Provincial health authorities in Saskatchewan, Canada, are investigating a South African-trained radiologist for allegedly misinterpreting enough routine imaging procedures to require new readings for 70,000 exams.

Tens of thousands of Saskatchewan residents, including provincial premier Brad Wall, await word about the accuracy of radiological procedures performed since 2004. Members of Wall's immediate family may have received questioned exams. Separately, a class action lawsuit was filed June 1 against the radiologist in question, Dr. L. Darius Tsatsi.

"The only thing we can say to the public right now is that we do not know how many instances there may be where care has been affected," said registrar Dr. Dennis A. Kendel of the College of Physicians and Surgeons of Saskatchewan in an interview with Diagnostic Imaging.

Tsatsi was trained and certified as a radiologist in South Africa. He arrived in 2004 on a temporary license for a locum tenens position in the Prince Albert region in central Saskatchewan before securing a provisional license to practice for the government-sponsored Sunrise Regional Health Authority in Yorkton. Sunrise operates hospitals and clinics serving about 56,000 residents in a largely agricultural region near the province's southeastern corner.

As Saskatchewan's top healthcare regulatory body, the college runs a Diagnostic Imaging Quality Assurance Program. Every three years, the program reviews the performance of physicians, such as radiologists, cardiologists, and obstetricians, who generate or interpret clinical imaging. According to a document released by the college in connection with a first review of Tsatsi's performance in 2006, the program "identified performance deficiencies that were sufficient [sic] worrisome" to grant a competency hearing.

Tsatsi volunteered to undergo remedial training at McMaster University in Hamilton, OT, to avoid a formal hearing. He completed a three-month program there nearly a year later. Although McMaster's faculty reports were uniformly positive about the radiologist's performance, they did not provide enough evidence that Tsatsi's knowledge and skill deficiencies had been rectified, Kendel said.

The college initiated a second competency investigation. It was later upheld in court after Tsatsi challenged its legality.

In early May 2009, a three-doctor panel released results of a review of 103 random cases interpreted by Tsatsi after his remedial education and more than two years after his practice first came under scrutiny. Investigators used statistical means to gauge clinically significant variation among readers. They found five cases in which diagnostic interpretation could have had "devastating adverse consequences" for patients.

"That level of clinically significant variation troubled us to the point that we felt obligated to advise the regional health authority and the ministry of health even before we could go through the formal hearing process," Kendel said.

Tsatsi's license with the college remains in good standing until his competence can be established by the hearing. The American Board of Medical Specialties confirmed that Tsatsi is not certified as a radiologist in the U.S.

Sunrise Regional Health suspended Tsatsi's practice privileges as of May 14 and ordered a review of all 70,000 studies interpreted by him since his arrival in Saskatchewan. Some studies involve patients who reside in neighboring regions, such as Cypress, home to Premier Wall. Some of Wall's family members were waiting for diagnoses that may have been performed by Tsatsi, according to the Toronto Globe and Mail.

The physician's wife, Lisa Tsatsi, told the Regina Leader-Post that her husband will cooperate with the investigation. He did not respond to Diagnostic Imaging requests for comment.

Provincial health authorities plan to complete the review within 45 days but have warned residents that the process might pose logistical challenges. They are currently enrolling radiology groups from in and outside Saskatchewan to conduct what they consider a massive undertaking. A final decision from the performance hearing may not be reached before September, Kendel said.

The case has led to a backlash against foreign-trained physicians and raised political questions about the efficacy of the regulatory bodies that deal with performance issues in healthcare. Online discussion boards maintained by several media outlets have published comments from outraged Canadians who questioned whether non-native physicians should be allowed to continue to practice after failing a certification exam.

Kendel cautioned Canadians to remember that foreign-trained professionals in every field of medicine, including radiology, have made extraordinary contributions to maintaining the health of residents in the region.

The Tsatsi case is not just about the radiologist's performance but involves the whole health system, Kendel said. It may not be foolproof, but it has actually worked as intended.

"This program did pick up a performance deficiency, which otherwise would not have been detected," he said.

Some think otherwise. The class action suit was filed against Tsatsi in Regina's Court of the Queen's Bench on behalf of Sharon Fabrick, a Yorkton resident, and 30 other former patients. Fabrick claimed that Tsatsi twice failed to correctly characterize her shoulder injury on x-rays. According to the suit, she underwent surgery to correct an impingement after a second physician identified the condition nearly a year after Tsatsi's initial and repeat readings.

The suit also names as defendants the provincial government and several health regions for allowing Tsatsi to interpret studies, despite twice failing the Royal College certification test. The college grants Saskatchewan radiologists three attempts to pass before disqualification.