Inside a coal company exam

Introduction

GRUNDY, Va. — The digital clock on the sign for the Buchanan General Hospital read 7:57 a.m. when Dr. Gregory Fino pulled into the parking lot in a red Porsche Cayenne. He walked past muddy trucks and beat-up sedans with bumper stickers that read “Friends of Coal” or “The Heartbeat of America” and entered a brick clinic building.

Inside, on a chilly morning last February, miners filled one of the waiting rooms and spilled into the hallway. There were about 15, many accompanied by family members, and each had an 8 a.m. appointment. Some had come from West Virginia or Kentucky to this small town in the southwestern tip of Virginia.

They were all here for the same reason: They had filed for black lung benefits, and now they had to undergo an exam by a doctor of the coal company’s choosing. For these men, like so many others, the companies had chosen Fino.

For decades, Fino has been one of the go-to doctors for coal companies. Like others in this group, Fino travels regularly to examine groups of miners. Every couple of months, he drives from Pittsburgh to Grundy and examines an average of 20 to 22 miners over two days, he estimated recently.

In 2012, he examined 204 miners, all of them on behalf of coal companies, he said. He also reviews evidence and provides reports about miners he hasn’t examined. Asked why he virtually always performs his work for coal companies, not miners, he said: “You’d have to ask the claimant’s side. I’ll say it like it is.”

Fino declined to say what he charges. Other doctors have testified in recent years that they charge up to $2,500 per exam, including preparation of a written report, and as much as $700 an hour to review records or testify in depositions. The Labor Department would not disclose how much it pays doctors to examine miners.

Fino has drawn enmity from miners and their lawyers. The National Mining Association enlisted him to critique scientific studies linking coal dust to diseases such as emphysema and chronic bronchitis, even when the classic form of black lung wasn’t present. Fino questioned such a connection and concluded there was no evidence that coal dust could cause disabling cases of these illnesses. The Labor Department, rebutting his statements, finalized a rule in 2000 recognizing these diseases as manifestations of black lung.

In 1999, the Kentucky Board of Medical Licensure discovered that Fino was conducting exams in a motel room in Pikeville without a license to practice in the state. Fino said recently he thought he had a valid license. When he applied for one, the board asked him to withdraw the application or face a formal complaint.

Fino is not on the list of doctors certified to examine miners on the Labor Department’s behalf, but other doctors who testify regularly for coal companies are. A miner could unwittingly choose to be examined by one of these physicians. Dr. George Zaldivar, for example, frequently testifies for coal companies but may appear to be a convenient choice to miners living near his practice in Charleston, W.Va. Zaldivar did not respond to messages requesting an interview.

Dr. Lawrence Repsher, who also has testified regularly for coal companies, is also on this list. In 2009, he examined a miner in an Arkansas motel room but didn’t have a license to practice in the state, the Center for Public Integrity found. Asked about the exam, Labor Department officials said they weren’t aware of it. Repsher, who told the Center that he retired a few months ago, said he didn’t recall the case or whether he was ever licensed in Arkansas, but acknowledged that he had occasionally performed exams in motel rooms.

Fino said there was nothing inappropriate about conducting exams in motel rooms, such as at the Landmark Inn he used. Barred from Kentucky, though, he moved just across the border to the rural hospital on Slate Creek in this small Appalachian mining community.

After initially objecting to a reporter’s presence at one of the exams in February, Fino called the law firm that had retained him, returned and said, “I have nothing to hide.”

9:11 a.m.

Retired miner Roger Potter heard his name called. A short but sturdily built man with a mustache and wispy brown hair streaked gray, Potter had worked underground for more than 35 years. Now 68, he was struggling to breathe, and he hoped to avoid going on oxygen for as long as possible.

An X-ray of his chest taken in September 2012 showed widespread scarring, according to two radiologists. Their readings supported the opinion of the doctor who examined Potter for the Labor Department: He had the advanced form of disease known as complicated coal workers’ pneumoconiosis.

In the waiting room, he had no illusions about what was going to happen. “They said he’d probably turn me down,” he said of Fino, expressing a sentiment echoed throughout the waiting room all morning. “He turns everybody down.”

Fino told the Center his own records show that, of the miners he has examined during 2012 and the first half of 2013, he’s found about 20 percent disabled at least in part because of black lung. If these opinions aren’t showing up in court records, he said, it is because lawyers don’t submit them — something he can’t control.

When Potter was called back, Fino, 61, with a ring of short gray hair, sat behind a desk in a small office. He went through the form Potter had filled out, asking him questions and tapping at an Apple laptop.

“Do you smoke?” Fino asked — a crucial question, as cigarettes are a favorite alternative explanation for many doctors testifying for coal companies.

“No,” Potter said.

“Did you ever smoke?”

“No.”

“Do you wheeze?”

“I wheeze so bad at night I scare myself.”

After about 10 minutes, Fino took Potter to an examining room next door, listening to his chest with a stethoscope.

This typically is the end of Fino’s involvement in the patient’s day. Because a reporter was present, he insisted on being called when Potter was about to undergo his exercise test, saying he wanted to be able to answer any questions that arose.

10:32 a.m.

Potter sat at a stationary bike with a hospital technician and Fino watching. A few minutes earlier, he’d undergone an X-ray, then had blood drawn from his wrist.

The exercise test is an important, and sometimes controversial, portion of the exam. To win a claim, it is not enough for a miner simply to have black lung. He must prove that it has caused him to become totally disabled. One way to prove that is to show that his lungs aren’t able to transfer enough oxygen to his bloodstream.

The technician is supposed to draw blood from the wrist — something even hard-bitten miners describe as painful — while the patient is exercising. If the analysis reveals oxygen levels below a threshold number, the miner is considered disabled.

The key, however, is to draw the blood during exercise, as Labor Department regulations require. For every second the miner stops exerting himself, the oxygen level can rise, making a disabled person seem healthy.

That’s why many doctors — including Dr. Donald Rasmussen, who frequently examines miners for the Labor Department — insert a catheter into the miner’s wrist. A technician then can easily attach a cartridge to extract blood periodically without having to re-stick the miner.

Fino doesn’t do this, saying he doesn’t want to risk tearing or blocking the artery. The result, however, can be an awkward attempt by the technician to find the artery as a miner is pedaling or a race to get blood drawn as an exhausted miner slows or stops.

As Potter pedaled, Fino and the hospital technician encouraged him. They needed him to reach 50 revolutions per minute. After a few minutes, Potter began to struggle. As he slowed, the technician managed to grab his wrist, then stick the artery. Potter grunted.

Other miners have described undergoing similar testing during a Fino exam that they contend may have masked the extent of their disability. Tim Lafferty said the technician told him to slow his pedaling and found the artery only after three or four attempts.

“I said, ‘I thought it was supposed to be done while you were pedaling,’ ” Lafferty recalled telling the technician. “And he just looked at me.”

Ronnie Kern said his exercise test was a walk down the hallway that included multiple stops to avoid other patients. The technician didn’t try to draw blood until he was back and sitting down, he recalled.

“She stuck that needle in there, and she busted my artery,” Kern said. “And I mean blood was squirting everywhere. It scared her.”

After a few minutes, another technician got a sample drawn, he said. Fino pointed to the results of the test as proof that Kern wasn’t disabled. Two other doctors who examined him used catheters and found that his oxygen levels dropped to disabling levels during exercise.

11:15 a.m.

Another way to prove disability is through a series of lung-function tests known as spirometry. Among miners, this testing is despised.

Potter was no exception. He bit down on a green mouthpiece with a tube leading to large machine. At the technician’s command, he sucked in a deep breath, then blew out violently. A line on the computer screen nearby shot up, then slowly descended as the technician urged Potter to keep blowing. Finally, he stopped and gasped for breath, his face red.

Doing this even once for miners with lung problems is draining. They must do it multiple times to ensure the study is valid. If they stop blowing too soon or don’t blow out hard enough, they have to do it over.

This series of tests measures a variety of things, such as the amount of air a miner can blow out in one second and the total amount of air he can expel from his lungs. This helps detect if the lungs are unable to expand fully or if the airways are blocked.

The torturous nature of these tests is one of the reasons — along with the low success rate — the Labor Department believes frivolous black lung claims are rare. The agency wrote in a 2000 regulation, “The complete pulmonary evaluation … includes difficult tests, and the Department does not believe that a miner would deliberately subject himself to that testing if he did not truly believe that he met the Act’s eligibility criteria.”

Months later, Potter had yet to receive Fino’s final report. A Labor Department official awarded him benefits, but the company has appealed.

1:30 p.m.

Miners filled a small waiting room with about a dozen chairs in the section of the hospital where the testing was performed. Potter had gone home, but many miners’ exams remained unfinished.

“This is pitiful,” retired miner Chuck Simpson said, frustrated with the slow progress.

At 50, Simpson walks with a cane; his legs and back were crushed when a mine roof caved in. After 26 years of mining, he needs oxygen full time. He wore a plaid shirt, jeans and a goatee, and a pony tail hung out back of his hat, which read “Joy” — a favorite manufacturer of continuous mining machines, which Simpson used for years to tear through coal seams.

“We’ve killed ourselves for them, and the company has moved on,” Simpson said. “Now they’re fighting us tooth and nail. It ain’t right.”

The men tried to pass the time with stories of the mines. Despite the destruction the work had wrought on their bodies, many romanticized their days enshrouded in dust.

The hours dragged on, and reminders of their current station filled the void. Some hacked and wheezed. Periodically, a technician would enter the waiting room to draw blood from a miner’s wrist. The others looked away.

One man arrived in a wheelchair, hooked up to an oxygen tank. A technician told him to remove the tube and let his oxygen level drop to where it would be otherwise before they performed the tests. For about an hour, the life seemed to drain from him. He curled up, head buried in his hands.

Yells and gasps were audible from the room where the lung-function testing took place, separated from the waiting room by only a door. The miner clearly was struggling. He’d been at it for more than 20 minutes. The technician spurred him on.

Between coughs, one sentence was clear: “I’m blowing as much as I can.”

Everyone in the waiting room heard it, but no one spoke. Some miners shook their heads. Most just stared at the ground.