Muzzled

In November, an academic surgeon from UMass
Memorial Health Care spoke candidly about the tensions brought on by managed care. Days later, he was fired. He refused to leave. Now he's fighting for his job. Consider it a harbinger of things to come.

by Kristen Lombardi

In this era of profit-driven health care, one thing liver surgeon William Meyers has learned is to be careful of what he says. In a lunchtime conversation at a fundraising strategy session in November, Meyers, who heads the surgery department at UMass Memorial Health Care, told two UMass Memorial donors about the tension that exists between hospital administrators and doctors. Talk centered on whether UMass Memorial's leadership had "lost touch" with doctors. Meyers noted that although administrators and doctors often don't get along -- a situation aggravated by managed care -- he believes UMass Memorial to be "in better shape" than most institutions facing cutbacks and mergers.

His comments were truisms, for sure. Yet days after the lunch, Meyers was called before Peter Levine, the UMass Memorial CEO, and fired for having made a "discrediting remark." Levine ordered Meyers to pack his belongings by 7 a.m. the next day. A stunned Meyers refused, unwilling to abandon his position at UMass Medical School -- a position in which he's catapulted the surgery department to national prominence and attracted millions of dollars in research grants, as well as world-renowned surgeons, to UMMS.

As word of Meyers's "firing" spreads, academics across the nation are reacting with shock. "We're all looking at this with incredulity," says Andrew Warshaw, chairman of the surgery department at Massachusetts General Hospital. And a UMass Memorial insider (who, like many, asked to remain anonymous) exclaims, "You could have knocked me over with a feather when I heard the news. . . . Firing a chair in this fashion is the rarest of rare birds."

Administrators at UMass Memorial have said little to shed light on what looks like a precipitate action. Instead, they have worked behind the scenes to have Meyers removed. The administration first offered to pay Meyers several years' worth of compensation to leave quietly; when he declined, Levine formally requested that Aaron Lazare, the UMMS chancellor, initiate a job-evaluation process that could lead to Meyers's dismissal by February. Since then, the administration has tried to set up a paper trail after the fact: Meyers received two registered letters of reprimand and a document outlining 22 separate instances of "institutional disloyalty." Meyers claims that the administration hired at least one private investigator to look into his background.

Levine and fellow administrators have even pulled Meyers's colleagues into the fray, calling them to discuss leadership positions in the new regime while shutting out Meyers from regular, administrative meetings.

All of this has taken an undeniable toll on Meyers. The prominent surgeon tries hard not to reveal his pain, shrugging off the debate's personal nature and instead focusing on his dejected staff. When asked how it feels to be the subject of scrutiny, though, he sighs and, in a hushed, measured voice, confides, "Way down deep, it hurts terribly." He later adds, "The worst part of this whole thing is having to watch my friends turn away whenever I walk down the hall."

Meyers's predicament serves as a chilling example to academic physicians at UMMS of what they may be risking by speaking freely. In the two years since the UMass Medical Center, a teaching hospital, merged with the private Memorial Hospital in March 1998, it has offered an unwelcome dose of corporate life to the medical teaching world. Yet the increasing corporatization of health care -- and its attendant restrictions of free speech -- isn't unique to UMMS. Just last year, New England Journal of Medicine editor Jerome Kassirer was fired for his opposition to the practice of using the journal logo on spinoff publications. And Farrin Manian of St. John's Mercy Medical Center, in St. Louis, was fired last October for publishing a newspaper opinion piece, in which he stated that financial pressures were jeopardizing the quality of patient care. Ultimately, clashes like these could mark profound changes for academic medicine.

THAT MEYERS should have to defend himself and his work would have seemed improbable just a few years ago. Then, UMMS fought hard to lure the pioneering physician to Worcester. Meyers was well known for his work; he performed the first liver transplant in the South, in 1983, and served as chief of general surgery at Duke for 13 years. In 1995, UMMS chancellor Lazare approached Meyers about chairing the surgery department and asked him to create a wish list of what he'd need to set up a nationally ranked department. Soon afterward, Meyers was offered an impressive package that included a $350,000-plus salary and seed money for new clinical programs.

Since his UMass tenure began in 1996, Meyers has accomplished much of what he set out to do. He built up his department's research program by attracting first-class scientists to study trauma, cancer, and transplantation. The division currently boasts $5.5 million in federal research grants.

In 1998, he helped establish the highly successful liver-transplant program, navigating a lengthy political process that pitted UMMS against Boston's teaching hospitals. And just last year, Meyers and his colleagues won special state approval to produce a new heart-transplant program, making UMass Memorial the only Massachusetts hospital outside Boston allowed to do so.

Today, Meyers, 50, is a tall, fit, bespectacled man who comes across as not just a person, but a presence. Impeccably dressed, with a certain boyish charm, he can be at once forceful yet pleasant, self-assured yet self-minimizing. When he reflects on his work, for example, his pride becomes apparent in his gesticulating hands and animated speech -- until he apologizes for "sounding boastful." He then adds: "You don't have to be particularly bright; you just have to put your head down and work."

What he takes great pride in is what he calls the "spirit of collaboration" among the city's physicians today. When he first moved to the area, he noticed that doctors at UMass Medical Center, Memorial Hospital, and St. Vincent Hospital often saw each other as competitors, although they dealt with the same medical students. "There wasn't much of an esprit de corps," he recalls. So he coordinated a Saturday-morning conference for surgical residents and physicians, which has evolved into a regular, well-attended event. As a result, he says, "the hostility is changing."

It is in this same collaborative vein, Meyers maintains, that he's gone to administrators whenever he sees need for improvement. Indeed, Meyers, who backed the merger of UMass Medical Center and Memorial Hospital, has a habit of challenging the new leadership on a host of issues, including boosting fundraising and improving employees' benefits.

Meyers has been most pointed and vocal over UMass Memorial's billing methods. For months Meyers, along with fellow surgeons, pressed the administration to reconsider how it collects money from insurance companies, so that patient bills and payment appeals could be processed more efficiently. "All we were trying to do was improve the system, and we were met with resistance," he claims. Yet his unremitting pressure eventually led to a task force that's about to implement ideas Meyers lobbied for -- a sure sign, among colleagues, that his complaints haven't been unjustified.

"Meyers has been heavy-handed in his criticism," says one long-time UMMS employee, "but not without solid foundation."

PERHAPS LEVINE thought he would improve things at UMMS by firing Meyers, but he should have thought twice before acting. Ever since the scandal became public, paranoia has descended upon everyone from surgical residents to staff physicians. Morale has suffered; rumors have swirled. "People are afraid," acknowledges one surgeon. "They worry, if someone like Meyers can be forced out, who will be next?"

The uncertainty -- specifically, the uncertainty of Meyers's fate -- translates into tangible costs as well. The flap, which has coincided with the annual recruitment campaign, has prompted prospective students to re-examine UMMS. "Applicants want to go to a place where they know who is chairman," explains Robert Quinlan, a UMass Memorial chief surgeon who had worked at Memorial Hospital for 19 years and is a friend of Meyers's.

Another surgeon sighs and reveals that prime residents and staff newcomers, some of whom were set to start on January 1, have delayed because, he says, "they don't know if their boss will lose his job."

Such an outcome, a very possible one, is upsetting to department colleagues -- and not simply because of Meyers's apparent strengths. It's also because, if he's dismissed, the chances of attracting an equally qualified successor seem slim. After all, potential candidates will scrutinize the debate. "It gets to be a difficult position to fill," says Mass General's Warshaw. "People will be asking, `What the hell happened to Bill Meyers? Is that a frying pan I want to get into?' "

Moreover, those who've followed Meyers to the UMass system -- both staff and patients -- may follow him out the door. If that happens, departmental peers predict, his dismissal will bring lasting, crippling effects. Warns one veteran UMMS employee: "This department has achieved an excellent national reputation, but you can destroy the reputation quicker than you can build it."

Not only has the controversy tarnished the fledgling system's own image, but, according to one official, it's hindered fundraising efforts for the anticipated $100,000 UMMS research facility. "UMass Memorial has taken real hits," the official laments -- hits that he, among others, attributes to Meyers's "unfortunate" choice to go public rather than push quietly for resolution.

In a faculty memo released to the Worcester Telegram & Gazette last week, Lazare, who has kept a rather low profile so far (he declined to be interviewed for this story), confirms that the dispute has damaged UMass Memorial. "Our national image as an effectively governed, rapidly growing academic health center is under scrutiny," Lazare writes. The memo continues: "Some have questioned whether the merger itself is in jeopardy. I say in the strongest terms that this merger will not and cannot be undone."

THE LEVINE-MEYERS dispute never would have happened if not for the UMass Medical Center-Memorial Hospital merger, a still-evolving union between two distinct institutions. Which is why many onlookers cannot help but view their dispute as a merger story, at least in part. "This is the merger playing itself out," says one Worcester politician who was involved in legislation that allowed the merger to take place.

If anything, the debate has called attention to unanswered questions about the kind of control Levine, as hospital CEO, should have over clinical-department chairs, all of whom serve on the UMMS faculty. Chief surgeon Quinlan says he thinks the controversy lays bare a "merger shortcoming."

"It may point out the need for compromise, for some kind of shared power," he says.

The notion is hardly unreasonable, considering the number of cases illustrating the hazards of hospital unions -- especially those that involve academic medical centers. Take the 1996 merger of Beth Israel and New England Deaconess in Boston, which has spawned dissension and poor morale. Just last year, the chief surgeon resigned amid complaints; six surgeons left for other hospitals; and the entire liver-transplant team moved to the Burlington-based Lahey Clinic. That institution, too, experienced a merger mishap when, in 1997, its two-year union with Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, unraveled because of cultural differences and leadership disagreements.

Until now, the UMass Memorial partnership has gone fairly well, save for tough, somewhat prickly negotiations at the outset. But what makes mergers difficult is the clash of brutal economics with independent-minded physicians and an academic medical center's mission -- namely, teaching, research, and patient care.

To be sure, the Levine-Meyers feud has highlighted the system's persistent, ever-intensifying money problems. Countless newspaper articles have depicted the economic crisis affecting not just UMass Memorial, but teaching hospitals elsewhere. Though it's trimmed purchasing costs and management jobs, UMass Memorial, which employs 10,400 people, continues to face drastic federal Medicare-reimbursement cuts. In 1998, it lost a reported $42 million, followed by another $6.6 million during the first quarter of fiscal year 1999. The administration later revealed that the fiscal year 2000 budget could have a shortfall of up to $50 million, which would certainly lead to program slashes.

To UMass Memorial insiders, this larger economic picture has most likely fueled the latest debate. After all, cost-cutting pressures have strained the administration. One UMass Memorial official confides that administrators are working under taxing constraints, and adds: "This situation is related to pressure upon Levine to keep the place operating efficiently. . . . We have to remain healthy and viable."

A UMMS professor puts it more bluntly: "If I were Levine, I'd be petrified. The cutbacks have scared medicine to a point where it doesn't know if it can exist."

Maybe so. Yet despite the financial burdens, Levine doesn't seem to get much sympathy from UMass Memorial physicians -- mainly, they argue, because of unhappiness over how the administration conducts business. One doctor complains that fellow doctors feel disenfranchised, excluded from the decision-making process. "The administration," he says, "has the attitude that it is in control and that it has the all-knowing plan."

THAT SAID, some observers say there may be something personal in the Levine-Meyers dispute. Not many UMass Memorial doctors, in fact, are surprised that Levine appears to be its instigator. Levine, a bright, determined man, gained a reputation for ruling Memorial Hospital with an "iron fist." In a January 7 Telegram & Gazette op-ed piece, Michael Bradbury, a veteran ophthalmologist who charges Levine with intimidation, alludes to the CEO's past, saying: "There is a history of controlling information, stifling debate, and disenfranchising medical staff from governance of a hospital where they care for patients."

UMass Memorial insiders reinforce such allegations, asserting that Levine's "thin skin" has fostered an environment where people cannot voice opinions without fearing retribution. One person who has seen the CEO at the negotiating table sums up the attitude best: "Levine is an autocrat. He believes in his right to run a . . . school where everyone does as he says."

Levine declined to be interviewed for this story, citing "private personnel" reasons. In a five-line prepared statement provided to the Phoenix, he states, "As a courtesy to Dr. Meyers, and in order to protect his privacy, I have refrained from comment as to the particulars of this situation." He concludes, "Matters such as these should be conducted with dignity and with respect for the rights of individuals involved, and not aired in the media."

To be fair, the feud couldn't have intensified without a willing, resolute Meyers -- a fact his detractors have seized on. Just as Levine's management style has come under fire, so too has the department chairman's. Former division chiefs, in particular, have decried his "self-absorbed," relentless tactics; in a T&G letter to the editor, a previous chief's wife wrote that Meyers had forced staff resignations by slashing salaries and reducing responsibilities. Now, she argued, Meyers is finally tasting his own medicine. Even supporters recognize that he's a demanding leader who can be rough in his administrative handling.

Because Meyers has spoken publicly about his firing, he's undoubtedly angered and thus alienated sympathizers, many of whom sent letters of support to Lazare denouncing Levine's action. Though Meyers agrees unfavorable publicity hasn't helped his cause -- with the administration, anyway -- he's reminded that his plight had gained momentum before it gained the spotlight. (It should be noted that Meyers denies tipping the T&G, which broke the story after receiving a hand-delivered copy of remarks that he'd made to his peers.)

Still, there's little question the escalating debate is a product of both personalities. One observer who supports Meyers calls the embattled chairman a "winner," and says: "When he fights for something, he goes all the way. . . . That's how he's been with Levine."

But there's something else about which there's little question: the furor may spell the end for the openly critical Meyers.

YOU HAVE to prove academic reasons to fire someone," says Charles Hafferjee, director of cardiac electrophysiology at the Boston-based St. Elizabeth's Medical Center. Yet in this incident, he points out, a hospital CEO might be empowered to take unilateral action, running roughshod over the cherished tenet of academic freedom. "We all feel very threatened by this case," he says.

Even though academic freedom is considered one of the basic American freedoms of speech and expression, the idea didn't take hold until 1900, when Edmund Ross, a Stanford University economics professor, set out to test how beholden he and colleagues were to college benefactors. Despite being a consummate scholar, Ross suffered a nasty forced resignation after a contentious two-year stint during which he championed unpopular political views about labor rights, free silver, and immigration.

A century later, people in academia will tell you that an educational institution intolerant of dissenting opinion is a poor one at best. Still, like any ideal, academic freedom doesn't always translate into reality. "Academic institutions are just like businesses or government," muses Robert Oldman, a doctor who once worked at an academic medical center but now has a private practice in South Carolina. "They are full of people and their human frailties."

Oldman should know. The former head of oncology at Vanderbilt University became a controversial figure himself when he criticized the adverse influence that funders can have on medical research. He eventually stepped down of his own accord, but his experience left him convinced that "anyone who speaks out, even in academia, will find himself in a precarious situation."

Considering Meyers's habit of challenging the UMass Memorial leadership, it's no wonder observers have come to view the debate as a modern-day test case, emblematic of the inevitable tensions between corporate and academic influences. And because more teaching hospitals are merging with private, profit-conscious hospitals, the UMass Memorial case could mark a profound change for academic medicine.

"This is about whether a corporate hierarchy will impose itself on an academic institution," one observer says, adding: "Are teaching hospitals to become just another arm of the corporation?"

The importance of that question might explain why three highly regarded "external experts" have agreed to come to Worcester from Boston, Baltimore, and Virginia in early February. UMMS chancellor Lazare appointed the three-member panel in accordance with the medical school's bylaws, which is standard among higher-education institutions. The panel is expected to review the charges against Meyers, along with his rebuttal, then speak to both men. The outside experts -- Mitchell Rabkin of Beth Israel, Edward Miller of Johns Hopkins University, and R. Scott Jones of University of Virginia -- will provide recommendations to Lazare, who will have the final say.

All of this, though, must be done within 90 days of the official termination request -- by mid February. Otherwise, Levine has the authority to fire Meyers under the UMass Memorial agreement.

As the deadline nears, Meyers and his supporters have held fast in hopes of a favorable ending. The besieged surgeon takes comfort in the belief that Lazare, who has a reputation for being judicious, will strive for fairness. And he believes his fight for academic freedom not only will prevail, but will benefit all.

"There are wrinkles in our system that need to be ironed out," he says, "but we can do it and it will help our institution."

Yet only, it seems, with aid from the UMass Memorial leadership.

Kristen Lombardi can be reached at klombardi[a]phx.com.