Tension arises over doctors' training

The dean of USF's medical school ended an arrangement with TGH, to mixed reviews.

Published August 18, 2005

TAMPA - When Dr. Stephen Klasko became dean of the medical school at the University of South Florida a year ago, one of the school's 62 programs stood out as an immediate problem.

A national board put USF's anesthesiology program on probation in March 2004. Its national accreditation was at risk, a potential blow to USF's prestige.

Klasko took an unusual step. He ended the university's anesthesiology practice at Tampa General Hospital, where USF's residents get the most training, and signed an agreement in April with the private practice at TGH to teach them.

The change means that many residents, who are doctors receiving specialized training after medical school, are being taught by doctors in the private practice - the same ones they and USF faculty were competing against just a few months ago.

Because of the change, some USF faculty doctors have left, and Klasko has hired a new department chairman.

The move has some praising Klasko's innovation, while others say that residents are being hurt and that the program puts too much power in the wrong hands, with an arrangement that raises questions about conflict of interest.

Both sides agree on one thing: Tension was inevitable.

"These groups of people were competitors, like Wal-Mart and Target, and now they're one group," said Dr. Peter Fabri, USF's associate dean of graduate medical education. "They have to work together. That doesn't happen overnight."

But some doctors are worried.

Many of the private group's doctors have no teaching experience, they say, and presumably little interest in teaching, until recently.

"I am very concerned about the residency program," said Dr. Malcolm Klein, one of the faculty members who left Tampa General. He is now a staff anesthesiologist at James A. Haley VA Medical Center. "I see a number of deficiencies, and I have a number of concerns that residents have brought to me."

Klasko and Fabri acknowledge that some of the doctors need help learning to teach.

"They're very, very good at what they do, but most of them have never been asked to be teachers before," Fabri said.

Fabri said he's meeting with the doctors and working to improve teaching skills.

He and Klasko, however, said that the change will allow residents broader training. Before the switch, the larger private group was handling more complicated cases at Tampa General.

Now, residents will be able to train there in more complex procedures, such as transplants.

"The reality is, the residents weren't happy before," Klasko said. "If the residents were happy before, we wouldn't have been on probation, and I wouldn't have been meeting with them at 6:30 a.m."

Fabri said he thinks the anesthesiology program will, in the long run, be "substantially better" for the change at Tampa General, where the residents get about 40 percent of their training.

The rest comes from rotating through several other hospitals.

The proof of Fabri's opinion will come this fall.

That's when the national group, the Accreditation Council on Graduate Medical Education, will visit to decide whether the program should get its full accreditation back - or lose it entirely.

Unlike many medical schools, USF doesn't own a teaching hospital. Klasko said going to the private group was better than his other options, such as ending the residency program or hiring several expensive new doctors.

USF pays the practice $52,000 a month, but Klasko said the cost works out about the same as before.

One part of the new arrangement raising eyebrows is that the new department director, Dr. Enrico Camporesi, has longstanding ties to Dr. Devanand Mangar, the influential anesthesiologist who directs the private group.

Mangar studied under Camporesi at the State University of New York, and the two have published several papers together.

Now, Camporesi will earn about half his pay from USF and about half from caring for patients in Mangar's practice.

"I'm concerned about Dr. Camporesi's independence from Dr. Mangar," Klein said.

The question more than one doctor has raised: Can Camporesi fairly evaluate whether USF's residents are getting a good education from Mangar's doctors? Can he step in if there's a problem?

"You have a lot of incompatibility," Klein said. "You need a chairman who can clearly address the issue, and make sure that resident training does not interfere with patient care, and I do not believe he has sufficient autonomy to do that."

But Klasko and Camporesi said Camporesi will be independent. "It absolutely complicates it" that Mangar's group pays so much of his salary, Klasko said, but Camporesi doesn't report to Mangar.

"The reality is, there's only one person who can hire and fire him, and that's me," Klasko said.

Mangar couldn't be reached for comment, and Camporesi said other academic doctors juggle a similar mix of teaching duties and private patient pay.

"I probably graduated 270 residents and 60 fellows in my time," he said, adding there clearly was no conflict. "You end up knowing some people."

The accreditation council cited five violations when it put the residency on probation. The most substantive was that residents weren't always supervised closely enough at Tampa General. USF officials said that a few times when the hospital was quiet, one anesthesiologist was supervising three residents, instead of two as required.

Those problems were fixed before Klasko made the changes, Fabri said, and USF already could have "squeaked by" another council visit. But, he said, the old competition between USF faculty and Mangar's group always would have been an issue.