Distaff Is Restless

A resident gets cut from Maricopa Medical Center's surgical training program. She says it's discrimination. It's just the latest problem facing the center's taxpayer-funded contractor, Medpro.

Dr. Magda Cynkutis-Simon immigrated to the United States from Poland when it was still under a Communist regime. She knows better than most the frustrations of dealing with the arcane rules of bureaucracy, unresponsive officials and violations of her dignity.

She just never expected to face those problems while a resident at Maricopa Medical Center.

Cynkutis-Simon was placed on administrative leave--in effect, fired--from her position as a doctor at the county-owned hospital on October 1. She and her attorney, Jim Vaughan, went from office to office trying to find someone who would offer her a reason.

The only response she got: Call the County Attorney's Office.
When Vaughan asked Dr. Beverly Rowley, who runs the Office of Academic Affairs at the hospital, the reason for the firing, Rowley replied, "No reason is needed."

Vaughan demanded, "Is she a threat to patients?"
"I'm not going to respond to you," Rowley said.
Why? Vaughan asked.
"Because I don't have to," Rowley said.

Cynkutis-Simon thinks she knows why, however. She says that her firing is retaliation for reporting sexual discrimination in the surgical-residency program at the county hospital. She intends to file for an injunction against the county, asking a judge to overturn the dismissal.

She's not the only one who's complained of sexual discrimination. Two other residents made the same allegations before Cynkutis-Simon did.

Cynkutis-Simon's charges are the latest problem for the private contractor which runs the training program for medical students at the hospital, Medical Professional Associates Inc., also known as MedPro.

In the past year, surgical students' test scores have fallen. The director of the surgical-residency program has been fired, and the doctor who took his place is no longer board-certified, as required by accreditation councils.

All this is worrisome, partly because MedPro's doctors and residents at Maricopa Medical Center deliver the majority of care to patients there, especially in emergency medicine. MedPro is also using county, state and federal dollars to train medical students. And Maricopa County taxpayers cover the costs of defending malpractice suits against MedPro's doctors.

Taxpayers will also be picking up MedPro's tab for Cynkutis-Simon's discrimination lawsuit.

But despite the massive public investment in MedPro, the county government hasn't taken much of an interest in public oversight. Maricopa County's Board of Supervisors and administrators have demanded little accountability. Instead, with few exceptions, they seem content to let private contractors like MedPro run the day-to-day operations of the hospital.

Since 1996, MedPro's contract has dropped by $10 million after county negotiators began questioning MedPro's charges. But even MedPro's most recent contract was passed quickly and without much scrutiny or public comment.

County officials and representatives of MedPro declined comment for this article.

But MedPro still has a bright future with the county. The Board of Supervisors is now considering a variety of options to privatize the hospital, something it's been trying to do since 1994. MedPro figures prominently in almost all of the plans.

While the county struggles to find a way to divest itself of the financially troubled hospital, one thing seems certain: The doctor bills will continue to be delivered to the public--and right now, county administrators keep paying them, no questions asked.

MedPro--formerly known as the Maricopa Faculty Association--is one of the most powerful players in the local health-care industry, despite its low profile.

It is the second-largest physicians' group in Phoenix, and trains 237 medical residents in a variety of medical specialties, including surgery. It currently pulls in more than $32 million from the county for its services at the publicly owned Maricopa Medical Center, plus more from private billings generated by its doctors for work done at the hospital. MedPro's doctors--students and teachers--are responsible for almost all the care delivered in the most critical areas of the county hospital: trauma (emergency), general surgery and the burn unit.

MedPro is controlled by Dr. James Malone. As president, CEO and chairman of the board of MedPro, Malone has the power to fire other doctors in the corporation immediately, with 10 days' pay, according to the corporate bylaws. Malone has also negotiated with the county for MedPro's contract. And, in the attempt to privatize the hospital, he has served as the corporation's spokesman and is chair of the hospital's department of surgery.

Malone didn't return phone calls for this article. But those who know him describe his powerful intellect and his controlling personality.

Malone took over surgical operations at the county hospital in the mid-1980s in the manner of a surgeon: swiftly, decisively and sharply. Previously, doctors had more or less donated their time as teachers, getting only a small stipend and hospital privileges. They taught the medical residents at MMC while keeping their own outside practices. Malone changed that--he didn't want doctors to have practices outside their duties to the hospital and to the contracted physicians' group. In the process, several doctors were told their services were no longer needed.

"The scenario previously was that we could maintain private practice and still donate time to the medical center--but Jim Malone wanted full-time faculty, which is pretty common," Dr. Salvatore "Sam" Casano says. Casano covered one or two trauma rotations a month under the previous arrangement.

"But obviously, [Malone] made his plans apparent to me, and unfortunately for someone, I don't know who--me, the patients, Maricopa County--there was a change," Casano says.

Dr. Ames "Berne" Yee, now in his own practice, recalls that the kick out the door was swift. "We used to do some volunteer attending work with the residents, and we were told, basically, 'You're not needed anymore,'" he says. "We were sent a letter. There was no 'thanks for helping'--it was just sort of a 'get lost' letter."

For doctors like Yee, who had done his residency at Maricopa, the separation was abrupt and painful. Doctors from Phoenix used to be invited to meet and discuss cases regularly with students at the hospital. Malone let it be known that they weren't welcome anymore, Yee says.

"My general impression was that he didn't want the general community knowing what was going on at the hospital, that he ran the place his way," Yee recalls.

Yee believes that was a loss for the hospital. "[The residents] got a lot of good, practical, hands-on experience [from the doctors]," Yee says. "Malone kind of changed how things worked, so I thought the residents didn't get as good an education as they did in the past."

In 1992, Malone's surgeons group merged with the other doctors at the hospital and, in 1993, entered into one contract for all services under the name of the Maricopa Faculty Association, later changed to MedPro. Under the arrangement, the county negotiates with one provider for all the hospital's health care, instead of dealing with each individual specialty. This group also teaches medical students who do their residency at Maricopa County's hospital. In addition to being president of the physicians' group, Malone is also responsible for the surgical-residency program--a position he's held for most of the past decade.

After finishing four years of medical school, med students are required to complete a residency at a teaching hospital before they can become fully accredited doctors. In exchange for the experience, they're expected to provide long hours of cheap labor. A medical residency is often the most grueling three to six years of a doctor's life.

Dr. Deborah White, a resident at Maricopa Medical Center from 1989 to 1992, says there's no doubt that the surgical program is tough. A lot of that just has to do with the realities of surgeons and surgery, she says.

"You kind of have to have this ego and bravado to do this, so you get a bunch of cowboys," she says. "You'd be up two days straight, go home late at night and have to be up at 4 in the morning. And you do that for weeks and weeks, and you get this real battlefield mentality. Even though you're supposed to have four weeks off a year, people rarely took them, because if you took them, that was a sign of weakness . . . and they would think of you as a weenie. And the last thing you want, especially as a female surgeon, is to be thought of as a weenie."

Adding to the pressure is the knowledge that you can be fired at any time, for almost any reason, White says.

"Not only are you doing a job where you never feel like you know enough, you're terrified of killing somebody," she explains. "You're afraid that each mistake you make might cost you your job and you might never find another one, and all those years will have gone to waste."

However, the surgical-residency program at the Maricopa Medical Center might have crossed the line from demanding to simply punitive.

Dr. Magda Cynkutis-Simon and her husband, Robert Simon, a civil rights attorney, contend that MedPro has gone after Magda to get even for her report of sexual discrimination, and that the Maricopa County government is now adding to the damage to her career by defending MedPro.

Cynkutis-Simon says she was doing fine in the program until her second year. Then a number of problems started, she says.

Malone, whom she says never worked with her on a procedure, gave her low marks on a faculty evaluation in September of last year. Malone wouldn't grade other surgeons he hadn't worked with, she says. "He didn't do that for me, even though he did that for others. He decided to trash me."

Cynkutis-Simon also ran into problems with two rotations of her program: at the Barrow Neurological Institute and at the Mayo Clinic. Her evaluators cited concerns about Cynkutis-Simon's attitude, her inability to work with others and her surgical skills.

On March 19, Malone wrote a memo to Cynkutis-Simon requiring her to seek counseling.

"Your preceptor . . . has informed members of the committees that your interpersonal skills may be to blame for your poor scores, and that some of your grievances regarding your . . . rotations may be justified," Malone wrote. "Therefore, the Governance Committee has agreed to permit you to seek counseling, rather than place you on probation."

In April, the faculty committee sent another memo to Cynkutis-Simon, spelling out in more detail and stronger language its problems with her performance.

"There is not one service on which you rotated this year where you did not receive unsatisfactory and/or unacceptable performance grades by one or more of your evaluators," Dr. Peter Ferrara, the committee's chair, wrote.

Placing Cynkutis-Simon on "clinical concern" (an informal level of probationary action which is not required to be reported to the state's Board of Medical Examiners), the committee required her to meet regularly with her faculty adviser, in addition to the counseling. "Failure to improve your performance will result in disciplinary action," the memo warns.

Throughout May, June and July, Cynkutis-Simon wrote memos to her superiors at MMC, trying to schedule meetings to discuss her status. She says her efforts were unsuccessful.

Finally, after several months, Cynkutis-Simon was told in an August 27 memo that, in order to finish the year, she'd have to go to the Mayo Clinic for a gastrointestinal rotation.

That was impossible and MedPro knew it, the Simons say, because on June 20, the Mayo Clinic had already told MedPro it didn't want Cynkutis-Simon there because of concerns about her performance.

Cynkutis-Simon was told she'd have to convince Mayo to change its mind by September 15 if she wanted to finish the 1997-98 year. If she couldn't, she'd be fired. And no matter what, she would not be coming back for the 1998-99 year. The committee voted to terminate her contract after 1997.

"They just kept putting the goalposts back further and further," Robert Simon says of the process. "Every time she'd meet something they wanted her to do, they'd just say, 'Okay, now you have to do this.'"

Still, as MedPro was writing memos expressing concern about Cynkutis-Simon's competence, she was given more responsibility as chief resident of the burn unit.

"[This is] one of the things I'm proudest of about my wife," Robert Simon says. "There she was, running the most difficult, most intensive care unit in county by herself, knowing they're just waiting to see something she screwed up. Yet, all that time, she kept her cool."

A petition on Cynkutis-Simon's behalf was also circulated by the burn-unit nurses, who urged the hospital to keep her.

Before being fired, Cynkutis-Simon requested a grievance hearing from Frank Alvarez, the CEO of the county hospital. She also wrote to the County Attorney's Office. No hearing was held, and the only response from the County Attorney's Office has been that it will be defending MedPro against Cynkutis-Simon.

MedPro referred all questions to Michael Green, the outside counsel hired by the county to represent the physicians' group in this matter. Green declined to comment.

"The bottom line is, no one here is willing to talk to you on the issues . . . ," Bob Milligan, MedPro's private attorney, says.

Cynkutis-Simon feels she's left with only one option: sue, or give up her medical career.

She says she's not about to give up. "I don't take any crap from anybody," she says. "I say what I think. If I think somebody's full of it, well, then, I tell them."

Even as Cynkutis-Simon was being watched and criticized by her evaluators, another investigation was taking a parallel track. The Maricopa County Attorney's Office was looking into complaints of sexual discrimination against female residents.

In fact, Cynkutis-Simon believes her complaints of discrimination and her support of other women residents are the real reason for her troubles.

One of those residents who complained wrote a letter on February 27 to then-program director Dr. Terry Simpson about her problems.

"We also discussed the issue of discrimination I have been subjected to since I started the program," Dr. Isabelle Simoneau, who has since left the program, wrote. "It is clear to me that this influenced the whole course of my internship and caused non-reversible damage to my reputation. I strongly believe that co-workers' attitudes towards me were guided by prejudice as a result of early discrimination."

(Simoneau has since moved out of state and could not be reached for comment. Simpson, now in private practice, declined comment on his employment at MedPro.)

Cynkutis-Simon says she supported the allegations made by others at a special staff meeting in February with Beverly Rowley, the academic-affairs director.

Secretary of State Betsey Bayless--then still a county supervisor--recalls that Dr. Simpson came to her with the concerns of female residents in the program.

"Terry Simpson came to see me, and said, 'I would like to have a couple of female residents come and see you,' and I said, 'What about?' and he said, 'Sexual harassment,'" she recalls. "[I told him] it's inappropriate for me to meet with any residents, but I think that the appropriate place for this to go [is] to the County Attorney's Office."

Bayless referred the matter to County Attorney Rick Romley. Cynkutis-Simon was the only female resident to come forward to the County Attorney's Office. Simoneau transferred out of the program, and the other female resident apparently dropped her complaint.

After meeting with Cynkutis-Simon, Romley sent the matter on to his civil division for investigation.

Bayless also gave a heads-up to Alvarez, the hospital CEO, about the problems brewing with the female residents' complaints of sexual discrimination.

When Cynkutis-Simon was ordered to seek counseling--while the investigation was ongoing--Robert Simon wrote a memo to Maricopa County Human Resources protesting Magda's treatment and charging retaliation.

"This requirement is not imposed on male residents with similar or worse 'attitudes,'" Simon wrote. "This requirement was imposed after my wife testified in support of the sexual discrimination claims of two other female residents."

Also, Simon charged, his wife had never seen the evaluations on which she scored poorly, and that some of the evaluations were proof of the discrimination Magda suffered during her rotations.

The County Attorney's Office closed its investigation in July--in fact, just a day after the faculty at Maricopa voted not to renew Cynkutis-Simon's contract for 1998.

The investigation was unable to substantiate discrimination. "Our investigation revealed that MedPro . . . had legitimate non-discriminatory reasons for requiring you to get counseling," a deputy county attorney wrote to Cynkutis-Simon on July 22.

But even though that was the end of the county's inquiry into MedPro, Cynkutis-Simon says retaliation by MedPro continued.

As an example, she points to the promotion of residents to attending physicians. The attendings are responsible for teaching the residents in the surgery program. But MedPro has advanced four recent graduates into attending slots even though they've had problems, she says. One attending was on clinical concern for two and a half years, according to Cynkutis-Simon, while two others flunked their qualifying exams on the first try. Other residents have been suspended and rejected for rotations before, Cynkutis-Simon alleges. (One of the residents promoted to attending was a woman, however.)

Dr. White, the former resident now in private practice in Scottsdale, says there were instances where she was treated differently because of her gender. Once, a male resident made inappropriate advances toward her, and the incident was laughed off by Malone.

"I'm very tough to offend," she says. But "somebody pushing me down in the parking lot and putting their tongue down my throat" was too much, she says, so she complained and was told "no big deal."

"That comes to your word against theirs, and if that person is senior to you, which he was . . . it really is a no-win situation. They don't like complainers."

White's style of dress was even brought up in committee meetings, she recalls.

"You're not supposed to know what goes on in the governance committee, but you hear snippets," she says. "And once, someone defending me said, 'Look, she dresses very appropriately, nothing seductive, and if it's something in the way she walks, then, well, we have a problem here.'"

But White stresses that she doesn't think the program is biased against women--it's tough on everyone, men and women alike.

"Everyone had it hard, just in different ways," she says.
White adds that the pressure of the program is also hard on the people who run it; it's often difficult for them to sort out problems.

The most important thing, White emphasizes, is that she received a good medical education at MMC.

But the surgical-residency program faces problems on the educational front as well. During the past several years, the number of residents passing their certifying exams has dropped sharply, internal memos show.

The Accreditation Council for Graduate Medical Education--which is responsible for certifying residency programs nationwide--noted the decline in a letter to Malone dated July 23, 1996.

"It was reported that all four residents who completed the [surgery] program in 1995 failed the qualifying examination of the American Board of Surgery on the first attempt," Dr. John Boberg, head of the residency review committee, wrote. "Only three of the previous 19 residents had failed the examination on the first attempt."

That means MMC's first-time success rate on the qualifying exam was 68 percent for 1996. The national average for that same year was 77 percent. For the certifying examination--the next level up for the surgical residents--the 1996 success rate for those taking it for the first time was 73 percent, five percentage points below the national average. A residency program which falls below a 50 percent success rate risks losing accreditation.

Malone offered apologies and a solution in a letter back to the residency review committee on September 6, 1996.

"I believe it is only fair that I accept some of the blame for this disappointing and unacceptable performance," he wrote. "Maricopa Medical Center . . . has been in a major transition the last two years, as it moves toward becoming a private, not for profit, facility. As president and CEO of the Maricopa Faculty Association [MedPro], I have been, and continue to be, largely responsible for overseeing the facilitation of this sale."

Malone told the committee he was handing leadership of the teaching program over to Dr. Terry Simpson.

"He is an excellent teacher who is admired and respected by the student body," Malone wrote, noting awards Simpson won for his teaching abilities.

But four months later, Malone fired Simpson and took back control of the general surgery program. Malone, however, is not currently board-certified in surgery, as required by the ACGME standards.

The ACGME's Dr. John Boberg knows that Simpson left but says the council won't micromanage residency programs.

He concedes that Malone's lack of board certification is unusual, but that the committee sometimes waives that requirement for program heads who show academic accomplishment, such as publishing papers. Malone has a host of publications and inventions to his credit.

Boberg is concerned about the test scores. But until the program falls below the 50 percent standard, the council can't take any action, he says.

Boberg says there also are no plans to review MedPro's surgical-residency program before the next scheduled site visit in 1999.

Besides the national ACGME, Maricopa County is the only other agency that has responsibility over MedPro's residency programs. But the county hasn't had the best record when it comes to keeping an eye on its contractor.

When the county began efforts at privatization of the hospital in 1994, S.K. Ching and Associates conducted an audit which found that the doctors of MedPro weren't working the full amount of hours they were being paid for. Malone and MedPro contested the results of that audit at the time.

A 1995 memo from the Office of Management and Budget complains that MedPro's contract was approved by the Board of Supervisors without ever being reviewed by county budget officials.

The result: The county paid MedPro millions more on previous contracts than its services were worth, according to Betsey Bayless.

Bayless was a frequent critic of MedPro when she was on the Board of Supervisors. "I was the con person. Everybody else was a pro person," she says.

In 1996, Bayless asked county staffers to look into MedPro's charges. What they found was that MedPro's contract was overvalued by several million dollars. But they recommended the 1996 MedPro contract anyway--and the Board of Supervisors approved it. Bayless voted against it.

"I am disappointed that our staff, attorneys and consultants recommended this contract to the board and represented that [MedPro] was at risk, when, in fact, it was not," Bayless told the county administrator.

Earlier this year, Quorum--the consulting firm that has been running the hospital--whittled down the MedPro contract from $35 million to its current $32 million. Bayless voted for that contract.

MedPro, in sometimes-heated correspondence with the county during contract negotiations, has defended the value of its services. But in the spirit of what Dr. Malone called "compromise," it has allowed the value of the contract to drop from $38 million in 1995 to its current level.

Still, even the current contract was passed under "emergency measures" because time was running out for approval and there was little scrutiny by the board or staff and no public comment.

Bayless says that it was important to keep the same physicians in place. "The best thing for Maricopa County is to have some stability at a reasonable level, which I felt that contract obtained for the first time in years," Bayless says.

Maricopa County now pays about $7.1 million for MedPro's teaching responsibilities. The program operates at a loss which must be made up by the taxpayers.

The Maricopa Medical Center leads the state in receiving state Medicaid funds for graduate medical education--about $6.1 million, or 33.8 percent of the total state funds, according to a report by the Arizona Council for Graduate Medical Education. MMC is second in the state in receiving medical education funds from public sources, the report says.

Overall, Maricopa County's graduate medical education shows a net loss of $3.8 million per year, according to a report by Quorum to the Board of Supervisors.

Quorum has recommended closer oversight of MedPro's management of the residency programs. In a recent report to the board, the consultant said, "The means to monitor, assess and ensure accountability by the contractor should be strengthened."

To do that, Quorum recommended that MedPro's payments for teaching be renegotiated based on national benchmarks and that responsibility for academic affairs be moved from MedPro to the county hospital administration.

It's unclear if any of those changes has taken place. Frank Alvarez, a Quorum employee and CEO of the hospital, declined to be interviewed for this story on the advice of his attorney.

"The Maricopa Integrated Health System . . . is committed to the highest standards in physician training," he said in a written statement.

And Maricopa County remains committed to MedPro. The county supervisors, in their continued search for a private partner to take the county hospital off their hands, are exploring a variety of options, most of which anticipate MedPro's continued service.

Quorum has already drafted a request for proposals for two new management options. One envisions a partnership between the county and a private contractor, the other an arrangement where physicians run the hospital. MedPro could become a part owner of the hospital, its manager or simply continue as a contractor. The draft RFPs specify a five-year contract.

Whatever MedPro's future may hold, the Board of Supervisors seems unwilling to question the way the contractor has done business in the past.

This was reflected in the reception Cynkutis-Simon's attorney, Jim Vaughan, got when he went to the Board of Supervisors directly, just a few weeks before Magda was fired, to plead with the board to take action before the matter came to litigation.

"The greatest problem with privatization of public services lies in the failure of the county to retain sufficient control to prevent windfall profits to the contractor and gross injustices to the county workers," he said, reading from a prepared statement. "In the present case, Dr. Cynkutis-Simon followed the rules at each stage in her attempt to fix something which damaged the county medical education program. . . . If successful in firing her . . . then MedPro will end her chances of being a surgeon. Is this to be the price the county allows to be imposed upon those who follow the rules?"

The Board of Supervisors stared back blankly after Vaughan finished, then adjourned.

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