I am rebuked in this issue [see Letters page] for my recent column on Martin Luther King Jr./Drew Medical Center by an old acquaintance, Director Mark Finucane of the Los Angeles County Department of Health Services (DHS). Actually, Finucane, while defending his operations, takes issue with my accuracy on only one point, which I shall return to later.
Otherwise, our local health czar mostly lauds things as they are at the DHS hospital system in general and King/Drew in particular. My contention is that things ought to be and could be better.
Finucanes basic disagreement is that I suggest that the second-largest hospital in the county system should, without increased funding, be providing better patient care. He criticizes my airing some concerns of the Joint Council of Interns and Residents (JCIR) about working conditions: In a perfect world interns and residents would be paid far higher wages and work shorter hours, he says. Actually, I didnt say anything about those terrible hours. Finucane continues, We operate teaching hospitals that provide interns and residents with the hands-on experience, oversight and education they need to become physicians.
There is a classic ideological dictum underlying this statement defending the current, century-old teaching hospital system it resembles the old drill sergeants motto: Train hard, fight easy. The problem is, of course, that the hands-on experience Finucane refers to involves the health and lives of as he acknowledges members of the countys 3 million uninsured people.
In the dawn of the teaching-hospital era, it was acknowledged by the medical establishment that doctors learned (and, lets not forget, made their beginners mistakes) on charity patients and earned on the privileged clients of subsequent private practice. The fairness of this system is increasingly questioned. Better working conditions for learning doctors probably do little to interfere with the onerous basic process of a medical education. It certainly increases the odds that those doctors indigent patients will get better treatment. It may even be one of the cheapest ways to do that.
As to certain favorable official evaluations of King/Drew, I think that Mr. F. is confusing matters. He refers to the Joint Commission on the Accreditation of Health Care Organizations rating King/Drew 94 percent overall and 100 percent on its ambulatory-care survey. Although this score is nothing to be ashamed of, it has little relevance to the quality of Drew medical schools teaching and inpatient care that I wrote about. Finucane says the average first-time pass rate for Drew students across the board is about 75 percent. This, while not a disgrace, is not very creditable. He says the American Board of Internal Medicines rating of King/Drews internal medicine has risen from 54 percent to 90 percent. Sorry, but this didnt show on ABIMs own Web site. The most recent figures available are for 1999 and show a pass rate of 54 percent. (In the same DHS system, Harbor-UCLAs internal-medicine pass rate is close to 100 percent.)
Speaking of the senior teaching, as opposed to junior learning, doctors, Finucane mentions the critical need for physicians and other health-care professionals who are willing . . . to provide care to the most vulnerable in our community at the expense of lucrative private practice. This is either wishful thinking or furtive irony. The last time I checked, many, if not most, of the senior teaching doctors in the county system maintained private practices on the side, whose priorities sometimes have allegedly interfered with their public-health work. Indeed, one not-altogether-atypical King/Drew eminence, the recently retired Dr. Ludlow Creary, appeared, from time to time, to have several practices plus dozens of other personal enterprises.
This may be a DHS-wide problem (and one that is tough to address), but it certainly doesnt help the quality of education at the Drew school.
King/Drews malpractice claims may or may not fall within the county norm, whatever that is. But, adjusted for patient volume, they exceed the claims against the other county teaching hospitals. And individually, each of them stands as a grim indictment of a system that, even if it has treated 2,624 trauma patients last year, as Finucane says, has a substandard reputation among the population it serves.
For whatever reasons, the increasingly Latino South Los Angeles doesnt sufficiently trust the largely African-American-run institution. Not speaking for attribution, officials in both Supervisor Gloria Molinas and former Councilman Richard Alatorres offices have told me that they are troubled by the extra patient load imposed on County-USC by patients coming from the South-Central King/Drew service area.
This is suggested by the fact that most of Big Countys beds are currently full. There are usually at least a hundred empty beds at King/Drew. Its about time that the DHS accurately determined to what extent the public distrust of King/Drew is creating the controversial patient load at County and to remedy that mistrust.
Finucane does not mention the rising unrest among the staff at King/Drew. He does state that hes trying to meet some of the interns nonfiscal demands. Good. But I dont see how he can ignore the need for new management at this long-embattled institution as demanded in the anonymous letter I cited.
(Incidentally, King/Drew intern Dr. Adi Klein of the JCIR, whom I cited in my last King/Drew piece, says he wants it made clear that his organization isnt associated with that letter.) Over the years, this column has reported some glaringly bad management: Dr. Eugene Hardin, for instance, who forged much of the publications record on his credentials, then continued to hold his chair of Emergency Medicine after Finucane was informed of this error by a county audit. Weve mentioned Ludlow Creary, who retained his chiefdom in Family Medicine after months of refusing county auditors access to his clinical records and years after facing a mammoth cash judgment and consent decree on his Bay Area clinical operations.
King/Drews problems no longer affect just that institution and its patients. They also appear to be causing problems even in Finucanes own office. Last summer, Finucanes own top assistant, Dr. Donald Thomas III, was eased out for his role in signing off on certain enterprises of senior King/Drew physician Jeffrie Miller. The problem was that Miller somehow arranged, through the DHS system, to get $900,000 in federal pharmaceuticals diverted to patients of his for-profit Metro South Provider Network. Under law, these drugs were reserved for nonprofit operations. When asked to pay what was owed, MSPN went into bankruptcy (another for-profit operation that benefited from the same ill-placed largess, John Wesley Community Health, paid up what it owed). Thomas has taken the case of his ouster to the countys Civil Service Board, where it awaits action early next year.
Thomas was, according to an official August 7 DHS memo, let go because he was the person in charge of the DHS contract employee who actually did the deal, one Dr. Janet Aiso. But Thomas has told reporters that he initially objected to this contract, and only authorized it after his own objections were ignored. On the basis of my own dealings with Thomas and the general laxness of DHS discipline, Im inclined to believe him.
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Finucane correctly notes that his department is facing very significant financial and policy challenges in the coming years. What he probably means here is that the federal government, which funds most county health operations and which has with increasing reservations generally tolerated DHSs slow progress toward reform over the past five years, cannot be counted on to do so in the future. Particularly under President George W. Bush. Finucane implies in his letter that, with more money, he could solve some of the countys health-service problems. With more money, we could all solve all our problems, or so we all like to think.
In practice, as our Republican friends delight in pointing out, this doesnt always work.
But what is really needed to make King/Drew in particular and the DHS in general work better is a precious commodity without a price tag: courage.
As I understand his letter to this paper, Finucanes going to try once more to persuade the supervisors to hire Dr. Rodney Armstead to assist him in some major DHS reorganization. I do hope Armsteads qualifications include deep reservoirs of courage. If he gets the job, hell need it.