfeeding successfully, which was the main reason why lauren and her husband had decided to do this procedure.

That was the whole point, right?

That was the whole point, right? And over the next couple of years, June had a number of issues that there's no official medical diagnosis for. But Lauren has attributed a lot of her behaviors to what had happened to her when she was just a few days old.

I mean, you couldn't close the fridge door too loud, or else it would set her. You know, we would attempt to take her for a stroller walk on the green belt, which is the walking path. And she'd be asleep in her car, know, stroller. And someone would try to pass us on their bike and ring their bell, and it would startle her, and it would just set her off. So she just was very fragile.

So Lauren just wanted to get answers, and she really wanted to hold Melanie and the dentist accountable. So she gathered all of the paperwork that she had, texts, emails, other correspondence, and she went to the Idaho board of dentistry, where she filed a complaint against the dentist. And then she also went to a professional organization that certifies lactation consultants and filed a complaint with them as well.

And did she get anywhere with either of them?

At first, no. The Idaho dentistry board didn't want to investigate, and Lauren appealed, and she lost her appeal. And she didn't initially hear back at all from the lactation board.

No one wanted to take responsibility. That's the thing. No one wanted to stick their neck out there. What's the alternative story never gets told.

And that's when she decided to reach out to us. And after our story came out, the lactation board finally told Lauren that they were investigating Melanie and Katie.

You guys were reporting the story. I'm assuming you reached out to both the dentist and to Melanie. What did they say?

Beyond a very brief phone conversation that I had with Melanie in which she defended her work, and she said that she had a number of very satisfied customers. She didn't respond to detailed questions about Lauren's story or the stories of her former clients. And Dr. Zink did not respond to our requests for comment. But he did tell the dentistry board that Lauren's baby's procedure was uneventful and that an extremely small percentage of patients do not respond well to the procedure.

And how big of an issue is this, Katie? I mean, how common is it for mothers to have an experience like Lauren's?

So after we got the tip from Lauren and we dug deeper into her story, we found ourselves really surprised by how big this industry was for tongue tie releases. And in part, it's been driven by this movement for breastfeeding and the Breast is best campaign. And a growing number of parents who are choosing to breastfeed their children, in turn, that has sparked this big boom in tongue tie releases. One study that we found showed that these procedures have grown 800% in recent years.

Wow.

Yeah. And also, as we started talking to other parents around the country, we learned that some of them had similar stories to what Lauren had told us. There's plenty of instances where there's no harm done to the baby at all when they get these procedures. But we also found cases where babies were know, where they developed oral aversions, which basically means that they don't want to eat because they fear having anything put in their mouth, including a bottle. We found cases where babies became malnourished, had to be hospitalized. We found more than one instance in which babies had to be given a feeding tube just weeks after the procedure.

So these sounds so painful and awful for a newborn, these problems. But, you know, there's always a risk, Katie, in any medical procedure, right? I mean, how much of this is just the risk you sign up for when you agree that your baby should have a surgery?

Well, that's true. I mean, there's always a risk. But what you're supposed to do is weigh the risks against what the potential benefits of a procedure are. And when we really started drilling down into what those benefits were and into the medical research, we found there just wasn't a lot of potential benefit for these procedures, if at all, in many cases.

Really? So the procedures don't have a medical reason to exist?

That's right. We reviewed all of the best quality medical research on this. And other than that old fashioned snip under the tongue, which does show that in some cases, it can reduce pain for breastfeeding mothers. But otherwise, all of this growth and all of these other more invasive procedures, we found there just wasn't good evidence that they help babies. And the more we looked into tongue ties and started to connect it to the other reporting we were doing, we started to realize that it was driven by some really big forces in our healthcare system that really had the potential to harm patients.

We'll be right back. So, Katie, we talked about this new surge in a procedure that surgically unties infants'tongues from the bottom of their mouths, often needlessly, sometimes even harmfully. And you said your reporting found that this surgery was actually part of a broader trend. Tell me about this trend and what's driving it.

So that's what this investigation was really about. To find the procedures that are doing unnecessary harm to patients and to really kind of understand why this is happening, what's driving the prevalence of these procedures. And there's just a lot of unnecessary surgeries out there. But we decided to center our reporting on three particular surgeries that had the potential to harm patients. In addition to tongue ties, we focused on a particular hernia surgery, a bariatric surgery, which can be overdone and cause harm, and a vascular surgery done on patients legs to help us understand the forces that were at work that were driving all of this.

And what did you find when you dug deeper into those surgeries?

Well, it's very complex, but we ultimately found three main drivers that were underlying all of these. First, there's a financial incentive for the doctors to perform these surgeries. There's also a real push from the medical device companies that make these surgeries possible. And last, there's a huge information void for solid medical advice that a lot of these doctors and companies take advantage of in order to push the surgeries.

Okay, so let's start with the money.

Katie, how exactly is that incentivizing doctors to perform a lot more of these procedures? Like, what are the mechanics of that?

So the reality of our healthcare industry today is that in many places, even in places like nonprofit hospitals, the doctors who work there are not getting a salary. A straight salary. That's just kind of, you get paid for showing up to work that day. Instead, they're actually getting paid based on the procedures that they're doing, how complex those procedures are, possibly how lucrative. And it's not every doctor. There are still doctors that get paid salaries, but it's increasingly the case that doctors have at least a part of their pay is tied to the procedures that they're doing.

Interesting. So the procedure is growing in importance in terms of actual compensation for doctors.

Right. I mean, in part, it's kind of baked into the healthcare system that we've always had. You can even think about it as the small town doctor who operated his own independent practice or her own independent practice. It's essentially a small business, and they would get paid based on the patients that they saw. But increasingly, even in, for example, large hospital systems, where you might think that a doctor is just getting paid a salary to work in a hospital, in fact, a chunk of their bonus, for example, can sometimes be tied to the procedures that they're doing. And that is increasingly the case.

Interesting.

And so one particularly egregious example of this was at a hospital that's in New York, Bellevue hospital. And basically what my colleagues found there was that they had basically turned their surgery department into an assembly line for bariatric surgery, which makes your stomach smaller and can lead to weight loss. But what we found was that they were green lighting patients that basically didn't meet the qualifications for the surgery, which is a serious surgery. And what they found was that there were several situations where people had very serious outcomes as a result of getting the bariatric surgery there.

Okay, so this is an extreme case of a hospital turning to a particular surgery to drive profits. And it wasn't uncommon. In your reporting, it sounds like.

No, it wasn't the only example, but it was the most striking. And when we reached out to Bellevue, they defended their work, and they said that their practices were helping patients who wouldn't otherwise get. You know, our reporting was pretty conclusive that the program was turning through a record number of surgeries.

So what else was driving this increase in harmful surgeries that you guys found?

So we found it wasn't just the hospitals who were benefiting. The other major player that benefits are these companies that are making the tools and the products that doctors are using during the procedures. And in order for them to sell more of their products, a lot of time, what they end up doing is promoting the procedures themselves.

So, like medical device makers, like the company that made the laser in June surgery.

Right. And they do this in a number of ways. They're giving them loans to help them buy the equipment, and in some cases, they're even lending them money to help set up those clinics where the procedures are performed.

So they're really underwriting these doctors so that they can perform more surgeries and ultimately sell more machines.

Yes. And the other things that they do is the laser companies, for example, they will host webinars where they will have dentists who frequently perform these procedures, show other dentists how to do the procedures. We even discovered this conference that was created by one of the laser companies, and it had kind of a wild name. The name of the conference was tongue ties and tequilas.

Oh, God.

Right. It brought in dentists to talk about how to make money off the procedures, how to promote themselves on social media, how to actually perform the procedure. And of course, when they were all done, they got to celebrate with an open tequila bar.

Okay. So a lot of this really amounts to these companies trying to popularize these procedures, basically, like, to get the word out, even if the procedures don't really work or in some cases, cause harm.

Right. But they also play a big role in the other factor that's driving a lot of this, which is the information that they put out there about the surgeries. These companies often sponsor research, which doctors often rely on to guide their practices. And part of what we found is that it can kind of create this echo chamber, where doctors feel more comfortable and justified in doing these procedures when they have kind of this whole alternate universe that is telling them that it's okay to do these procedures, and, in fact, it's beneficial to patients.

So tell me about this echo chamber effect.

The best example of this we found was a doctor in Michigan named Dr. Jihad Mustafa. He calls himself the legsaver. And what we found was that he and several other doctors do these procedures called atherectomies, which is basically like inserting a tiny rotor router inside an artery to get the blood flowing. Dr. Mustafa, in particular, was not only a very prolific performer of these procedures, but he actually founded his own medical conference and even helped start a medical journal that was devoted to using these, you know, like tongue ties. There's really no good evidence that these are actually beneficial to patients. And in fact, despite his nickname as the legsaver, one insurance company told Michigan authorities that 45 people had lost their limbs after getting treated at Dr. Mustafa's clinic over a four year period.

45 people lost their limbs?

Yes.

I mean, that is the ultimate version of harm, right?

Right. Now, he did speak to us, and he defended his work and said that he treats very sick people. And despite his best efforts, some of these patients are already so sick that they sometimes lose their limbs.

And how much did he receive for each procedure?

Doctors like him typically receive about $13,000 for each of these atherectomy procedures.

Wow.

But we found that that misinformation or poor information also applied when doctors were learning new types of surgeries.

Really? Like how?

So? One of the areas we looked at was the area of hernia surgery that I mentioned, and there's a particular type of surgery. It's a very complex version of a hernia surgery called component separation. And the expert surgeons that we spoke to said that it's difficult to learn and you have to practice it over and over and over again to get it right. But one recent survey of hernia surgeons said that one out of the four surgeons had taught themselves how to perform that operation.

Really?

Yeah. Not by learning it from an experienced surgeon, but by watching videos on Facebook and YouTube.

I mean, how unusual is that? I guess, to me, it strikes me as very unusual. I mean, I think know learning about how to take my kitchen faucet apart on YouTube, but I do not think of a doctor learning about how to perform a surgery on.

And, you know, it has actually become increasingly popular in recent years, and there's not good vetting of the quality of the instruction. We even found videos on a website run by a medical device company that was intended to be a how to for how to do these surgeries. But the video contained serious mistakes.

Wow. And Katie, all of these videos, some of them with serious mistakes. I mean, is this something that would be subject to medical regulators? Like, is there any kind of rules of the road for this?

Know, there's less than you would expect. Sometimes hospitals have rules about what sort of education their doctors need before performing a surgery. But we were surprised that there was a lot less regulation than we thought there would be and much less vetting of these videos than we anticipated.

So essentially what you found was this complex, oftentimes interconnected group of forces, device companies pushing their products, hospitals bolstering their bottom line, and rampant misinformation. That, as you said, all really trace back to the same motivating factor, which is money. But wouldn't the fear of being sued for medical malpractice prevent a lot of this behavior?

This kept popping up during the course of our reporting. I do think we had this idea that anytime a doctor does anything wrong, they're going to get sued. But that just wasn't always the case in our reporting. There's a lot of statutes of limitations, time limits on when somebody can file a lawsuit in other ways that make it somewhat hard to really hold a doctor accountable. One example is the regulatory organizations that oversee doctors. The one doctor that I mentioned earlier, Dr. Mustafa, state investigators had found that his overuse of procedures had led people to lose their legs, and yet he ultimately settled with the state and he was fined $25,000. That actually adds up to about two of these atherectomy procedures.

So it sounds like malpractice is not necessarily going to be the route to rectifying a lot of this, but I guess I'm wondering if the federal government could actually rein some of this in before the patients are harmed.

It's possible, but this is just a very difficult issue. Some of the themes that we explored in this reporting are really just firmly embedded in our healthcare system and the way that it works. The fact is that we have a for profit healthcare system, right? So everyone from doctors to hospitals to the device companies benefit when more procedures are done. All of the incentives are pointing in the same direction, right? And so trying to find one or two simple solutions will probably not easily fix the issue as much as we all hope that it could.

So is the lesson here be much more discriminating and vigilant as a patient? I mean, to get a second opinion when you're standing in front of a doctor or a dentist who's telling you that you or your baby needs a procedure.

Yes, I think that is one of the takeaways. But look, we understood that even reporting on all of this was risky because people could hear about these harmful surgeries and start wondering if everything that their doctors tells them is a scam. And, of course, while some of these procedures are harmful, a lot of procedures are life saving. But ultimately, for now, patients are kind of left on their own to navigate what's a pretty complex and opaque healthcare system. When you have somebody standing in front of you saying, you should do this, it can be very confusing.

Right.

And this is something that Lauren talked a lot about, just how confusing all of this was for her.

There's a lot of information that you're getting that is truly like someone is speaking a foreign language. And because they do it all day long, it's not user friendly. Like, it isn't designed for the comfort or understanding of the person receiving the information. There is so much blind trust and faith that you have in the system, in the providers who are giving you this information you trust, like, this is what they do all day long. So there is no real reason to question that is the system that we have in this country.

Katie, thank you.

Thank you.

We'll be right back.

Here's what else you should know today. On Friday, the russian authorities announced that opposition leader Alexey Navalny died in prison. He was 47. Navalny, a charismatic anticorruption activist, led the opposition to Vladimir Putin for more than a decade. His popularity was broad, extending far outside the realm of liberal Moscow. And that proved threatening to the russian authorities, who attempted to poison him in 2020. Navalny survived and later extracted a confession from his wouldbe assassin on tape. Navalny believed that Russia could be a free society, and he had the extraordinary ability, through sheer force of his personality, charisma, and confidence to get others to believe it, too. Though he had been in prison since 2021, his death still came as a shock.

Stoitlimia, which is.

His wife Julianovalny, made a surprise appearance at a security conference in Munich. Shortly after the russian authorities announced her husband's death. She received an emotional standing ovation. In Moscow, my colleague Valerie Hopkins, spoke to Russians who were placing flowers in his honor and expressing disbelief that he was gone.

And I asked them if they believe.

In the beautiful Russia of the future.

That Navalny talked about, and they said, yes, but we don't think we will.

Survive to see it.

At least 400 people have been detained since his death, including a priest who had been scheduled to hold a memorial service in St. Petersburg. Today's episode was produced by Asta Chaturvedi, Diana Wynn, will Reed and Alex Stern with help from Michael Simon Johnson. It was edited by Michael Benoit with help from Brendan Klinkenberg. Contains original music by Diane Wong and Dan Powell, and was engineered by Alyssa Moxley. Our theme music is by Jim Brunberg and Ben Lansberg of Wonderland. That's it for the daily. I'm Sabrina Tyronisi. See you tomorrow.