Doctors’ contracts are set to expire at the end of this month, hospital staff’s WARN notices are still pending, and now SUNY DMC is pulling the plug on LICH’s residency program – or as one doctor called it, the “backbone” of the hospital.
Meanwhile, the lawsuit filed by Long Island College Hospital (LICH) against State University of New York Downstate Medical Center (SUNY) has been postponed indefinitely. And SUNY’s new Sustainability Plan submitted to the state on June 1 excludes LICH almost entirely – except for the dollar sign on their property value.
Despite court ordered restriction, SUNY is continuing to unravel the threads holding LICH together. By withdrawing their closure plan, they have been able to quietly cease operations at LICH. They have delayed LICH’s lawsuit by changing attorneys in the eleventh hour, claiming a “conflict of interest,” pushing the date beyond the original closure date of June 18. Most crippling of all, they have recently taken action of removing every resident doctor away from LICH.
Dr. John Romanelli calls LICH the proverbial “carcass picked apart for assets and then left to die.”
In 1860, two years after the hospital was opened, LICH introduced the idea of bringing medical training to bedsides. LICH was the first medical institution in the world to implement this sort of training. Today, the program has been instituted worldwide. After completion of medical school, every future doctor must complete and be certified through a residency program similar to LICH.
Although residency students are still under the authority of the doctors they work side by side with, they are capable of diagnosing and treating a patient, just as a doctor does. Residents are paid by the hospital they train with; the hospital is also paid by the state to train them.
LICH currently has 42 resident doctors who not only are receiving training to practice medicine in the future, but they are also valuable assistance to doctors by filling in gaps. They take on extra patients and provide extra hands for a certified doctor, allowing more patients to be cared for than a standalone doctor. “They are an extension of the attending medical staff,” Dr. Romanelli explains. “The residents help manage the patients on the hospital wards with the attending staff supervision. Without them, LICH would be less profitable, provide less patient care and create a much greater workload for attending doctors.
On June 23, 2013, the very last residency class of LICH finishes the program and graduates. On June 30, 2013, SUNY has mandated that the residents who have yet to complete their program at LICH be moved back to the SUNY campuses and finish training at UHB.
The 42 residents will be replaced by 20 physicians’ assistants (PAs) and nurse practitioners (NPs). But Dr. Romanelli estimates that the hospital will need at least 60-100 to replace the residents.
No substitute for doctors
Dr. Romanelli explains the burden this will place on the remaining doctors of LICH. PAs and NPs cannot substitute the place of doctors. PAs cannot diagnose and treat patients, although they can render care by way of doctors’ orders. The doctors must also sign off on an NP’s diagnosis and treatment. If the NPs make a mistake, the doctors are liable.
SUNY has also hired Pitts Management Company to run and facilitate hiring and operations of the hospital. When John Burns, the acting Chief Operating Officer (COO) of LICH “essentially had no contract and was let go,” Dr. Romanelli said, James Karkenny of Pitts Management took over.
James Karkenny has been the interim Chief Operating Officer since early May after Burn left the hospital. At a recent meeting, he addressed the doctors and attending physicians, saying “clearly this month has been one of transition.” He described his role “to plug the majority of holes in administrative, clinical leadership as well as nurses.”
When addressing the residency plan, he said, “I understand the challenge. I’m not sure if there’s anything else I can offer. The plans are in place; the decisions have been made. We’re doing our best with many of [the doctors] to fill the gaps and the holes. The last thing we can do is put our patients at risk and infect the quality of patient care.”
Meetings of the medical leadership – or chief doctors at LICH – began the day the decision the end the residency program was handed down. According to Karkenny, LICH’s administration is working towards “[re]staffing on a daily basis.”
“What’s the cost of this?” asks Dr. Romanelli.
“Significant,” replied Karkenny.
“Do you have a number?”
“We have some numbers. It’s a huge amount. Obviously.”
“More than one million?”
“Six million, ten million?”
“It’s in that range.”
“It’s the best information available to us today.”
Full Court Press
“We committed to a full court press to get these folks in, vetted through the interview process credentials and in place by the time the residents are gone,” Karkenny promised. “We still have a hospital that’s open, it’s open for the foreseeable future, and we’re committed to bringing the resources in to maintain excellent care.”
Letters dated Monday, May 20, 2013 were sent to the heads of all three existing residency programs from Stephen Wadowski, Associate Dean for Graduate Medical Education (GME) at SUNY. In a copy obtained by the Star-Revue addressed to Mary Fatehi, the Program Director for Obstetrics and Gynecology (OBGYN) at LICH, the letter states, “According to the Accreditation Council for Graduate Medical Education (ACGME) Institutional Standards, residency programs accredited by the ACGME must be operated under the authority and control of on Sponsoring Institute.” SUNY is currently the “Sponsoring Institute.”
The letter goes on to read, “A motion of voluntary withdrawal of ACGME accreditation for the SUNY Health Science Center at Brooklyn – Long Island College Hospital Program in Obstetrics and Gynecology was made and approved by the Committee. Withdrawal of the accreditation is to become effective at the end of the 2012-2013 Academic Year and no later than June 30, 2013.” The letter gives three days for the program directors to “appeal this determination,” and submit “in writing to President John Williams before noon on May 23, 2013.”
The program directors of Radiology and Internal Medicine received the same letters.
The ACGME’s mission is to “improve healthcare by assessing and advancing the quality of resident of resident physicians’ education through exemplary accreditation.” They were established in 1981 based on a consensus in the medical academic community calling for an independent accrediting organization. In the academic year 2010-2011, there were 8,887 ACGME-accredited programs in 133 specialties nationwide. As of July 1, 2013, LICH will no longer be one of them.
“Now we suddenly are losing the residents, and I don’t think this hospital could work without them. I would like to know why we lost the residency program,” pressed Dr. Marwin Attalah
However at a June 3 meeting with the medical staff, SUNY Chief Medical Officer, Michael Lucchesi, claimed that residents filed letters of complaints with the ACGME. Lucchesi could give no further information on how many complaints were filed, the nature of the complaints or any other pertinent information regarding the issue.
Lucchesi also said ACGME visited the hospital on May 29, 2013 and decided the residency program needed to be shuttered. However, two weeks before the site visit, SUNY called the department heads of Internal Medicine, Radiology and OBGYN and demanded that they voluntarily withdraw their residents beyond June 30. The phone calls happened at 9:30 pm on a Monday night – May 20 – and the letters were sent out Tuesday morning.
Dr. Millicent Comre, OBGYN Clinical Assistant Professor and Chief of Service, and Dr. Fatehi appealed the decision in a letter to Dr. Williams dated May 23, 2013. They “formally appeal the determination” for “voluntary withdrawal of ACGME accreditation,” citing the program is “in full compliance with all standards required for successful education of residents in our specialty.” The doctors provide a list supporting their cause including, “a full and stable complement board-certified faculty;” “adequate numbers of patient volume and procedures;” and “adequate resources to support continued education.” The letter continues, “In addition, we await your response concerning our request made in writing May 9, 2013 to maintain an independent residency in Obstetrics and Gynecology at LICH […] A plan to offer uninterrupted care for our patients in the absence of house staff must be outlined and adequate staff secured.”
Romanelli said, “SUNY is controlling the process before it goes to ACGME. SUNY initially told our program directors that they were merging our residency programs into their programs. Earlier this week, a late night phone call to the LICH program directors by the GME director, Dr. Wadowski forced them to voluntarily withdraw their respected residency programs under ACGME. He then had a public meeting with medical and attending and resident MD staff telling them that as of June 26, there will be no medical residents at LICH, essentially crippling our hospital.”
In response to pulling the plug on the residency program, Head of Nursing, Catherine Gallogby-Simon submitted a letter of resignation effective July 1, 2013. Her protest of the withdrawal was described by Romanelli as the “final nail in the coffin,” because it is impossible to for her to run the nursing department in the manner SUNY is proposing to operate the hospital.
Dr. John Romanelli said the complaints were in regard to the residents not having enough attending doctors to run the program. Those attending physicians were pulled from LICH – by SUNY, of course – earlier in the year. Many critical doctors that teach residents were not replaced by SUNY, causing the hospital to become deficient in its training process.
Romanelli also stated that reversing the process and allowing residents back into the residency program is “very extensive” and would take many months, as well as being extremely costly.
Dr. Toomas Sorra, President of Concerned Physicians of LICH, said “SUNY has FORCED [us] last week to withdraw its residency program for the first time in history, and are thereby trying to convert LICH into the equivalent of a walk-in clinic/hospital, instead of the full service hospital that it is at present. This is a major assault on LICH by SUNY.”
Many questions remain about the employment gaps LICH now faces. Who is going to supervise the PAs? How will LICH get the PAs recruited, certified and trained in less than 30 days? And how will the hospital be able to afford such an enormous expense at this point?
Karkenny could not answer these questions. SUNY officials offered no response. And the medical staff of LICH is left to deal with the consequences.
The lawsuit filed against SUNY and the Department of Health is in response to SUNY violating a temporary restraining order (TRO) from early February. The TRO, which was extended indefinitely by Judge Johnny Lee Baynes on February 21, barred SUNY’s Board of Trustees from even discussing the closure plan with the Department of Health. The TRO specifically states that the “Defendants-Respondents are hereby TEMPORARILY RESTRAINED and shall not take any action in the furtherance of the closure plan for Long Island College Hospital submitted to the DOH.”
On March 8, 2013, Crains published an article entitled “Long Island College Hospital closing still on hold. An unnamed SUNY spokesperson was quoted, saying, “ ‘We will respect the process and await his [Baynes] ruling.’ “
In the press release announcing the withdrawal, SUNY President John F. Williams, Jr. said, “We are withdrawing the closure plan so we can work with the state and other stakeholders on a sustainability plan for Brooklyn’s only medical school and to ensure quality medical care throughout the borough. The current legal proceedings prohibit this dialogue.” Many have suggested that the withdrawal was simply a “bargaining chip” to trick LICH into dropping the lawsuit, while SUNY quietly took all measure to ensure that LICH would fall apart.
Since the closure plan was formally withdrawn from DOH on April 26, SUNY has continued to take action towards causing the hospital to close on its own accord. Removing the residents from a hospital that has been a teaching institution since their inception in 1860 is as one doctor states, like “removing the backbone” of the LICH in a “very mean and stupid” way.
Dr. Sorra writes, “SUNY/DMC continues to do everything possible to ‘de facto’ close LICH, despite all our efforts.”
SUNY has taken equipment and supplies out of LICH’s hands. They have not provided adequate staff to keep many departments open. Several floors of the Hicks Street Location have been cleared and remain deserted. On June 3, six Operating Room (OR) nurses resigned. As a result, the OR had to be downgraded from 10 rooms to 8 due to lack of staffing
Councilman Brad Lander said, “We’re worried time is not on our side.”
In a report released by the American Medical Association (AMA) called “AMA Center for Transforming Medical Education and AMA Advocacy Resource Center,” predicts that the United States will face shortages of physicians by the year 2025. “To ensure an adequate physician workforce and better access to care, proper GME funding is a must.” SUNY has failed to provide LICH with that funding, and has created the loss of their residency program due to lack of staffing, resources and finances.
LICH’s lawsuit against both SUNY and DOH is still pending, but the court date has been postponed indefinitely. “The problem is – is there enough money and legal willingness around to pursue this to its correct conclusion?” asks Dr. Sorra.
SUNY held a town hall meeting for a public discussion of their sustainability plan at their Downstate Medical Center on Monday, May 20. Carmen Pimentel, a register nurse at LICH began her testimony by saying, “This town hall meeting is not a substitute for meaningful serious consultation with stakeholders.” She also added that, “Our three minute comments today are not the consultation with stakeholders required by law.” Herdley Hill, a psychiatric nurse at LICH testified, saying “Instead of seeking meaningful input, SUNY is holding this so-called town hall meeting, which by no means fulfills SUNY’s legal obligations.”
Later in the day, SUNY followed the meeting with a council meeting for an update on the sustainability plan. All talk about LICH as a part of the plan was averted, citing the TRO prohibiting SUNY from further discussing the closure of LICH.
Even thought the decision to remove residents from LICH had already been put into process, nothing was mentioned to the general public. Nor has anything concerning the exit of the program been mentioned at any public meeting to date.
Attorney for LICH’s lawsuit against SUNY and DOH, Hanna Fox of Arnold & Porter LLP sent a letter to SUNY officials on May 23. “My understanding is that you will send us a description of how the residency programs at LICH will be managed going forward, including how staffing will be managed to ensure appropriate patient care for any period during which residents are not present at LICH, and plans for resuming the residences’ presence at LICH. Although we did not explicitly discuss the fellowship programs yesterday, they are also an integral part of LICH and we request that you address SUNY’s plans with regard to fellows as well.”
The email was sent under the announcement that residents at LICH would be temporarily sent to SUNY with the understanding that residents would be sent back to LICH after the ACGME’s May 29th inspection. Once all three departments had “voluntarily” withdrawn, SUNY announced the withdrawal was permanent.
In addition to the RFI, SUNY opened a small window for questions regarding the request. The questions were posted online along with corresponding answers. Under Question #2, regarding inspection paperwork, seven certifications were listed as “not currently available,” including architectural, electrical, plumbing, heating, ventilating and air conditioning systems, and elevator certifications, as well as service/preventable maintenance records for mechanical and biomedical equipment and flame spread documentation. Fire Stopping and Fire Alarm system information would available through “an appropriate due diligence process.”
Most disconcerting, is a request for the emergency generator report. The response listed is simply, “There is no emergency generator.” According to Dr. Romanelli, every hospital is required by DOH to have a backup generator. This oversight on SUNY’s part is a strong indication that they are very unaware or unconcerned about LICH. If the hospital did not have a back-up generator – as SUNY has suggested – DOH would be forced to close down the hospital.
Other questions that SUNY’s officials were unable to answer include asbestos-containing material throughout the building, square footage of individual rooms and much of the financial documents requested – which of course would also be provided after “an appropriate due diligence process.”
Although Concerned Physicians of LICH and other of the hospital’s medical staff submitted questions to the inquiry, none of their questions were posted on the website or ever answered, according to Dr. Sorra. “Not one community voice has been listened to. Not one ounce of concern has to be considered about the value for the community if LICH shuts down.”
One option for LICH is to operate themselves, if they can find “good leadership,” said Dr. Sorra. He also confirmed that LICH would be submitting a written response to SUNY’s RFI. However, they were derailed the same week with the prospect of losing their residency program. Despite the setback, the doctors still submitted their written proposal. “We haven’t had a board [of trustees] for 14 years; that’s what we want,” said Dr. Sorra.
Dr. Romanelli says, “We can’t make a decision. The state owns us. They’re the ones that hold the purse strings.”
At least three hospitals have expressed interest to SUNY’s RFI, possibly as many as seven. Lutheran Medical Center in Sunset Park has submitted to the RFI, but only for outpatient services. All existing in-patient services would be lost and the majority of LICH’s real estate sold for residential development.
In her testimony, Pimentel also stated, “the RFI document offers very little insight into hospital finances, a tad more information about current operations, and a great deal of detail about LICH real estate.”
Dr. Sorra said, “the process is flawed if there is no financial information available. SUNY has stated that their RFI presented for potential suitors for LICH is the only way that LICH will survive. And they have said in various statements that there are ‘one, two or five’ suitors who are interested in taking over LICH. But they have refused to give us information about these apparent potential suitors.”
So many uncertainties lie ahead for the patients and medical team of LICH. And SUNY is leaving many questions unanswered. The situation they have created carries strong implications they are taking all measures to ensure LICH cannot survive, thus ending many months – or possibly even years – of sustaining LICH before negotiations can be finalized. “We all want to have some kind of answers. I don’t have one; I don’t think we’ll get one today,” said Dr. Attalah.
WARN notices of termination dated for June 18 have yet to be rescinded. “Since the reason for the termination notices – LICH’s closure – no longer exists, we consider the termination notices to be null and void. We expect those notices to be rescinded,” said Semente. “It’s obvious to us that the termination notices must be cancelled if LICH’s closure was cancelled. Are they planning to terminate the employees on June 18th as part of their sustainability plan that must take effect by June 15th? Is this just another sneaky way to close LICH or severely reduced from a full service hospital?”
In addition, contracts for all hospital employees end June 30. None have been renewed. According to Karkenny, the hospital is “looking at [their] options,” including month-to-month renewals.
While SUNY declined to comment on the majority of the Star-Revue’s more detailed questions, Ronald Najman, Director of Communications and Special Projects, emailed a statement saying, “SUNY last week submitted to the governor’s Budget Division and the NYS Health Department a sustainability plan that we believe will ensure the long-term success of Downstate Medical Center, its medical school and its other educational components, as well as create a blueprint for how to provide more health care partners in Brooklyn to put that plan into place.”
LICH serves diverse communities across Brooklyn, especially Red Hook, Gowanus and Downtown Brooklyn. In 2012, LICH averaged a 90% occupancy rate. During Sandy, LICH took in patients who were evacuated from other hospitals.
LICH is still in danger of closing as SUNY continues to take underhanded, out-of-sight measures to cause LICH to fail. “We have the history. We have the location. We have the medical school. We have the best staff. But unfortunately now we are for sale and being sold off,” Dr. Attalah sadly remarks.
Will SUNY pull the pieces of LICH apart one by one until the whole operation is forced to crumble? Every day the picture changes a little bit as SUNY reveals more smoke screens and mirrors from SUNY. Unless state officials step in and demand more consideration for LICH and the communities it serves, the hospital that has dedicated so many years and saved so many lives will be another waterfront property to lay claim to.
Nancy L. Zimpher, Chancellor of SUNY, wrote in the 2012 Annual Financial Report, “Our university now serves as an economic engine for every region and the state as a whole.” “We take very seriously our responsibility to be good stewards of public dollars and will continue to be as efficient and creative as possible in managing our resources.” Like breaking new ground on a new building, while claiming the university system at Downstate will be completely broke by July 1, 2103. By running LICH into the ground to later reap the benefits of their real estate value. And of course by destroying LICH’s residency program, depriving the hospital of supplies and staff, as well as creating months and years of deception to gain nothing more than additional “public dollars.”