Upheaval Update

In all its ocean-linerly majesty, the Los Angeles Times veered a few degrees from its usual course last week better to scrutinize the ongoing crisis in Los Angeles’ ramshackle Department of Health Services. The story, which could have appeared at any time over the past year, spoke of endless waits in clinics, understaffed wards, crowded emergency rooms, faltering funding. All of this is true and important to say.

But even more important to say is where to begin straightening out this bureaucracy-clogged entity charged with preserving the health of the poorest 40 percent of our county‘s population. Simply to say that it’s all problematic implies that there‘s no place to begin fixing our DHS. But clearly, there are places where the remedy isn’t more money (scarce everywhere in public health since Proposition 13) but the kind of courage and determination we haven‘t seen in Los Angeles County government since I can recall.

For instance, there’s the DHS‘s albatross-in-perpetuity, Martin Luther King Jr.Drew Medical Center, which has long resisted reform and restructure, scandal after scandal. KingDrew’s hierarchy could teach the Rampart Division a thing or two about closing ranks and clamming up. Particularly regarding its egregious patient deaths and disablings over the past decade.

The latest ruckus at KingDrew, however, is due to its recent designation as the worst U.S. medical school in a single crucial area. Internal medicine is perhaps the most important and inclusive practice category. And 58 percent of KingDrew medical students in that field were not passing their qualifying exams, according to the American Board of Internal Medicine (ABIM).

That‘s quite a distinction, even for a medical complex that’s been criticized like no other in the state. And which has cost the county uncounted tens of millions in patient-injury and death settlements while also being a target for accusations of -- and some successful litigation on -- racial bias.

It‘s a sad climax to a 25-year institutional history. Martin Luther King Jr. HospitalCharles R. Drew University of Medicine and Science rose -- literally -- on the ruins of the 1965 Watts Riots. It was perhaps the most enduring outcome of the collective wills of then--County Supervisor Kenny Hahn and the South Los Angeles stakeholders. It was to remedy one of the black community’s major lacks: a local public hospital for the underserved African-American community. And a university teaching hospital, for the presumed purpose of admitting African-American medical students who were less than welcome at that time at some major medical schools.

This last provision was the project‘s most ambitious aspect: an African-American education center in the medical arts that might one day perhaps equal those of Morehouse College in Atlanta and Howard University in Washington.

But it was not to be. Possibly the problem was that, unlike most teaching-hospital medical-school institutions, KingDrew was not built on the foundation of an extant university, whose administration could regulate both its standards and its performance. Instead, an ad hoc teaching establishment was created out of thin air. Without the traditions and regulatory powers of a genuine educational institution, what was intended as a lighthouse of medical learning became a bedlam of county and local politics. While the original purpose -- adequate treatment of its client population -- fell to a low priority.

One clear indication of this affair was the rating of KingDrew as the national worst (in contrast, the internal-medicine board rated Howard and Morehouse among the top medical schools in the Southeast) in the internal-medicine category. But this rating had one positive effect: It spurred an anonymous handful of KingDrew residents and interns to demand -- in two unsigned missives -- a shake-up of the hospital’s management.

According to one letter (which several interns and residents at KingDrew said they were familiar with, but would not comment on), ”The administration is interested only in preventing the truth from leaking out and . . . not in dealing with the realities of our sub-optimal training.“

It continues: ”The thought of being called the worst is indeed chilling to us . . . certainly, this is not what we were told when we were recruited.“ It‘s further alleged that KingDrew’s reputation has so spread nationally over the past three years that this year, ”despite the growing national demand for primary care residencies, not one person from any part of the country opted to join our program.“ The memo further criticizes the leadership of the internal-medicine department, but does not refer to the egregious settlements the county‘s paid out on KD’s behalf -- including three recent infant-death and infant-disability claims that together totaled more than $2.2 million.

”We are aware of the letter and its allegations,“ said a spokesman for DHS chief Mark Finucane, adding that the allegations were ”being looked into.“ Haven‘t we heard this before? What we have not heard -- over a decade of KD controversy and criticism -- is any forthright DHS proposal to clean house at KD.

Unforthrightly, however, something similar was recently proposed to the Board of Supervisors. In closed session, the board tabled (or, realistically speaking, sank) a Finucane proposal that, although postponed many times, had not been aired in public. Finucane sought the hiring, at $150,000 and for one year, of a special DHS ”consultant.“ This was not a general job posting, soliciting qualified applicants: Instead, a very specific individual -- Dr. Rodney Armstead -- was proposed. Among Armstead’s qualifications was his service as executive vice president at the Watts Health Foundation. Among the duties offered him was ”to provide high-level clinical and administrative consultation [for] KingDrew Medical Center.“

Armstead was also to handle less gnarly matters, including the reorganization of the office of Finucane‘s ousted former associate director, Dr. Donald Thomas. (Thomas has filed a claim that he was fired due to racial discrimination. His Civil Service hearing was postponed several times this month.)

But Hall of Administration gossip suggests that another named duty -- ”evaluating and implementing changes in management“ -- meant that Armstead might have been a hired gun, his likely targets certain senior politically protected managers at KingDrew and elsewhere, whose ousters Finucane might not want on his own resume.

The proposal’s rejection, however, means that if Mark Finucane wants to see heads lopped on the tumultuous Lynwood campus, he‘ll have to do it himself. If he can’t, perhaps his successor can.

While some KingDrew problems are unique, others are systemic. The latter also exist at the county‘s two other teaching hospitals: USC and Harbor-UCLA. While you could blame some of these difficulties on the obstinate official bureaucracy, many stem from tradition.

As it happens, while one group of KingDrew interns and residents is anonymously fighting for an upgrade in training quality, another group is openly battling for better wages and working conditions. Their union, the Joint Council of Interns and Residents (JCIR), is also fighting a long-standing perception of how young doctors are best trained.

The JCIR wants to change the tradition that the first three years of on-job physician training ought to be as onerous as possible, with the maximum possible hours and minimal amenities and comforts. According to Dr. Adi Klein, who speaks for the JCIR’s KingDrew unit, negotiations with the county hit an impasse in October, and the county has petitioned for a mediator from the Employee Relations Commission. But some of the things the JCIR wants most wouldn‘t cost much: These include decent sleeping quarters in or near county hospitals, so that interns and residents could catnap on their 24-hour shifts, and 247 basic food service.

”There’s also a living-wage issue,“ Klein noted. If this phraseology sounds surprising, coming from a representative of America‘s most prestigious profession, consider that an intern’s starting DHS wage is $31,000. Which was typical of the clerk-typists represented by the Service Employees International Union Local 660 until they got a 12 percent raise in their recent settlement. Currently, Klein said, interns and residents -- who typically carry a medical-school debt of at least $100,000 -- get a subinflationary 3 percent raise per year, with few benefits (interns and residents are temporary employees, since their mature careers generally lead elsewhere). JCIR would like a raise in the range of what clerk-typists got.

The JCIR contract deadlock parallels the impasse the Union of American Physicians and Dentists has struck in representing senior county doctors. But -- although, technically, they‘re supposed to be learning -- interns and residents are really the working stiffs of the county system: They’re likely to be blamed when something goes wrong, and many county settlement documents allude to the learning doctors‘ judgment failures. Perhaps these failures were the interns’ or residents‘ fault. Then again, perhaps better working conditions might have elevated the young doctors’ judgment and saved some precious patient lives.


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