The Doctor is Out

Beset by internecine battles, troubled leadership, and funding cuts, the local office of the Florida Department of Health is in need of intensive care.

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."

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