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.

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.

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