No, by the numbers
There is an unmistakable pattern in Wheeler’s readings. The Center identified more than 1,500 cases decided since 2000 in which Wheeler read at least one X-ray; in all, he interpreted more than 3,400 films during this time.
The numbers show his opinions consistently have benefited coal companies:
- Wheeler rated at least one X-ray as positive in less than 4 percent of cases. Subtracting the cases in which he ultimately concluded another disease was more likely, this number drops to about 2 percent.
- In 80 percent of the X-rays he read as positive, Wheeler saw only the earliest stage of the disease. He never once found advanced or complicated black lung. Other readers, looking at the same images, saw these severe forms of the disease on more than 750 films.
- Where other doctors saw black lung, Wheeler saw tuberculosis, histoplasmosis or a similar disease on about 34 percent of X-rays. This number shoots up in cases in which others saw complicated black lung, which is so severe it triggers automatic compensation. In such cases, Wheeler attributed the masses in miners’ lungs to these other diseases on two-thirds of X-rays.
Asked if he stood by this record, Wheeler said, “Absolutely.”
“I have a perfect right to my opinion,” he added. “I found cases that have masses and nodules. … In my opinion, those masses and nodules were due to something more common.”
When his views are questioned, Wheeler often shares anecdotes. He tells the story of performing an autopsy during his residency on a woman thought to have breast cancer; his examination revealed undetected tuberculosis. Other common stories include his father’s severe illness from histoplasmosis and a colleague’s bout with the infection after spending a rainy night in an abandoned chicken coop.
In a case decided in 2010, a doctor disputed Wheeler’s narrow view of black lung, and the miner’s lawyer asked Wheeler during a deposition whether he could cite medical literature to support his views.
“I don’t think I need medical literature,” Wheeler replied.
In a 2009 letter submitted in another case, Wheeler questioned two doctors who read X-rays as positive for black lung and wrote that he and a colleague who had provided opinions in the case “are clinical radiologists at one of the two or three best known hospitals in the world.”
The judge was not impressed. “This self-serving, egotistical diatribe is unwarranted and very unprofessional,” he wrote.
Wheeler took a similar approach in a recent interview, challenging the views of any doctor, judge or organization — including the Labor Department, NIOSH and the International Labor Organization — that contradicted his. He said he’s never been told an interpretation of his was wrong and he’d admit a mistake only if a biopsy or autopsy showed black lung — and was performed by a pathologist with “proper credentials.”
“I know my credentials,” he said. “I'd like to make sure that the people proving me wrong … have … credentials as good as mine.”
Proof in the tissue
In fact, tissue samples from miners’ lungs have proven Wheeler wrong again and again.
The pathologists providing the interpretations were enlisted by the coal company in many cases, and they often came from well-regarded academic medical centers, such as Washington University in St. Louis and Case Western Reserve University, where Wheeler himself was a resident. Some helped write widely accepted standards for diagnosis of black lung with pathology and have been frequent experts for companies defending claims.
Wheeler’s readings were negative even in some cases in which the company conceded the miner had black lung and chose to fight the claim on other grounds.
When clear pathology evidence did exist in cases reviewed by The Center, it tended overwhelmingly to show that the doctors who had found black lung — not Wheeler — were correct.
The American Lung Association, NIOSH, the Labor Department and a paper published by the American Thoracic Society say black lung usually can be diagnosed with an X-ray, knowledge of the miner’s exposure to dust and studies of lung function. Biopsies, which Wheeler insists are “very safe,” are invasive, risky and usually unnecessary, government officials and doctors said.
Still, of the cases in which Wheeler submitted at least one negative reading, miners or their surviving family members submitted evidence from a biopsy or autopsy in more than 280 cases, a Center analysis found. Contrary to Wheeler’s contentions, the pathology did not resolve most cases. In about half, the tissue evidence proved inconclusive or was disputed.
Of the remaining cases, 75 percent revealed undisputed evidence of black lung. In the other cases, the tissue did not show evidence of the disease, but, as the law states, this doesn’t mean the miner didn’t have black lung — only that it wasn’t present on the piece of lung sampled.
In the cases in which pathology showed Wheeler was wrong, other X-ray readers saw black lung 80 percent of the time, and no interpretations outside of Johns Hopkins existed in another 12 percent.
Most times, then, only Wheeler and his Johns Hopkins colleagues failed to see black lung.
Diagnosis after death
Sometimes miners had to die to prove they had black lung.
George Keen worked 38 years in the mines and tried for 22 years to win benefits. At least two physicians interpreted his X-rays and CT scans as showing complicated black lung. Wheeler and his colleague Scott read them as negative — probably tuberculosis, they said. Keen lost.
Three years after the most recent X-rays and CT scans read by Wheeler were taken, Keen died. The company’s chosen pathologist agreed the autopsy revealed complicated black lung.
John Banks, who started loading coal by hand at 17, had multiple claims denied. More than a half-dozen doctors saw black lung; Wheeler suspected cancer. When Banks died, pathologists looking at his lung tissue debated whether the disease had reached the complicated stage, but both sides agreed: He had black lung.
Emily Bolling suffered through much the same experience with her husband, Owen, who spent most of the last six years of his life on oxygen but wasn’t able to win benefits.
“They would keep hiring more doctors and more doctors to read his X-rays, and we had just one,” she said.
Wheeler read a 2002 X-ray as negative. Owen died in 2003, and two pathologists found that the autopsy showed black lung, allowing Emily to win her widow’s claim. “It seems awful, but that’s what it took,” she said recently. “It’s just wrong.”
Illene Barr is trying to win benefits following the 2011 death of her husband, Junior, who worked 33 years doing some of the dustiest jobs in the mines. In his final years, his health progressively worsened. “He loved to do things around the house,” Illene recalled. “He had a garden. But he became so short-winded he couldn’t do any of that. He ended up basically just sitting on the deck.”
He lost claims in 2008 and 2010 after Wheeler read X-rays as negative, saying histoplasmosis was much more likely.
“We just couldn’t believe that it was happening,” Illene said.
Four months after Wheeler’s most recent opinion that Junior likely was suffering from the bird-and-bat-dropping disease, he died. Pathologists for both sides saw black lung on the autopsy. Illene’s benefits case is pending.
The Wheeler standard
Wheeler learned the strict criteria he applies from his mentor, Dr. Russell Morgan, a revered figure at Johns Hopkins. In the early 1970s, Morgan helped NIOSH develop the test to qualify as a “B reader” — a doctor certified to read X-rays for black lung and similar diseases. Wheeler served as one of his test subjects. The radiology department bears Morgan’s name, and he went on to become dean of the medical school.
Morgan testified for companies defending a wave of lawsuits over asbestos-related disease. Wheeler testified before Congress in 1984, arguing that false asbestos claims were rampant and that plaintiffs should prove their cases by undergoing a biopsy. He asserted that similar problems existed in the black lung compensation system.
There is general acknowledgement now that X-ray evidence was misused in some asbestos claims. The black lung benefits system of today, however, is a different universe.
In some asbestos claims, plaintiffs won large verdicts or settlements, and lawyers got rich. For black lung, the payouts are comparatively meager — the maximum monthly payment, for miners with three or more dependents, is about $1,250 — and few lawyers will take cases because the odds of winning and ultimate compensation are low. Settlements are not allowed, and miners have to prove total disability caused by black lung, not just show a minimally positive X-ray.
Wheeler continues to express concerns similar to those he voiced in 1984. “It comes down to ethics,” Wheeler said. “If you think it's appropriate for somebody with sarcoid to be paid for [black lung] because he has masses and nodules — do you think that's appropriate? I don't think so.”
After Morgan’s death, Wheeler took over the “Pneumoconiosis Section.” Asked if he viewed himself as the coal industry’s go-to radiologist, Wheeler said: “Dr. Morgan was the go-to guy. … I've replaced him … in the pneumoconiosis section, yes. … I can view myself as the doctor for a number of companies, not just coal companies.”
In depositions and during the recent interview, Wheeler has insisted he is relying on the criteria Morgan taught, praising his predecessor as an innovator and genius. His criteria, however, do not comport with mainstream views on black lung.
“When you take this very strict view, where you put in all these rules, none of which are a hundred percent, what will happen is you’ll wind up excluding people that have the disease,” NIOSH’s Weissman said.
According to medical literature and experts consulted by the Center, black lung does not always fit the narrow appearance Wheeler requires. Shown a text, for example, that says the disease may affect one lung more than the other, Wheeler said: “I don't know where they get this idea. … It's not what Dr. Morgan taught me.”
In fact, the statement comes from the standards established in 1979 by the College of American Pathologists. The report was compiled by a group of eminent doctors, including some who have testified regularly for coal companies.
Doctors interviewed by the Center said they had seen many cases of black lung that did not fit Wheeler’s standards. “You’ll see a variety of different presentations,” said Dr. Daniel Henry, the chair of the American College of Radiology’s task force on black lung and similar diseases. “The image can vary.”
In one case decided in 2011, NIOSH got involved at the request of the doctor who examined the miner for the Labor Department. Multiple doctors had diagnosed complicated black lung, but Wheeler had read X-rays as negative. The spots on the X-rays didn’t follow the pattern he wanted to see, he’d said; histoplasmosis was more likely.
Two NIOSH readers, however, saw complicated black lung on the film, and Weissman wrote a letter saying Wheeler’s views “are not consistent with a considerable body of published scientific literature by NIOSH.” The miner won his case.
Assumptions and ‘bias’
A pair of assumptions shapes Wheeler’s views in ways that some judges and government officials have found troubling.
Former miner Gary Stacy’s struggle for benefits lays bare the effects of these beliefs.
When he filed for benefits in 2005, Stacy was only 39 years old, yet three doctors believed his X-rays and CT scans showed complicated black lung. He had worked for almost 20 years underground and had never smoked.
Wheeler, however, read two X-rays as negative. He wrote that Stacy was “quite young” to have complicated black lung, especially since the 1969 law required federal inspectors to police dust levels. Histoplasmosis was much more likely, Wheeler thought.
A judge denied Stacy’s claim in 2008, and it would take years of fighting and a rapid decline in his breathing before he won.
In reaching his conclusions about the cause of the large masses in Stacy’s lungs, Wheeler drew upon beliefs that pervade his opinions: Improved conditions in mines should make complicated black lung rare; whereas, histoplasmosis is endemic in coal mining areas.
In case after case, Wheeler has said complicated black lung was found primarily in “drillers working unprotected during and prior to World War II.”
Wheeler’s contention contradicts a series of published studies by NIOSH researchers showing that the prevalence of black lung actually has increased since the late 1990s and that the complicated form increasingly is affecting younger miners. Wheeler contends these peer-reviewed studies aren’t conclusive because they have not been confirmed by pathology.
Gary Stacy is the kind of miner NIOSH says it now sees more often. Just 47 today, he appears trim and healthy, but a few minutes of conversation reveal a different reality. His sentences are interrupted by hoarse gasps for breath.
Stacy now undergoes pulmonary rehabilitation to prepare for a lung transplant. As his illness worsened, the evidence became overwhelming, and his employer agreed to pay benefits.
The fact that nothing in Stacy’s medical history indicated he’d suffered from histoplasmosis or tuberculosis didn’t prevent Wheeler’s readings from being credited in the 2008 denial. Someone could be exposed, show no symptoms and still develop masses that remain after the infection has fizzled out, Wheeler often has said.
This is theoretically possible, said doctors consulted by the Center, including an expert on histoplasmosis at the Centers for Disease Control and Prevention. But, doctors noted, in cases with masses as large as the ones Wheeler often sees on film, the patient likely would show symptoms and have some record of the disease in his medical history.
NIOSH’s Weissman said the two diseases should rarely be confused on film. “The appearance of [black lung] is different from the typical appearance of … histoplasmosis,” he said. “That shouldn’t be hard, in general, to make that differentiation.”
Wheeler’s main alternative suggestion once was tuberculosis, but he has switched to suggesting histoplasmosis more often. “Well, initially, I thought TB was … causing these things,” he said in an interview. Yet many of those cases, he now believes, “very likely were [histoplasmosis].”
Could he be wrong again? “I could be,” he said. “But I'd like to be proven wrong with biopsies.”
In written opinions, judges have said Wheeler’s assumptions seem to have “affected his objectivity” and “inappropriately colored his readings.” Another wrote in 2011 that Wheeler had a “bias against a finding of complicated [black lung] in ‘young’ individuals.”
In some cases, judges have questioned Wheeler’s demands for biopsy proof and his speculative suggestions of other diseases. “The reasonable inference to be drawn from Dr. Wheeler’s report and testimony is that he does not accept a diagnosis of [black lung] based on x-ray or CT scan alone,” one judge wrote in 2010.
Another judge succinctly summarized Wheeler’s opinion: “I don’t know what this is, but I know it’s not [black lung].”