Monday, May 28, 2007

The Doctor is Out

By Ted B. Kissell
Published: December 10, 1998

Info:Correction Date: 12/17/1998

Dr. Kunjana Mavunda sits, arms folded, behind her desk in the small, gray office of her private practice on Ponce de Leon Boulevard. In her lilting accent -- she is Indian by descent, Kenyan by birth -- the bespectacled 41-year-old respiratory physician mentions that she attended medical school in Poland.

Like most Kenyans, Mavunda grew up speaking both English and Kiswahili, in addition to her parents' Indian dialect. Her medical school courses were in Polish, a language she didn't speak before enrolling. She learned it well enough to earn her M.D. in 1980.

Mavunda moved to Dade County in the early Eighties, earning a master's degree in public health from the University of Miami and learning Spanish in the process.

After nine years on the UM faculty teaching pediatrics and pediatric pulmonary medicine, she started a private practice in 1996. In October of that year, one of her former professors at UM, Dr. Eleni Sfakianaki, recruited her to join the Miami-Dade County office of the Florida Department of Health (DOH).

Mavunda signed on with the state agency at a crucial point in its history.

Previously it had existed as a part of Florida's Department of Health and Rehabilitative Services (HRS). In 1996 the DOH became a stand-alone department and continued a shift in emphasis away from the traditional mandate of primary medical care for the poor. Locally those services were assumed by the Public Health Trust, the Miami-Dade County agency that operates Jackson Memorial Hospital, among other health care facilities and services.

Employing 970 people, the Miami-Dade branch of the DOH still offers clinical services at ten local outlets. Among these services are treatment for tuberculosis (TB) and sexually transmitted diseases (STDs), screening for HIV, family planning, a Healthy Start program for newborns, and immunizations. Recently, though, the DOH has concentrated on monitoring disease trends and preventing outbreaks that could become epidemics.

As director of epidemiology and disease control, Mavunda figured to play a vital role in the DOH's redefined mission. Her enthusiasm, however, quickly turned to disillusionment. The DOH, she found, was an agency beset by political infighting, ineptitude, and poor leadership. "There are a lot of diseases within the county that the department is not addressing," she says now. "People are getting sicker, and the environment is getting worse."

Mavunda did not keep her concerns to herself. In December 1997, she sent a terse memorandum to Dr. Sfakianaki, the department's medical executive director and Mavunda's immediate superior. "I do not have the staff to investigate" reported cases of hepatitis C, Mavunda wrote. "We do not have the time or the resources to adequately follow up chronic hepatitis B cases. This can be an explosive situation."

Mavunda added that despite what she described as an efficient departmental staff, her short-handed team could not keep track of food-borne-illness complaints, and that her reporting of cases to Tallahassee was being delayed.

In fact the home office in Tallahassee noted that for 1997 the Miami-Dade DOH office accounted for 61 percent of the missing case-report forms statewide. "The reason for this negative report is that my staff is busy investigating and acting on acute problems," Mavunda noted, "and unfortunately that takes priority over paperwork."

Personnel moves, Mavunda says, also seemed ill-conceived, even capricious. Her suggestions for the epidemiology unit, which include replacing high-salaried administrators with lower-paid but more essential outreach and clerical workers, were ignored, she recounts.

As a single mother with two children and her parents living in her home, Mavunda continued to run her private practice one day per week even after taking the DOH job. Her father, who had helped her manage the practice, died in June 1997; Mavunda says she originally planned to close the practice and devote her energies solely to the health department. Instead, this past March, less than two years after joining the DOH, she resigned in disgust. "I was not able to do the job I was hired to do," she charges.

Dr. Sfakianaki hired another highly regarded physician in 1997, Dr. Toye Brewer, to head the department's section dealing with HIV, TB, and STDs. The 42-year-old Brewer, like Mavunda, was charged with reforming her unit. As part of these efforts, Sfakianaki and Miami-Dade DOH's executive administrator Annie Neasman requested two reviews of the local STD program: one internal, the other conducted by an internationally recognized STD expert. Both found shoddy record-keeping and substandard clinical care.

Equally disturbing, the 1997 reviews attributed many of these problems to the department's half-dozen physicians who specialize in STD diagnosis and treatment. The reviews also noted that nearly all of these doctors, most of whom had worked at the DOH for years, were actively resisting the reforms proposed by Brewer and her superiors.

Neasman concedes that her agency has had its problems, but attributes these to decreasing funds. As for the low-quality service at Miami-Dade's five STD clinics, she says she and her staff are doing everything they can to improve the situation.
But these pledges did little to mollify Brewer.

In June of this year, she, like Mavunda, bolted from the troubled department, taking a faculty job at the University of Miami.

The DOH's shift away from primary care reflects a nationwide trend a decade in the making. In the late Eighties and early Nineties, private health maintenance organizations (HMOs) began to accept Medicaid patients en masse, leaving to public health departments a diminished client population, mostly uninsured and nonpaying. For this reason Miami-Dade's branch of the DOH has been downsizing for several years and turning over its primary-care clinics to the county's Public Health Trust.

As the number of insured patients has dwindled, so has funding from the state legislature. In response, Neasman says, she has concentrated her resources ($44 million for 1998-99) on the "core functions" of public health, the services that private doctors are unlikely to assume, including STD treatment among the poor and indigent.

And so Eleni Sfakianaki created a new position -- director of STD, HIV, and TB services -- to ensure that the department was delivering the best possible care. (HIV and AIDS are generally considered distinct from other sexually transmitted diseases, by the DOH and the medical community in general.) Her choice for the job was Toye Brewer, an expert in infectious diseases. Today Sfakianaki describes Mavunda and Brewer as "my star recruitments."

Part of the process of improving STD care involved the two evaluations requested by Sfakianaki and Neasman, one of which was conducted by a team of reviewers from Tallahassee. When the six reviewers (doctors, nurses, and administrators) came down in June of last year to scrutinize every aspect of the Miami-Dade STD treatment program, Toye Brewer had just begun her job.

The review group released its fifteen-page report one month later. In her assessment of Miami's five STD clinic operations, nurse and senior DOH staffer Karla Schmitt noted that "clinicians" (meaning the doctor or nurse who conducts examinations) were routinely providing substandard care.

"For whatever reason, they weren't following the state guidelines in treating people," Schmitt says today. Among the deficiencies she noted: Clinicians were still treating gonorrhea alone, without simultaneously treating chlamydia, when "federal and state guidelines recommend presumptive treatment for both infections in the presence of gonorrhea"; treatment of a woman for any STD was sometimes delayed until her next menstrual period, a delay which, if an infection were present, could lead to complications, even sterility; and many clinicians were reluctant to dispense (or were unaware of) proper medications. Even routine procedures such as Pap smears, which test for abnormal or cancerous cells on the cervix, were being inadequately performed.

Not only were clinic staffers providing poor service, but they weren't keeping track of the services they did provide. The existing system of records, an abbreviated computer printout, "does not allow the provider to fully document findings," Schmitt wrote.

Given the suspect record-keeping, Schmitt now questions the low number of STD cases reported by the Miami-Dade DOH. "Miami-Dade County has 40 percent of the state's population, and it doesn't deliver 40 percent of the STD cases," she says. "There's no reason it shouldn't. It has a young, poor, sexually active population. It ought to have more cases than it does." Last year Miami-Dade (population just over two million) reported an average of 25 STD clinic visits per day, the same as Orange County (population 800,000), and fewer than Duval (26 visits per day, population 742,000).

Schmitt's section of the report specifically criticized the performance of six STD clinicians, five of whom were doctors. That number itself seemed wrong to Schmitt. No other urban county in Florida employed more than two clinicians at its largest STD clinic, and most employed no full-time physicians, relying instead on nurse practitioners.

The "nurse-practitioner model," Schmitt says today, is the nationwide standard for STD care, both for financial reasons (Miami-Dade's DOH doctors earn between $65,000 and $75,000 annually; nurse practitioners earn between $50,000 and $55,000), and because many in public health believe that nurses, trained to be more empathic and less judgmental than doctors, are better suited for STD treatment.

Schmitt also pointed out that the doctors appeared to be underworked. In April 1997, for instance, the five clinicians at the main DOH clinic on NW Fourteenth Street (four of whom were doctors) averaged 8.6 physical exams per day, "one-third the state standard," Schmitt wrote.

In sum, the picture Schmitt painted was of high-priced doctors standing idle, performing incompetently, and filing inadequate records; "out-of-date, both in guidance and documentation," Schmitt observes today.

A former department employee who asked not to be identified concurs, especially with regard to the doctors' competence. "They do not want to treat herpes and genital warts because they [the doctors] are from the Eighties and they haven't read anything since then," the source asserts. "They know gonorrhea and syphilis and they don't want to be bothered with anything new."

The report, Schmitt notes today, took into account the funding reductions that have beset Miami-Dade's DOH office. "They do not get all the money they would need to serve the population, but that doesn't mean they're managing the money they have well," she says. "The foundation of a good STD program is efficient clinics with quality care, active outreach, and good relationships with private doctors. None of that is happening yet in Miami-Dade."

The report validated Sfakianaki's reasons for hiring Toye Brewer: The STD program clearly needed fixing. Indeed the management section of the report stated that most of the STD program staff "feel that Dr. Brewer's expertise and commitment are an outstanding addition."

Not all of Brewer's subordinates agreed. The doctors whose work Schmitt excoriated, for instance, were furious, none more so than Dr. Manuel Rodriguez, senior physician of the department's STD program. Rodriguez had applied for the new position eventually awarded to Brewer. (When contacted for this story, Brewer declined comment, citing ongoing negotiations between the Department of Health and the University of Miami to form a partnership in which UM would take over much or all of the STD program.)

Both the internal and outside STD reviews mentioned overstaffing; shortly after the Tallahassee report was issued, two STD doctors were slated to be laid off. Rodriguez maintains that the attempts to lay off doctors made no sense, and that the criticisms of their competency were unfounded. "It wasn't fair," he declares. "The reason for the decline of gonorrhea and syphilis is the work that we did. And it's contradictory that the price of a good job is layoffs."

He and other STD doctors articulated their concerns in letters and memoranda, distributed both within the DOH and to state and federal legislators. The gist of the physicians' letters: There was a movement afoot to replace them with nurse practitioners; Brewer was spearheading the effort; and the two evaluation reports were merely excuses to justify canning them.

Rodriguez and two fellow STD physicians, Dr. Rusquin Duany and Dr. Federico Rosello, sent a form letter addressed to most of Miami-Dade's legislative delegation on June 27, 1997. Rodriguez recalls sending copies to U.S. Reps. Lincoln Diaz-Balart and Ileana Ros-Lehtinen; state Sens. Alberto Gutman, Mario Diaz-Balart, Roberto Casas, and Daryl Jones; state Reps. Luis Rojas, Kendrick Meek, Rudy Garcia, Luis Morse, Carlos Lacasa, and Jorge Rodriguez-Chomat. The letter was a plea for the legislators to do what they could to save the jobs of Duany and Rosello, who were in danger of being laid off. "The termination of these two physicians will have a detrimental impact to the community," the missive read.

Letters like that were but one manifestation of the flak Brewer was taking in her attempts to straighten out the STD program. Others in the department, including Sfakianaki and Hazel Ruffin, administrator of the Prevention, Education, and Treatment (PET) Center in Miami Beach, described Brewer as being "frustrated" with the politicking of her medical staff, even after the Tallahassee report was issued.

In December 1997 the STD program was reviewed again, this time by one of Brewer's former professors: Dr. King Holmes, a faculty member at the University of Washington's Center for AIDS and Sexually Transmitted Diseases in Seattle and an internationally recognized expert in STD treatment.

Holmes questioned the most recent figures for the incidence of gonorrhea, chlamydia, and syphilis. He noted that incidence of chlamydia per 100,000 people dropped from 145.1 in 1994 to 48.6 in 1995. "These sharp declines are remarkable but highly suspect.... I know of no area in the world that has experienced such a remarkable drop in chlamydia incidence, even with much more aggressive chlamydia control programs than those currently in place in Dade County," he wrote. "Current data undoubtedly underestimate the real morbidity [incidence rate] of STDs."

Holmes echoed Karla Schmitt's criticism of clinicians, especially at the main clinic. "Physicians were clearly not busy," he wrote.

Another point: "The ratio of male-female clinicians at the downtown clinic was 5-1 ..., a problematic and inefficient imbalance since examination of women by a male clinician ... must be done in the presence of a female staff member -- thus doubling the staff required to evaluate female patients!"

Holmes's report clearly reveals that he was taken aback by what he found in Miami-Dade. "The incomplete clinic record-keeping, the low productivity, the level of physician overstaffing, the idiosyncratic view of STD diagnosis, and management at the clinics are unparalleled in my experience," he noted.

Like the Tallahassee report, however, the Holmes review lauded Toye Brewer's leadership. "Dr. Brewer's initial efforts have focused appropriately on improving STD case-management guidelines ..., but she is experiencing resistance to obtaining compliance with these guidelines." Such resistance came, according to Holmes, from the STD doctors, chief among them Manuel Rodriguez.

If Rodriguez is dismissive of the Tallahassee report, he is downright disdainful of the Holmes report. "We are all open to criticism, but he met with me for only ten minutes. Can you write a report like this after only ten minutes?" he asks rhetorically. "It's easy to criticize. It's easy to destroy. To build is hard."
Not surprisingly, Rodriguez and his colleagues responded to the Holmes report by staging what amounted to an epistolary rebellion.

In a letter to DOH executive administrator Annie Neasman dated March 4, 1998, Rodriguez wrote (on behalf of himself and seven other physicians, including all the STD doctors): "The working physicians are constantly being demoralized by Dr. Brewer, who continues to criticize rather than teach and correct the impoverished aspects of physician's [sic] bureaucratic skills. ... In spite of this, our medical staff in the STD clinics continues to overcome these obstacles and provide the highest medical quality for the community."

Rodriguez laid the blame for the controversy squarely on King Holmes and Karla Schmitt, adding, "None of them see patients but they are quick to criticize."
He ridiculed the Holmes report as "a recommendation letter for Dr. Toye Brewer," and went on to cite his 1997 form letter: "I feel the department is back to the starting point as it was on June 27, 1997, when we originally spoke to the state Senators and Representatives."

Brewer and Eleni Sfakianaki responded to Rodriguez's accusations with a joint memorandum to Neasman. "Some physicians have consistently failed to adequately document clinic encounters and meet minimally acceptable standards," they wrote. "This is inexcusable and no one should have to go to the clinic to teach them to do so."

To an outsider the kinds of failings outlined in the two 1997 reports might look like grounds for termination. And indeed Rodriguez and his colleagues were assuming a defensive posture in apparent fear of losing their jobs. But though two of the physicians were targeted for budget-related layoffs in mid-1997, they kept their jobs that year, and neither of the reports placed anyone in danger of being fired outright.

"The reports say general things about the quality of care," Sfakianaki explains, drawing a distinction between layoffs, which are based on decreasing funds and internal reorganization, and firings, which are based on poor performance. "If you are to address the issue of firing someone, there has to be documentation on that particular person, with cases being mistreated, with people complaining perhaps. And there is no such documentation here."

The doctors' complaints to legislators did result in some pressure being brought to bear on the department this year, both at the county and state levels. In August U.S. Reps. Diaz-Balart and Ros-Lehtinen wrote to Dr. James Howell, secretary of the state Department of Health. In September state Senator Gutman wrote to both Howell and Annie Neasman. These letters concerned the possible layoff of physicians, and though all used cautious language such as "respectfully requesting your looking into this matter," the fact that the letters were sent at all upset others within the department.

"Every time Dr. Brewer tried to do something, it would only go so far," says Hazel Ruffin, administrator of the PET Center in Miami Beach (where Brewer worked one day a week as an HIV primary-care physician). "The only reason Neasman would pull back was political. [Tallahassee] did not want to have the Cuban connection upset by holding physicians accountable for doing their jobs."

Rodriguez (who, like most of the doctors under his supervision, is Cuban American) insists his only motivation for contacting politicians was to persuade them to send more money to the department and to preclude the need for layoffs. He wasn't trying to pressure Neasman or anyone else with the correspondence. "My number-one priority is my patients," he asserts. "After my patients, my staff. And when they were in danger of being laid off, I didn't vacillate. They are not my staff, they are my family."

Although Rodriguez denies he was trying to bully anyone, Eleni Sfakianaki disagrees. Asked if she feels Rodriguez was hoping to pressure Neasman, she responds: "Yes, I do."

Neasman acknowledges that she and her boss in Tallahassee have received letters from legislators, but will not elaborate on her reaction to them. And regarding her STD physicians' proclivity for appealing to politicians, she will only say: "Certainly as citizens they have a right to do that, and they have done that."

Sfakianaki declines to characterize the effectiveness of the political pressure on Neasman. "I'll let you be the judge," she says.

In the end the sniping and politicking took its toll on Brewer. This past June she resigned to accept an assistant professorship of clinical medicine at the University of Miami. Neasman views Brewer's resignation as simply a matter of UM offering the doctor an opportunity she couldn't pass up. The DOH's Karla Schmitt, however, sees it differently.

"Dr. Brewer was trying," Schmitt says. "She's a very fine physician. She gave it an honest shot and decided it wasn't working. She gave up in frustration, and many of us couldn't blame her."

Sfakianaki misses her star recruits Brewer and Kunjana Mavunda and feels she did all she could to keep the women on staff. (Mavunda's epidemiology post has been filled. Brewer has not been replaced.) "I was proud to recruit such young, dynamic, well-qualified physicians," she says. "I do share their frustration; it's not easy to work in public health. That's why some decide to stick with it and others don't."
On the first floor of the squat, battleship-gray main building of Miami-Dade's DOH, people queue up for the clinical services offered there.

Although primary care has been farmed out in recent years, the edifice at 1350 NW Fourteenth St., nestled against the county jail and the criminal courts, still offers STD and TB services, immunizations, and confidential HIV screening to the poor, the uninsured, and the underinsured -- those on the margins of the modern health care system.

In her spacious, unadorned third-floor office in that building, Annie Neasman sits at a conference table. A registered nurse who has run Miami-Dade's DOH since 1990, Neasman wears a black-and-white houndstooth suit and a serious mien as she discusses the turbulent two years since her department's move from under the aegis of HRS.

She agrees with the Tallahassee evaluators' judgment that the number of full-time STD doctors in the program is too high. By her reckoning, the high number of physicians is a holdover from the elevated levels of syphilis and gonorrhea Dade County experienced in the Eighties, and the relative glut of medical doctors countywide.

She also accepts the reports' stinging assessments of the subpar care those physicians provide. "There is no excuse for the quality of those services," she concedes. "Certainly we recognized that we needed individuals who were completely trained in those particular services. They were not particularly up-to-date on particular standards." She would not elaborate on which of the physicians' clinical shortcomings she found most disturbing, adding only that some of them have undergone additional training.

The main issues, Neasman insists, have been budgetary, and for that reason this past September, the two STD doctors with the shortest time of service at the DOH found themselves in the downsizing crosshairs: Dr. Rusquin Duany and Dr. Luis Arrue.

These two men were among the doctors who, as a group, were criticized for giving substandard care. They also were among the signatories of the letters that led to the political heat. If Neasman took umbrage at her subordinates overtly trying to exert pressure, she's not admitting it. And firing them for bad performance (as opposed to financial reasons), she notes, would have required going "the disciplinary route."

Neasman agrees with Sfakianaki that none of what was described in the reports warranted disciplinary action. She also seems to accept their intransigence and complaints to politicians as par for the course. "They are not any different from any employee we have in state government," she says. "They don't like change. When you make a change, you're going to have resistance."

As it happened the department did not pull the trigger on either Arrue or Duany. Arrue accepted a demotion. The death of another STD doctor and the retirement of a doctor from another program obviated the need for further physician layoffs this year, Sfakianaki says.

Neasman points out that a new and more comprehensive system of keeping medical records, designed by Brewer, has been instituted, thus addressing a complaint common in both the Tallahassee and Holmes reports.

The fact that the harshly criticized doctors are still working comes as no surprise to former DOH staffer Dr. Kunjana Mavunda. "People at the Department of Health are not doing their jobs, and they're getting away with it," Mavunda laments. "Some of those [STD] physicians are among the most incompetent and uncaring people there are. But the main problem we have is the administration, and Tallahassee knows that. They know, but they're not willing to act.

Published:Owing to a reporting error in Ted B. Kissell's story about the state Department of Health ("The Doctor Is Out," December 10), both the name of Dr. Bill Skeen's organization and his title were misidentified. The group is called the Florida AIDS Action Council. His title is director of public policy. New Times regrets the error.

1 comment:

Anonymous said...

Good post and Smart Blog
Thanks for your good information and i hope to subscribe and visit my blog STD Symptoms and more Scabies Clinical Manifestations thanks again admin