Some Doctors Not Always on Job : Private Practice Strains Public Medicine at King

It is after midnight in the emergency room at Martin Luther King Jr. / Drew Medical Center, and young doctors and nurses are scrambling to treat the night’s onslaught of sick and wounded.

The evening has brought an 11-year-old boy with a shotgun wound to the head and his 18-year-old friend, whose arm was partially blown off by another blast. There is also a 14-year-old youth whose calf was mangled by a pit bull. And languishing on a gurney in the hallway is a man whose leg was caught in a power lawn mower.

Four adults are waiting for intensive care beds, which are full. One patient--unconscious and hooked to a ventilator--has been lingering in the emergency room for three days.

But amid all the activity, the senior attending physician on duty is nowhere in sight. Although he is supposed to be supervising, tonight he is in a private room equipped with a bed.

Refuses Interview

When a reporter knocks about 2 a.m., he comes to the door stretching and yawning and declines to be interviewed.

It is not uncommon for senior physicians to sleep on the job or otherwise ignore their supervisory responsibilities in King’s busy emergency department, say many of the young resident doctors who come to the 430-bed, county-owned teaching hospital in Watts to complete their final training after finishing medical school.

“Look around,” says Dr. Bernie Clum, a resident in training in the emergency room. “There are no attending (senior physicians) in this emergency room. The attendings are here in theory only. They come for rounds and go retire in their room and go to sleep, come back (in the morning) and sign off on the charts.”

Close supervision of the emergency room is supposed to be provided by a corps of full-time senior attending doctors on the staff of the hospital. Eight of the 11 attending physicians--who are paid between $79,000 and $119,000 a year--have jobs outside the hospital, according to interviews and records obtained by The Times.

Problem Acknowledged

The hospital’s medical director, Dr. James Haughton III, said he discovered last fall that “a whole bunch” of attending physicians were working far fewer hours at King than they were being paid for.

Dr. Theodore Schlater, acting chief of emergency medicine, defended his staff as hard workers and diligent supervisors.

As for charges that some of them sleep on the job, Dr. Schlater said, “I don’t think there’s anybody who spends the majority of time in the bed. . . . I’d be the last to say ‘never,’ but when they (the residents) apply (that to) the majority (of attending doctors), that’s baloney.”

“We’re not all the same,” said one attending emergency physician, Dr. Caspar Glenn. “I put in my 40 hours (a week) plus more. . . . When I do work at night, typically I do not sleep and usually the bed is unslept in. . . . There may be perhaps one or two people who don’t do what the residents (young doctors) think they should . . . but the majority of individuals are doing what they are supposed to be doing.” However, Dr. Charles Whiteman, who graduated with top honors last year as the chief resident in emergency medicine, said of the attending physicians:

“At night, they’re back watching “Nightline” or something else on TV or asleep. In the daytime . . . they have to be a little more visible because administrators are walking around. But they’re definitely not supervising the residents or providing patient care.”

“It’s one of the worst things here,” said Dr. Ken Saunders, another resident. “That’s not true of other hospitals. Other places, they (attending physicians) are over your shoulder, involved, interested, giving advice.”

The problem of supervision may be symptomatic of a department that has long drifted leaderless. For more than seven years, emergency medicine has lacked a permanent chairman, something that Haughton, the medical director, acknowledged is “crazy.”

Haughton said he has gone into the emergency room at all different hours and “I don’t see the attending (physicians) doing a lot of patient care.”

In fact, he said, he discovered last fall that some of them were putting in far fewer hours at King than the 160 hours a month they are paid to work there.

“There’s this whole bunch of guys putting in . . . not even . . . 100 hours a month,” Haughton said he discovered.

Haughton confronted the physicians about what he viewed as their “dereliction of duty” at a meeting on Sept. 28 that, he said, got “a little hot.”

“The response I get is: ‘This is the way it’s been. This is the understanding,’ ” Haughton said.

“We separated friends, with the agreement that things are going to change.”

Among other things, Haughton said he laid down a rule last September requiring that two attending physicians be present to supervise the emergency room during the day.

But despite his efforts to require more participation from them, The Times monitored the activities of several full-time attending physicians and discovered that:

* Dr. John A. Williams reported working a full day at Martin Luther King Jr./Drew Medical Center in Watts on Nov. 18, 1988. He reported on his time card that he arrived at the hospital at 8 a.m. and checked out at 5:30 p.m. But a Times reporter and photographer who followed him that day found that Williams actually spent less than four hours at the medical center. He arrived at King about 8:40 a.m. He left at 12:08 p.m., and did not return. Instead, he ran errands and visited other hospitals where he treats private patients. He declined repeated requests for an interview.

* Dr. Gary Ordog was scheduled to work as one of two attending physicians in the emergency room during the day on Dec. 8, 1988, but he wasn’t there. Instead, he was 40 miles away working at the Henry Mayo Newhall Memorial Hospital in Valencia. Ordog works in the Valencia hospital’s emergency room even though he reported on a disclosure statement, which he was required to file with his supervisors, that he has no employment other than at King. Ordog said in an interview that he took compensatory time off from King on Dec. 8 and arranged for a colleague to cover for him at King while he worked at Henry Mayo.

* Dr. Glenn was scheduled to work as one of two attending physicians in the emergency room during the day on Jan. 27--such a busy day that by 11 a.m. the hospital was closed to ambulance traffic. But Glenn was not there. He acknowledged in an interview that he was home, recovering from having worked all night at another hospital, the Dominguez Valley Medical Center. Although Glenn was working there regularly, he did not report that he held this outside job on a disclosure form he filed with his supervisors at King. In an interview, Glenn said he did not think he was required to be on the premises Jan. 27. “The bottom line,” Glenn said, “is that I don’t think that anybody who knows me would question that I put in 40 hours a week, plus.” Glenn added that there are “probably one or two people who abuse the system” in the department of emergency medicine, but he said that he is not one of them.

Unlike King, some teaching hospitals flatly prohibit their full-time salaried physicians from engaging in private practice. The theory is that outside work tends to distract physicians from their obligations to supervise residents, conduct research, publish treatises, write grant proposals, and provide hands-on patient care.

Higher Salaries

But teaching hospitals that prohibit outside employment--like UCLA Medical Center and UC San Francisco--usually provide better financial opportunities for their doctors than are provided at King. Among other things, salaries are higher and research opportunities are vast. Also, doctors are usually given ample opportunity to treat private patients and bill separately for their services.

In recognition that the salaries paid doctors at county-owned hospitals are lower than what the physicians could probably earn in private practice, full-time doctors employed by Los Angeles County are permitted to hold outside jobs up to 24 hours a week.

However, under threat of disciplinary action or dismissal, the county requires doctors to obtain prior written approval from their supervisors for their outside work.

For years, these requirements have gone largely unenforced at King.

“Somebody forgot” to ask doctors to file disclosure forms reporting their outside jobs, said hospital administrator Williams Delgardo. He said he directed doctors to fill them out after The Times asked to see them last year.

A review of these disclosure forms shows that full-time attending physicians in all sections of the hospital are engaged in private practice. In some cases the outside work appears to be quite demanding. One full-time surgeon at King, for example, noted that his private practice consumes as much as 40 hours a week of his time.

While he was holding the job of full-time chief of cardiology at King, Dr. Ravi Prakash filed a disclosure form stating that he had an outside private practice in Torrance, but that it required only three hours’ work on Saturdays. But he has apparently been working at his private practice during the week, too. A reporter found him there on Wednesday afternoon, Jan. 25, with a waiting room full of patients.

Since then, Prakash has been promoted to chief of internal medicine. But in August, the department’s senior attending doctors sent him a memorandum expressing a “vote of no confidence” in his leadership because of his frequent absences from the department.

Won’t Talk to Reporters

Prakash defended his leadership in a memorandum and explained that school business sometimes takes him off campus. He has repeatedly refused to be interviewed by The Times.

In other cases, doctors at King have filed disclosure forms swearing that they had no outside employment when, in fact, they do, The Times found. For example, Dr. Schlater, acting chief of the department of emergency medicine, admitted in an interview that he did not disclose that he works part time at Daniel Freeman Memorial Hospital in Inglewood. Asked why, he said: “I thought that was so small that it wasn’t even worth mentioning.”

The Los Angeles County Grand Jury, investigating administrative functioning at King in 1987, received testimony from one King physician that many full-time doctors at King “have private offices and busy practices during weekday afternoons. The surgical staff, in particular, are notorious for their large outside private practices.”

Dr. Haughton acknowledged that the prevalence of off-site private practice among King’s 130 attending physicians is a problem.

“Your private practice should not become your primary practice, but how do you draw the line?” Haughton asked.

He cited an instance where surgery had to be canceled because the senior attending surgeon, whom he did not identify, failed to show up to supervise the operation. It turned out he had an emergency in his private practice.

“He didn’t come in and he didn’t arrange for somebody else to cover for him,” Haughton said. “That’s just not acceptable.” In an interview, Dr. Arthur Fleming, King’s chief of trauma and surgery, defended King’s senior surgeons as “a uniquely capable faculty for this institution.” And he said that to his knowledge their private practices have never interfered with surgery at King.

But in a memo he wrote in April 11, 1985, that was published in a book entitled “A Century of Black Surgeons,” Fleming acknowledged that the department of surgery at King was suffering from “a negative image throughout the institution” because of the widely held perception that attending surgeons are “not available when needed” and are extensively involved in private practice, with little commitment to King.

“All I ask from my fellow surgeons,” he said in the memo “is that they be accountable for what they do by reporting accurately the hours worked and the money earned. The Department of Surgery will continuously be accused of working only two to four hours at King-Drew Medical Center each day and making lots of money on the outside unless we become fully accountable.”

Dr. Harvie Dale Harrier, an attending surgeon at King who does not work anywhere else, said there is a “great temptation” for doctors who have off-site private practices to develop their businesses at the expense of their county obligations. He said that doctors with outside jobs “have conflicts of interest built in.”

“My problem,” said Haughton, “is making an assessment of the extent to which their having a private practice may interfere with their duties here. . . . It’s sort of an honor system.”

County auditors have long warned of lax timekeeping practices at King.

They have reported that physicians signed blank time cards that were filled out by clerical staff who never verified that the hours billed were actually worked. Some medical departments permitted doctors to bill for 24 hours of service on days when they were on call but not on the premises. And frequently the total hours billed did not correspond to the number of hours marked as “time in” and “time out.”

A management audit in 1987 by the private accounting firm of Touche Ross recommended that the medical center “immediately design and implement improved procedures for physician time-reporting and monitoring.”

King officials have told county auditors that they have done so.

Last year, King set up a so-called “faculty practice plan” that hospital officials hope will eventually allow physicians to supplement their salaries by treating private patients at King and billing separately for their care.

Haughton described the program as part of an effort to “pull them (the doctors) back to campus.”

Other county hospitals implemented such plans years ago. At Harbor General/UCLA, Haughton pointed out, the plan has significantly reduced the need for attending physicians to engage in off-site private practice.

But it will be some time before the plan gets off the ground at King. Meanwhile, physicians are continuing to go off-campus to set up private practices to supplement their incomes.