Yet another review, by four members the American Medical Foundation that looked at 157 cases over a weekend, found that one-third of them did not meet the standard of care and nearly one-quarter of the cases were so far off that they merited "special review."
"Particularly troubling is Dr. Midei's practice of repeatedly over-estimating the severity of lesions visualized during numerous cardiac catheterizations," a hospital committee noted in a confidential investigative report.
Investigators later interpreted that to mean Midei purposely inflated the degree of blockage to justify unnecessary stents.
When he appeared before a hospital committee to defend his decisions, Midei admitted that the percentages he recorded seemed high. He explained that he must have unknowingly defaulted to using the figures of 70 percent, 80 percent and 90 percent to represent mild, moderate and severe blockage, the report states.
He later came to believe that the differences between the blockage assessments could be attributed to the medical exams under review. The recorded images were of a much poorer quality than those available live on the day of the procedures, he said.
The figures Midei noted on patient records were "reflective of [his] judgment of that blockage at the time," he said last week. He also pointed out that great variance among reviewers is typical, especially when it comes to mid-level blockages.
"The notion that we in the cath lab, have a very precise method for mathematically determining the degree of obstruction is false," he said. "It's subjective."
A similar examination of any other practitioner's work would turn up comparable discrepancies, he claimed. He added: "It's unimaginable that anybody has gone through the kind of scrutiny I have."
Midei was formally suspended on July 8, 2009, and allowed to resign in November of that year after signing a form releasing St. Joseph from any potential claims. The hospital said it would provide a cursory letter of reference if asked, and Midei believed he would be able to get on with his life elsewhere.
But then St. Joseph began sending 585 of his former patients letters alerting them that their stents may have been unwarranted.
The letters drew national attention from media and malpractice lawyers and quickly quashed any hope Midei had of finding work. Within a few months, the state launched an investigation into unnecessary stenting, as did the U.S. Senate Finance Committee, which oversees the Medicare and Medicaid programs.
In June 2010, the Board of Physicians filed professional charges against Midei, beginning the process that would strip him of his medical license.
In November 2010, St. Joseph paid the federal government $22 million to settle claims of a kickback scheme with MACVA, which has since been dismantled, and to repay federal Medicare funds it received for Midei's so-called questionable stents.
And in December of last year, Midei went before an administrative law judge to fight the board charges.
He enlisted the help of Dr. William O'Neill of Miami, an expert cardiologist who was paid $10,000 a day for his time. O'Neill said he helped develop the stenting guidelines and found Midei's work appropriate based on clinical indicators.
But his opinion didn't sway the judge, who, after reviewing the evidence recommended to the board that Midei's license be revoked.
At the same time, the Senate committee released its findings, suggesting that Midei was too cozy with stent maker Abbott Laboratories, which may have "indirectly encouraged" his stent use. Abbott praised Midei's high stenting rate in a congratulatory email and once threw a pig roast at his home.
Midei calls the implication "ludicrous."