Clinics So Close Yet Also So Far Away

When Dr. Robert Lefkowitz is asked if there are compelling medical reasons for the county to build a new ambulatory care center at Ventura County Medical Center, he remembers the time he sent a patient on a one-block ambulance ride.

She was pregnant, close to term, and her baby’s heart rate had dropped dangerously during a routine amniocentesis at Lefkowitz’s clinic, the Women’s Health Center. The hospital was tantalizingly close--just across Loma Vista Road--but wheeling the patient across the busy street on a gurney was not an option.

This situation may be a worst-case scenario, but for Lefkowitz and others in the county health system, it offers the ultimate illustration of the medical need for the much-disputed new $56-million ambulatory care center proposed for the county hospital.

“I have to cross the street to go to the hospital--it’s no big deal,” Lefkowitz said. “But when you have patients near term in trouble trying to cross the street, it’s a problem.”

Representatives from Community Memorial Hospital, which has waged an aggressive campaign to stop the county from building the five-story ambulatory care center, as well as a new kitchen, cafeteria, laboratory and parking structure, agree with Lefkowitz that his patient was put in a dangerous situation.

But while the county argues that consolidating Lefkowitz’s clinic and four other outpatient clinics scattered throughout the neighborhood would fix such problems, Community Memorial’s attorney John McDermott counters that a genuine improvement in overall medical care could be better achieved in a different way.

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If the county hospital would agree to send some of its Medi-Cal patients to other hospitals with state-of-the-art facilities already in place instead of building an expensive new facility, everybody would be better served, McDermott said.

“The county could solve that problem tomorrow by signing contracts with the other hospitals in the county,” he said.

To date, the ugly war between the two hospitals has focused largely on the financial aspects of the project, with county officials touting the plan as a way to save money and Community Memorial representatives urging voters to vote against the plan March 26 because they say it will be a drain on taxpayers.

It is no surprise that the two sides don’t agree on the medical need--or lack thereof--for the new facility either. Community Memorial representatives don’t even touch the idea that quality of health care might improve if the clinics were under one roof.

“This has nothing to do with medicine,” attorney McDermott said flatly.

But doctors and administrators at the county hospital say the medical rationales for building the ambulatory care center are just as compelling as the financial reasons. Doctors say they have been squeaking by in coping mode for too long already.

“This facility is not meeting our patients’ needs,” said Dr. Christopher Landon, who heads the off-campus pediatrics clinic at 3400 Loma Vista Road. “I think our quality of care is excellent here, but I think we’ll be able to provide it better in a more appropriate setting.”

Landon and others say the center would fix a number of inefficiencies that plague the clinics. They say the center would give doctors better access to each other, make it easier for patients to get needed laboratory tests and X-rays and eliminate the dangerous dashes across the road.

“It is very difficult to run this hospital with my medical specialists scattered all over Loma Vista,” said county hospital Administrator Dr. Sam Edwards.

Things used to be different.

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The specialty clinics, representative of the growing trend toward managed care systems where more patients are treated on an outpatient basis, were originally housed primarily in several 1930s era buildings right behind the hospital.

“You’d be in the back of the hospital in two seconds,” Lefkowitz said.

But the buildings were in bad shape. Ceilings were crumbling, beams were slanting ominously, and rainy days brought torrents of water through roofs. Lefkowitz even remembers a “vermin” problem. To top it off, asbestos was discovered throughout the buildings.

In the late 1980s, the hospital staff began to abandon the buildings, moving into cramped quarters inside the hospital or to leased space in the neighborhood. The county now spends $288,000 annually on 22,564 square feet of leased offices.

Pediatrics ended up on the first floor of the hospital, with only two exam rooms and barely room to turn around. In 1989, Landon, head of the children’s clinic, decided it wasn’t adequate. He went walking in the neighborhood, looking for something to lease.

He found a physical therapist’s office at 3400 Loma Vista that seemed to work and took out a three-year lease. When a neighboring dentist and an acupuncturist moved, Landon snapped up those spaces. But it still isn’t enough, he said.

“It’s not an adequate facility,” he said. “I really consider it temporary.”

Some of the problems are with the facility itself--for example, the room where children receive chemotherapy treatments has no sink--but others are more logistic in nature. If patients need blood tests or X-rays, Landon sends them to the hospital lab, two blocks down the street.

“I have to send my patients out in the wind and rain,” Landon said.

Laura Dahlgren, spokeswoman for Taxpayers for Quality Health Care, the Community Memorial sponsored group that opposes the county’s plans, is unimpressed by Landon’s woes.

“It’s not a mile hike,” Dahlgren said. “And there is a crossing guard there all the time.”

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Landon says patients routinely return to their cars after appointments that run longer than expected and find parking tickets on their windshields. Physicians lament the time they have spent looking for parking spots around the hospital.

“There is a lot of wasted time,” said Dr. James Holden, head of Tower Surgical Associates, the county surgery clinic at 100 N. Brent St. that has the distinction of being the specialty clinic farthest from the county hospital.

“On an average day, I probably go back and forth three times,” Holden said. “It’s 10 minutes each way if I walk. The other day it took me 15 minutes to find a parking place. That is all nonproductive time.”

Though 10 minutes here or 15 there might not seem like a big deal for most people, Administrator Edwards says that time can be crucial in medical situations.

“A lot of bad stuff happens to a patient in 15 minutes,” Edwards said. “Four minutes is a lot different from 15.”

Doctors say one of the biggest drawbacks to the scattered nature of the clinics is the loss of access to each other’s medical expertise. In a five-story ambulatory care center, they would be able to consult more easily and frequently, they say.

“I could run up and say to Jim Holden, ‘Can you poke on this kid’s belly for me?”’ Landon said. “That might save a day of hospitalization.”

Holden said the way the system works now, it is nearly impossible for his colleagues to consult with him directly. They talk on the phone when they can, and end up scheduling future examinations that bring patients, many of them poor people without transportation, back to the hospital for another visit.

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But their opponents say this inconvenience is unexceptional and in fact typical of medicine today.

“I don’t know that that is a reason to spend $51 million on a new building without taxpayer approval,” Dahlgren said.

“It works the same way in the private sector,” she said. “Each one of us, as a patient, when it is us or a loved one that is ill, we want to have every specialist and every bit of technology available to us. But the reality is, that simply isn’t possible.”

Neurosurgeon Moustapha Abou-Samra has worked in both hospitals as chief of surgery, although he now practices primarily at Community Memorial. Though he said he hasn’t contributed to Taxpayers for Quality Health Care, he will vote no on Measure X. From a medical point of view, he doesn’t think the facility is justified by need. Patients at the UCLA Medical Center in Westwood have to cross the street all the time and wind and rain are infrequent inconveniences in Ventura, he said.

“If we lived in Chicago in the dead of winter that might matter,” he said.

What about the patient on the gurney who can’t get across Loma Vista?

“Suffice it to say medical emergencies happen all the time,” Abou-Samra said. “And they don’t always happen in a clinic setting. You don’t have to build a $51-million building to fix what is an exceptional occurrence.”

Both proponents and foes of the new ambulatory care center return repeatedly to the financial aspects of the project. According to surgeon Holden, practicing better medicine is indeed the goal of the new ambulatory care center, but the two issues can’t--and shouldn’t--be separated.

“Every dollar the county can save is another dollar they can put toward caring for patients,” Holden said.

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Proponents argue that the county wastes $288,000 annually on lease costs for six off-campus sites, including the Women’s Health Center, the Pediatric Diagnostic Center, Tower Surgical Group, the Family Care Center--where residents hone their skills--the Faculty Medical Group--where county employees covered by the county health plan go for care--and administrative offices.

They also say $175,000 is being spent on unneeded support staff. Each clinic has a receptionist and clerical help, but in an ambulatory care center, those activities could be centralized and some positions eliminated.

Taxpayers for Quality Health Care point to the leased space as evidence to support its argument that the county is trying to expand its patient load and run Community Memorial out of business. Do the math, they say. The county rents only 22,564 square feet now; the five-story ambulatory care center is supposed to be 76,985 square feet. There must be an expansion planned.

“I understand the mechanics of their argument,” hospital financial officer Dave Cattanach said. “But the point that gets missed is that the clinics are really being shoehorned into minimal space.”

“I think it is a misleading inference,” he said. “What would be the ambulatory care center is designed for an efficient operation. What they are using today are really inadequate, stop-gap measures.”

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Leading a tour past the barricaded, condemned buildings that used to house the clinics, Edwards shows his frustration with the talk of expansion.

“If you were building a building that was supposed to last for the next 50 years, wouldn’t you add a few square feet?” Edwards said. “If you didn’t, people would think you were crazy.”

“We are not expanding our functions,” he said. “The buildings we are in are not big enough.”

County officials say they can’t keep this bare-bones approach up for much longer. The hospital’s kitchen, cafeteria and laboratory will have to be replaced soon regardless of the overall status of the project. And Edwards said he is shopping for clinic space right now for several other departments, including internal medicine.

“I’ve got people meeting in closets and hallways,” he said.

Finishing his tour in front of the county hospital, Edwards throws up his hands in disgust over the disputed project.

“I don’t want to be building a building,” he said. “But bricks and mortar are a sad fact of life when you run a hospital.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Off-campus sites that would be relocated into an ambulatory care center at Ventura County Medical Center:

CURRENT LOCATION: * Family Care Center, 3170 Loma Vista Rd.

FUNCTION: Split between Clinic where medical residents see patients and learn outpatient family practice medicine and trailers behind the hospital

CURRENT LOCATION: * Pediatric Diagnostic Center, 3400 Loma Vista Rd.

FUNCTION: General and speciality care clinic for children.

CURRENT LOCATION: * Tower Surgical Group, 100 N. Brent St.

FUNCTION: General surgery clinic and surgical subspecialty consultations, some minor proceduresdone on site, but mostly used for exams / consultations.

CURRENT LOCATION: * Women’s Health Center, 3160 Loma Vista Rd.

FUNCTION: Obstetrics / gynecology speciality clinic.

CURRENT LOCATION: * Faculty Medical Group, 3180 Loma Vista Rd.

FUNCTION: Where county employees covered by county health plan are seen.

CURRENT LOCATION: * Utilization/Review, Quality Assurance, Nursing Education, Infection Control, 3212 Loma Vista Rd.

FUNCTION: Clerical offices where nurses review patient cases and other office support.

CURRENT LOCATION: ** G.U. Clinic, 145 N. Brent St.

FUNCTION: Urology clinic.

CURRENT LOCATION: ** Ear, Nose & Throat, 3081 Loma Vista Rd.

FUNCTION: Specialists see patients with ear, nose and throat problems.

CURRENT LOCATION: ** Opthalmology, 2859 Loma Vista Rd.

FUNCTION: Eye specialists see patients.

CURRENT LOCATION: ** Immunology Clinic, 3147 Loma Vista Rd.

FUNCTION: Immunizations.

*Leased space.

**Space in private physician’s offices used for a few hours or a day, once a week. If the ambulatory care center were built, these clinics would be conducted there.