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When some D.C. General Hospital doctors talk about putting patients first, they’re not being Hippocratic. They’re being hypocritical.

Photographs by Charles Steck

About a year and a half ago, an inmate from the D.C. Department of Corrections came to D.C. General Hospital for hernia surgery. He hadn’t seen his surgeon, Dr. Norma Smalls, in at least a month. But when the man arrived for his procedure, Smalls didn’t do a fresh pre-op physical exam—a step that most surgeons regard as routine. Instead, according to former Chief Medical Officer Ronald David and three other hospital sources, Smalls just had the man put under anesthesia and then cut him open—on the wrong side of his body.

Finding no hernia, David says, Smalls walked out of the operating room, wrote some notes in the charts, and then looked over the medical records. Realizing her mistake, Smalls had her patient anesthetized once more and cut him open again.

Fortunately, the patient recovered. Still, such a “sentinel event,” as a blunder like wrong-side surgery is known in the hospital business, is a very big deal, as serious a hospital disaster as an abducted baby or a rape by a staff member. The reason, of course, is that the kind of mistakes that lead to wrong-side hernia operations can lead to amputating the wrong leg or removing a healthy kidney.

If D.C. General were a normal hospital, Smalls’ blunder would have come under intense scrutiny. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires hospital medical staff to conduct a “root-cause analysis” of any wrong-side surgery and to implement an action plan to prevent such incidents from recurring. A hospital’s accreditation is partly based on how its medical staff handles sentinel events.

Initially, though, the medical staff wasn’t even planning to investigate Smalls’ wrong-side surgery, according to David. When pressed by the administration, a committee made up of the chief of surgery, the chief of anesthesiology, and the head of the nursing staff eventually did review each department’s role in the case. The nursing administration promptly fired a nurse who was found to be partially culpable. The doctors, however, found no problem with Smalls’ performance in the operating room. Dr. Richard Holt, the hospital’s chief of surgery, would not comment on the case.

Smalls declined to discuss the surgery other than to say, “I am a physician and citizen of high ethical standards,” and that the JCAHO, the hospital accrediting body, was satisfied with the hospital’s review process. “I have reams of documentation to show how well that was done,” she says.

Nonetheless, the story of Smalls’ surgical mistake spread through the hospital like a staph infection, raising eyebrows among nurses and other technical staff members who had heard constant rumors about her competency, according to several hospital sources. But that didn’t stop the physicians from later electing Smalls as president of the D.C. General medical/dental staff. And today, she is head of quality assurance for the hospital’s department of surgery.

Smalls and some of her colleagues on the D.C. General medical staff have been among the loudest voices complaining about the many problems ailing the District’s only public hospital. They have taken their complaints about the hospital administration to the mayor, to the D.C. Council, and directly to Congress. They have demanded the ouster of former CEO John Fairman and even summoned various investigative agencies to scrutinize the hospital, which has run up $109 million in budget overruns and is at risk of being closed down completely.

Patients themselves are deserting the hospital in droves: More than 90 percent of Medicaid patients and 97 percent of Medicare patients now go to other, private D.C. hospitals, as do two-thirds of the city’s 80,000 uninsured residents, according to D.C. Department of Health figures.

Yet during all the recent debate over the future of the city’s ailing public health system, few people have ever stopped to ask whether Smalls and some of her medical colleagues might themselves be part of the problem.

For years, the medical staff has eluded the demands for accountability that have slowly started to take hold in other parts of D.C. government. Instead, the doctors have successfully portrayed themselves as the lone champions of health care for the poor, which is the one thing that D.C. General inarguably dispenses.

Yet internal memos from the D.C. Health and Hospitals Public Benefit Corp. (PBC), the body that oversees the public hospital and its clinics, show that far from improving patient care, Smalls and some of the elected leadership of the medical staff have fought to overturn disciplinary actions against poorly performing physicians and defend doctors’ shoddy work habits. Even as they have complained about the quality of the nursing staff and hospital administrators, many of the physicians have fought off requirements to update their own skills, see more patients, and otherwise raise the standards of D.C. public health care. Moreover, past and present hospital administrators say that a vocal minority of those same doctors have played a key role in obstructing the very reforms that might put the PBC on better financial footing.

Deairich Hunter is the PBC’s former chief of staff and a former staff member for Ward 8 Councilmember Sandy Allen, chair of the Health and Human Services Committee, which oversees the PBC. When he worked for the council, Hunter spent much of his time trying to save D.C. General. When he came to work for the PBC last year, though, he says, “I started to wonder what it was that I was saving.”

To be sure, many of the 170 doctors who work for the PBC are devoted professionals who have a real commitment to public health care and labor under difficult circumstances. But then there are the others: the twice-bankrupt, many-times-sued OB-GYN and the former chief of trauma who allegedly saw only eight patients in a month, despite being paid for full-time work.

The city’s doctors are emboldened by the same civil-service protections that make all D.C. government employees nearly impossible to fire, and they are largely immune from outside accreditation investigators, who evaluate hospital procedures, not physician competency. Duly insulated, the PBC’s doctors have successfully chased out reform-minded administrators who have attempted to rein them in. “Using a good offense as their best defense, the medical staff has avoided accountability for years,” says one hospital administrator, who wishes to remain anonymous.

The bureaucrats’ attack on reformers is a time-honored D.C. government tradition. Such behavior has made city agencies like the Department of Motor Vehicles merely infuriating, but in a hospital, the consequences can be deadly. It’s no surprise that even as D.C. councilmembers go to bat for the jobs of city doctors, the poorest city residents are taking their business elsewhere.

Last August, D.C. General OB-GYN John S. Selden III featured prominently in a front-page story in the New York Times about racial disparities among women who die in childbirth. “Most obstetricians are afraid to talk about losing patients,” the story read. “But the doctors at D.C. General are surprisingly direct. Dr. John S. Selden, who has worked at the hospital on and off for the last 13 years, told of a death that occurred just a few months ago.” The woman Selden described died on the operating table, moments after a Caesarean section at D.C. General.

Selden was something of an odd choice for the hospital to offer up as a national expert. Had the Times interviewed some of his former patients, the paper might have discovered that Selden has a somewhat blemished record as a physician. But his story helps illustrate why some doctors at D.C. General are often so militant about protecting their jobs.

In the past 20 years, Selden has been sued at least six times, racking up some huge settlements. In 1984, Selden treated a pregnant woman named Vanessa Black who had come to Greater Southeast Community Hospital suffering from vaginal bleeding. Selden discharged her the next day with instructions for strict bed rest, without determining whether it was safe for her to move. Black was still spotting, and a day later, she went into labor, had an emergency C-section because of hemorrhaging, and delivered a brain-damaged baby. In 1993, Greater Southeast settled a suit filed by Black’s family for $1.3 million.

Another case is currently pending, filed by Cherif Abraham Haidara, alleging that during a 1997 delivery at D.C. General, Selden caused traumatic nerve injury to her baby’s arm, rendering the arm useless. In this case, the family isn’t likely to get a dime if it prevails in court, because Selden has no assets to speak of, having filed for bankruptcy protection twice in the past 15 years. And at the time of Haidara’s delivery, he had no malpractice insurance.

Ordinarily, as a city employee, Selden wouldn’t have needed malpractice insurance, because he would have been insured by the District. But Selden was working at D.C. General on a contract with the Medical Services Group, a private practice consisting of several OB-GYNs who had retired from D.C. General in 1995 and had immediately gotten a $2.9 million emergency contract from the hospital. The contract allowed the doctors to earn significantly more than they would have as hospital employees. After the Office of the D.C. Auditor criticized the contract for various improprieties, the hospital canceled it in 1997.

D.C. General provided most of the group’s clients, so when it canceled the contract, the practice shut down. During that last year, when Haidara’s baby was born, the Medical Services Group doctors were carrying no malpractice insurance. They blamed the city, which they claimed was supposed to pay for the insurance. (The doctors are currently suing the District over the issue.)

According to his deposition in the Haidara case, Selden remained unemployed for about a year after his practice collapsed, and he eventually filed for bankruptcy protection. Later, he went to work for Planned Parenthood for about six months before D.C. General rehired him in March of last year.

Selden could not be reached for comment.

Given Selden’s history, it might seem strange that D.C. General would be eager to have him back. But thanks to city pay-scale restrictions, the hospital is fairly desperate for specialists like OB-GYNs, whom it needs to maintain its accreditation. D.C. law bars city employees from making more than the mayor’s salary, which for most of the 1990s was about $90,000. The going salary for an OB-GYN in the private sector is nearly $300,000. (The mayor’s salary has since gone up, to about $120,000, but doctors’ salaries have remained capped at $99,000.)

Lawrence Johnson, the medical director at D.C. General for 15 years until 1997, says the salary cap has always been problematic in keeping the hospital staffed up. “We couldn’t keep a full-time specialist in some cases,” he says, adding that the hospital has always relied on a patchwork quilt of coverage. “It’s not the kind of arrangement that lends itself to building stability.”

The PBC’s poor pay—among the worst in the nation—combined with difficult working conditions and old-fashioned crony politics has helped make D.C. General a virtual dumping ground for troubled doctors. Alongside doctors like Selden, the hospital employs physicians who have left other troubled city facilities, like the D.C. Jail and the old city-run nursing home, D.C. Village, which was closed after a suit by the Justice Department, following the deaths of more than 30 residents from poor medical care.

Another of the hospital’s former medical directors is Dr. William Hall, former Mayor Marion S. Barry Jr.’s longtime eye doctor, who was the medical director of the D.C. Department of Corrections when the jail medical services landed in receivership for abysmal treatment of inmates in 1995. A federal judge seized control of the services shortly after an inmate with AIDS died while tied to a wheelchair, where he had sat in his own feces, neglected, for several days. Hall went on to do a brief stint as D.C. General’s medical director and is still employed at the hospital as an ophthalmologist.

Conventional wisdom holds that the trauma surgeons at D.C. General are among the hospital’s best doctors, because of their experience in handling life-threatening gunshot wounds and other medical crises. Despite their reputation, though, no data exist to prove whether D.C. General trauma surgeons are any better than, say, Washington Hospital Center’s. And there’s some evidence to suggest that they might be worse.

In 1995, an ambulance transported a transgendered man, Tyrone Michael (aka Tyra) Hunter, to the emergency room at D.C. General, where he later died after doctors failed to drain blood that had pooled near his heart, according to a lawsuit filed by Hunter’s mother, Margie Hunter. Her lawyer, Richard Silber, learned during the litigation that Joseph Bastien, the trauma surgeon who had treated Hunter in the emergency room, had flunked his surgical board exams three times and was not certified as a surgeon.

In fact, out of the eight attending physicians in the trauma unit at the time, five were not board-

certified, including the unit’s acting chief, Dr. Paul Oriaifo. (Two of those noncertified doctors still work at the hospital.) In 1998, a jury awarded Margie Hunter $2.3 million, and the city last week settled the case for $1.75 million.

Silber says he was astonished at the poor qualifications of some of the trauma surgeons at D.C. General. “There are terrific public hospitals in this country. Just because they are public doesn’t mean they have to have incompetent care,” he notes.

It’s 8:30 a.m. on Wednesday, July 5, and already the D.C. General orthopedic clinic is full of people on crutches or in wheelchairs, or sporting casts, slings, or metal staples in their knees. A man in a wheelchair with a full head rack and pins keeping his neck straight closes his eyes and exhales slowly. Almost 50 people have arrived in the basement of the hospital. Kenneth Reid, here for his broken knee, knows he’s in for a long wait.

“Last time I was here, I had a 9 a.m. appointment, and I didn’t get done until 4,” Reid says.

The clinic is open only on Mondays and Wednesdays, and the staff schedules patients for appointments between 8 a.m. and 10:30 a.m. Even then, it’s first come, first served. So people line up early and then hunker down in front of the TV. With luck, they’ll get their blood pressure taken by the time Bob Barker wraps up The Price Is Right. If you feel really bad, Reid says, you can go to the emergency room.

Or you can employ Monica Parker’s strategy: the fake faint. Parker, who recently broke both her legs, says she once got so tired of waiting that she staged a collapse on the way to the ladies’ room. “I got right in,” she says with a laugh. “You got to fall out right where everyone can see.”

An elderly man who gives his name only as Oscar, who has been waiting almost a year for surgery on his hip, knows the system pretty well. “The whole thing is not to have the doctors waiting to see the patients,” he explains.

There’s no chance any doctors will be waiting today. Medical residents doing training as part of the Howard University Medical School do most of the work here, but they haven’t arrived yet. That’s because on Wednesday mornings, the residents have to attend a meeting at Howard University Hospital. They usually don’t show up at the clinic until 10 a.m., even though patients have been sitting here for two hours by then. And as for the staff doctors, well, none of the patients seem to know when they get in.

Oscar says the attending physicians alternate covering the clinic because most of them also work somewhere else. Elaborating some common hospital folklore, Oscar explains confidently, “The hospital can’t afford to pay doctors for 40 hours a week.” The hospital does in fact pay the clinic’s attending physicians almost $100,000 annually for full-time work, but conversations with other patients make it easy to see how Oscar came to that conclusion.

While dozens of patients watch Maury Povich berating moms for dressing so sexy that they embarrass their children, a woman in a bright-red dress and heels storms out of the clinic door, cursing the people behind Booth 2. She comes back later and throws herself into a chair. “I had three appointments. They made me come in. The doctor wasn’t here,” fumes Mary E. Muschette. “This is the fourth appointment. One day I was here at 7:30 and left at 3 after I found out that they had discharged me without seeing me. I’ve made this appointment since April for a jammed finger. Every time I’ve been here, no doctor.” Muschette says she is supposed to see a specialist, but adds, “He’s never here. If I had a job and did that, I’d be in trouble.”

Muschette’s furious tirade is more entertaining than Povich, and it sets off a round of complaints and affirmations from the other patients. “I never see the doctor who signs the prescriptions,” Parker says. “I’ve only seen him once, and that was at Howard. He is on all my paperwork, though.”

Dr. Easton Manderson, the chief of orthopedics, is himself the subject of patient complaints about scheduling. An inmate at Lorton, David Spencer, is currently suing Manderson in federal court for allegedly bumping him off the surgical schedule for more than a year, delaying a bone graft on his arm and, he says, causing partial paralysis. Spencer filed the suit pro se, but a federal judge believed Spencer had a strong enough complaint that he took the unusual step of appointing a lawyer to represent Spencer.

But Manderson is a busy man. Along with his full-time job at D.C. General, he also has two private practices. On Tuesdays, Wednesdays, Fridays, and some Saturdays, he works at his Providence Hospital office. Then, on Tuesdays after 5 p.m., he works at his Eastern Avenue office in Maryland. Yet Manderson managed to collect $23,866 in overtime at D.C. General last year, according to documents provided by the PBC.

Manderson disputes this figure, and in a letter to the Washington City Paper, he said he spends only 12 of the 72 hours he works each week at his private office.

“I perform more surgery and see more patients than any other surgeon at D.C. General,” Manderson said in his letter.

Moonlighting by full-time PBC doctors is a common practice, which the doctors justify because of their low salaries, and there’s no rule against it. But the doctors are still expected to fulfill their duties for the PBC. It’s clear from the stories at the orthopedic clinic, however, that the hospital is not getting its money’s worth from some of its physicians.

The experience of the orthopedic patients was backed up in a recent review by Cambio Health Solutions, a consulting firm brought in by the PBC to analyze the hospital’s management problems. Cambio found that doctors’ overtime billing was based on the honor system and that the PBC had no system to document how much time doctors actually worked on behalf of the PBC. “Productivity standards are not existent,” the consultants wrote. An operational review found that clinics failed to start on time because most of the physicians had practices in other parts of the District.

Absentee doctors are problematic for a variety of reasons. Medical residents, because of their junior status, can’t sign any of the paperwork needed for billing, so patients routinely leave their charts with a physician’s assistant whose job it is to track down the attending doctors for their signatures. As the paperwork stacks up, patients are often left waiting for weeks to get disability claims filed, for instance. Or, as happened in Oscar’s case, the signature problem can delay treatment.

Oscar says that every time he comes in to the clinic, staffers treat him like a new patient and repeat the same tests, because they can’t find his medical records. The doctors’ failure to keep up on the paperwork also takes a financial toll on the hospital itself, because it can’t bill for services unless physicians document them—a problem highlighted by consultants from Cambio.

For years, the PBC doctors have gotten away with such poor performance because they could count on their patients to keep quiet. Parker, for example, says that even though she usually plans to wait between five and 12 hours whenever she comes to the clinic, it would never occur to her to complain to hospital officials. “I’m not going to cuss you out about not getting what I pay for when I’m not paying anything,” she says. Besides, she adds, “Nobody else will take me.”

When she broke her legs—she tripped in the grass while walking in high heels—Parker says she was taken to Howard. But when the hospital discovered she didn’t have insurance, it sent her by ambulance to D.C. General. “If I could go somewhere else, I would,” she says.

For years, D.C. General patients have told horror stories about being unwittingly operated on by what they call “ghost doctors”—unsupervised residents who have not yet completed their medical training. In a place where such legends are as common as bedpans, most malpractice lawyers and others who regularly heard the stories never quite believed them. But Debra Burton says that, in her case at least, not only is the legend true, she can prove it.

In November 1992, Burton saw Manderson, the orthopedic surgeon, at Providence Hospital on a referral from a doctor at Howard University Hospital, who believed she needed surgery to have a bone spur removed from her foot. Burton says she saw Manderson for “about five minutes.” She says he agreed to do the surgery but told her she had to have it done at D.C. General. So on Jan. 21, 1993, Burton checked into D.C. General, gave her Medicaid information, and was headed for the operating room when, she says, residents told her that Manderson wasn’t at the hospital but was on his way.

Burton had the surgery, but she never did see Manderson. A few months later, she was still in excruciating pain. After several more visits to other doctors, Burton learned several startling facts: A nerve had been cut in her foot, but the bone spur was still there. And, most troubling, Burton says, she learned that Manderson hadn’t actually performed—or supervised—the surgery as promised. Instead, she had been operated on by a couple of residents—doctors in training.

Burton has been disabled by the pain and unable to work ever since. She had hoped to file a malpractice suit, but she says her lawyer botched the case, and she eventually reported him to legal disciplinary authorities. She didn’t give up, though. Burton has been on a mission ever since to find some justice, and she has collected an assortment of documentation about her case.

Among her papers is a 1997 letter Manderson wrote to the D.C. Board of Medicine in response to a complaint Burton filed against him. In the letter, Manderson claims he never told Burton he would take her as a private patient, but that “I would arrange to have her surgery done at D.C. General.” However, Manderson’s name appears on all Burton’s D.C. General records as the admitting and attending physician, and her admission and consent form states that she agreed to surgery that would be either performed or supervised by Easton Manderson.

Ronald David, the hospital’s former chief medical officer, says that at D.C. general, attending physicians of record are expected to be responsible for their patients before, during, and after surgery—guidelines also specified by the American College of Surgeons.

In his letter to the medical board, Manderson maintains that even if he had agreed to do the surgery, he was not required to be in the operating room when residents were operating. He repeated this claim in his letter to the City Paper. In fact, in 1995, two years after Burton’s surgery, D.C. General almost lost its Medicaid accreditation for, among other things, allowing residents to operate unsupervised, according to reports in the Washington Post. And David says, “If he is the attending of record, he was supposed to be there.” Nevertheless, the board of medicine dismissed the complaint without any further investigation.

When she discovered that Manderson had billed Medicaid for part of the procedure, Burton filed a complaint with the city. Doctors at D.C. General are salaried employees and may not bill Medicaid individually for services they provide there; Medicaid pays the hospital directly. But Manderson and another doctor whom Burton claims she never saw both billed and were paid for services related to her surgery. In 1998, according to a letter sent to Burton in response to her complaint, the Medicaid office sought to recoup the money for what it called “erroneous billing.” No investigation was ever launched. PBC officials declined any comment on Manderson’s practice at D.C. General.

On Jan. 15, 1998, 93-year-old Ernest Higgins ran a stop sign at 10th and Constitution NE and was hit by a truck. He was admitted to D.C. General by trauma surgeon Dr. Chinwe Agugua suffering from some swelling on the side of his neck, but otherwise, he didn’t have any other obvious injuries. The hospital kept him overnight for observation, and the next morning a nurse called Higgins’ son, Daniel Higgins, and told him to come to take his father home.

The lifelong Washingtonian and former auto-parts store owner had been active for his advanced age, and his medical records even noted that he lived alone in a two-story house at 18th and Franklin Streets NE and was fully able to care for himself. But before Ernest Higgins was discharged, a nurse had to carry him to the bathroom.

“I thought this was odd, since the day before, he had been driving,” says Daniel Higgins. As it turned out, his father couldn’t walk, but no one at the hospital seemed to think this was unusual, so Higgins took him home. “I checked on him after [The Tonight Show], and he was sleeping. The next morning when I got up, he had passed away,” he says. An autopsy revealed that the elder Higgins had suffered two broken vertebrae in his neck and had died from a major spinal-cord injury.

The Higgins family decided to pursue legal action against the hospital. They went to three different lawyers before the last one told them—wrongly—that they would never be able to collect any money from the broke D.C. government, and in any event, because Ernest Higgins had been so old, there wouldn’t be much in the way of damages to recover. Before they had a chance to pursue the case further, the statue of limitations for filing a suit ran out. Still, Higgins’ granddaughter continued to demand that the PBC investigate the handling of the case, but she never got an answer. Dr. Richard Holt, who had been Higgins’ attending physician, said last month in an interview that he did not remember Higgins.

Doctors who work for the PBC are protected by civil service rules and the hospital’s peer review committees. As the Higgins case demonstrates, they are also largely insulated from scrutiny by the most effective, if de facto, medical regulators: malpractice attorneys.

Higgins’ claim was one of 17 notices sent to the District government since January 1998 declaring intentions to sue the hospital for wrongful deaths. Of those, 12 cases never went to court, including the Higgins case. Some were denied because the potential plaintiff failed to adhere to the strict filing timetable required under D.C. law. Anyone intending to sue D.C. General must notify the city within six months of the alleged malpractice. A lawsuit in a wrongful-death case must then be filed within a year; other malpractice cases must be filed within three years.

Diane Littlepage, a malpractice attorney in Baltimore who has successfully sued D.C. General, says that very few people are able to make the six-month deadline, which doesn’t exist for private hospitals. In addition, attorneys generally don’t regard D.C. General patients as attractive clients. That’s because wrongful-death awards are based on the value of a person’s life, which a civil suit reduces to a cold calculus of economic activity and life expectancy. If a patient was poor or unemployed, or had any kind of lifestyle issues that might shorten life span, such as criminal activity or drug abuse—all common issues with many D.C. General patients—that patient’s life doesn’t add up to much in a lawsuit.

Malpractice cases are also extremely costly to litigate, so lawyers who do take them pick up only clients whose potential awards will more than cover the costs of trying the case. Bill Lightfoot, a prominent malpractice attorney and former D.C. councilmember, says he routinely spends $50,000 to $100,000 to litigate a wrongful-death case.

Because of the lawyers’ informal vetting system, when malpractice suits do go forward against doctors at D.C. General, they are fairly serious. Here are a few recent examples:

* Tammara Kilgore, 22, arrived at D.C. General on April 26, 1998, suffering from nausea, fever, and highly abnormal liver functions. Doctors allegedly diagnosed Kilgore with a urinary-tract infection—without performing a urinalysis—gave her some antibiotics, and sent her home, according to the suit filed by her family. Kilgore died a few days later from liver failure stemming from hepatitis.

* Darryl Kelley, 19, arrived at D.C. General suffering from a gunshot wound to the face in February 1997. The bullet had broken his jaw, but he could talk, swallow, and breathe. Dr. Norma Smalls did exploratory surgery on his neck and put a tube in his windpipe so he could be hooked up to a ventilator after oral surgeons wired his teeth together. Two days later, Kelley was dead—but not from the bullet wound. An autopsy later showed that he had suffocated to death from a blockage in the tracheotomy tube. On April 11 of this year, the city settled a wrongful-death suit brought by Kelley’s family for $175,000.

* In November 1998, Gloria Porter, 50, was admitted to D.C. General to have a benign polyp removed from her duodenum. Instead of just removing the polyp, Dr. Paramjeet Sabharwal and two residents allegedly performed a risky surgery designed for excising advanced cancer, removing her gall bladder, part of her duodenum, and part of her pancreas. A week later, Porter, who didn’t have cancer, died from a massive hemorrhage—a complication of the surgery—according to a suit filed by her daughter last August.

Bruce Klores, one of the city’s leading malpractice attorneys, who has won several large verdicts against D.C. General, says that the hospital has “probably the most underreported malpractice of any hospital in the city.”

When David accepted the position of chief medical officer for the PBC in 1997, he was looking forward to having a hand in patient care once again. For the previous six years, he had been teaching health policy at Harvard University’s Kennedy School of Government. Before that, he had served as deputy secretary of health, and then acting secretary of health, under Pennsylvania Gov. Robert P. Casey. An African-American neonatologist and pediatrician who grew up in a mean South Bronx neighborhood, David was an idealist who believed passionately in the public service aspect of medicine.

But David quickly discovered that D.C. General was like no place he had ever experienced. To be sure, it had the usual problems of any public hospital: too little money, insufficient equipment and supplies, and an aging building that was suffering from disrepair. But that wasn’t what he found most troubling about the place.

When David arrived at D.C. General, he recounts in an interview, as patients waited hours upon hours in the emergency room, doctors were not coming to work on time, they were leaving early, and they were often sleeping on the job, in part because they were working full-time jobs elsewhere. The celebrated trauma surgeons refused to see other, “ordinary” emergency room patients who weren’t suffering from major injuries such as gunshot wounds, even when those surgeons weren’t busy with other patients.

After interviewing patients, David also discovered that some of the OB-GYNs were skimming off patients with insurance and Medicaid, sending them to their private-practice offices and delivering their babies at other hospitals, where doctors could bill the insurers or Medicaid for their services. “In some instances, doctors would actively dissuade patients from going to D.C. General,” says David. “We had patients tell us that doctors had told them not to come back.”

He also found that doctors weren’t showing up on time for clinics and were occasionally working in their private practices when they were expected to be at D.C. General. About six months after David took over as chief medical officer, someone in the emergency room paged Manderson, who was supposed to be on duty. The page was returned by a nurse at Providence Hospital, who said Manderson wasn’t available because he was in surgery.

The event was one of a long line of problems that prompted David to draw up a memo in which he told the medical/dental staff that he would be giving them a one-month amnesty period in which to clean up their act. After that, he told the doctors, they would be disciplined severely for a number of practices that had long been tolerated at the hospital.

In the amnesty memo, David told doctors that he expected them to work the hours that they were scheduled and paid for and that they were recording on their time sheets. He barred them from doing union work or private-practice work during regular hours and then working for the PBC afterward to collect overtime.

He required the full-time community health center staff to show up five days a week. He demanded that surgeons be in the operating room to supervise surgeries and that they be available to the patients immediately before and after surgery for follow-up. He barred doctors from ordering supplies and equipment for use in their private offices. And he asked that they fill out medical records on time.

Finally, David warned that if he caught any physicians collecting insurance information from PBC clients for the purpose of sending paying patients to their private offices, they would be in serious trouble. In his memo, David wrote, “Please know that my intent is to hold us to high standards of performance and integrity despite the prevailing political and economic forces that serve to undermine the PBC. I will not allow us to assume the role of victims.”

Although David’s demands seem rather basic—things one would expect from competent doctors who care about patients—the D.C. General medical staff was outraged. The doctors declared war on David.

Leading the charge against David was Oriaifo, then the acting head of trauma and later president of the medical/dental staff. A charismatic Nigerian who went to medical school in the former Soviet Union, Oriaifo had been active in the doctors’ union at the hospital, where he has worked for the past 16 years. David and Oriaifo first butted heads when David removed Oriaifo as acting chief of trauma and placed the trauma unit under the supervision of Dr. Howard Freed, the new director of emergency medicine.

The demotion prompted Oriaifo to call an emergency meeting of the medical/dental staff, alleging that he had been persecuted for speaking out about the administration’s failure to support clinicians. In a memo to the PBC board, Oriaifo claimed that Freed was not qualified to supervise him because Freed wasn’t a surgeon.

In fact, Freed was the first person ever to run D.C. General’s emergency department who had been both trained and board-certified in emergency medicine. He had more than 20 years of experience working in trauma centers and fixing troubled emergency rooms.

Oriaifo, on the other hand, is not board-certified in surgery or any other specialty. Furthermore, under his leadership, the hospital’s trauma unit has lost its Level 1 trauma designation from the American College of Surgeons—a designation that qualifies a trauma center to treat the most severe cases. (Oriaifo blames this loss on a lack of institutional support from the PBC, not any shortcomings of his leadership.) Nonetheless, Oriaifo soon got his job back after Mayor Barry intervened on his behalf.

Undaunted, David continued to discipline wayward doctors. He suspended and later fired a doctor for failing to complete medical records; he demoted a podiatrist who had refused to treat inmates and who the nursing staff had complained wasn’t starting clinics on time. After he discovered what outside consultants would later confirm—that the hospital had too many managers—David also demoted a physician who had been getting extra pay as the administrator of the “Neurology Department,” which had only two doctors in it.

David really angered the medical staff when he started showing up early at hospital clinics to see whether the doctors were at work on time. Nurses had complained that one particular doctor’s tardiness was pushing a clinic to stay open late in the afternoon, requiring the hospital to pay the nurses overtime. David caught the doctor red-handed, contacting her on her cell phone. She was dropping her kids off at school an hour and a half after she was supposed to be at the clinic.

The personal investigations prompted Oriaifo to stand up at a PBC board meeting one day and protest that David was “spying” on the doctors, which he said the staff considered highly inappropriate for the chief medical officer. David says Oriaifo didn’t get much sympathy from the board.

Oriaifo and the elected medical leadership defended the disciplined doctors, claiming that they had been singled out for criticizing the PBC. The medical staff believes itself to be an independent governing body under city law, and it often argues that only staff doctors can discipline other doctors, even for administrative rather than clinical matters. As a result, the group has tried to overturn many disciplinary actions imposed by the hospital administration.

In a 1998 memo to the PBC board complaining about David, Oriaifo wrote: “Dr. David has done nothing to support the practitioners as we struggle to render care to our patients…For all intents and purposes, and based on all available credible evidence, Dr. Ronald David appears to be a clueless enforcer and not a leader. WHERE DO WE GO FROM HERE?” A month later, Oriaifo helped organize the first of two votes of no confidence against David. The votes were largely symbolic, but they constituted a direct demand by the doctors to the PBC to oust David.

In an interview, Oriaifo contended that David was a failure as an administrator because he was an outsider: “Ron David just blew out of Harvard. What does he know about D.C. General?”

Nevertheless, David held on to his job. When PBC board member Victor Freeman, the medical director for quality for INOVA Health Care, voiced his support for David’s actions, the medical staff attacked Freeman, too. In a letter dated Feb. 3, 1999, Oriaifo wrote to Bette Catoe, the chair of the PBC board, complaining about Freeman. “How many more victims will be claimed by this scorched-earth, slash-and-burn, take-no-prisoner tactics before someone acts to stop the madness??” Oriaifo wrote. “WE ARE FRIGHTENED….We are UNDER SIEGE. We are at the brink of cataclysm….PLEASE HEAR MY CRY, PLEASE HEED MY CRY!”

David says his critics were mostly interested in covering up their malfeasance and laziness. “They threw up smoke screens,” he says, noting that they went after anyone who tried to discipline them. For example, David says, as Freed put pressure on the emergency-room doctors to be more productive and see more patients, they responded by calling in the D.C. Office of the Inspector General, filing sexual harassment and discrimination charges against him with the Equal Employment Opportunity Commission.

Despite the doctors’ resistance—and the dire warnings from the medical staff that the hospital was on the brink of disaster—David says Freed managed to reduce waiting times in the emergency room by better than 50 percent.

Finally, David attempted to put to rest the constant rumors about the surgical competency of Smalls. In March 1999, the JCAHO had approved the hospital’s procedures for reviewing Smalls’ wrong-side surgery. But the agency evaluated only the process, not the outcome, with which David was still dissatisfied. So he consulted Freeman, the PBC board’s quality-assurance expert, and they decided to send the case to an impartial committee of physicians from the D.C. Medical Society.

Late last summer, the medical society found significant problems with the surgery, which David used as justification to review some of Smalls’ past cases. He also ordered the doctors to create an action plan that would prevent such mistakes in the future. In the end, though, David says, his effort to compel the doctors to discipline themselves amounted to very little. Forcing them to put the patients’ interests before their own, says David, was a monumental fight.

When he first came to D.C. General, David says, he sustained faith in the miracles performed at the hospital, where he found that most doctors managed to do good work under very difficult conditions. For a while, he had even felt comfortable bringing his wife there for treatment for sickle-cell anemia. But when the medical staff failed to institute an effective peer-review system, David decided that he couldn’t maintain high standards at the hospital. He resigned last September. In a few weeks, he will be entering a seminary, where he hopes to learn some language of healing to bring to the practice of medicine. “It was just so dispiriting,” David says of his time at D.C. General.

After David left as chief medical officer, Dr. Robin Newton, a popular doctor who had recently been the president of the medical/dental staff, took over. She continued to pursue David’s quality objectives, and in February of this year, the hospital fired Oriaifo.

For many years, Oriaifo had also held a job at Providence Hospital, and the PBC administration believed he wasn’t putting in the time he was being paid for at D.C. General. An audit concluded that Oriaifo had seen only eight patients while working 24 hours a week from Oct. 15 to Nov. 15 of last year. Oriaifo disputed the veracity of the audit, and the medical staff organized a vote of support for him. Then the doctors called in the JCAHO, which sent surprise inspectors into the hospital in early March, prompting yet another crisis for the beleaguered institution.

Oriaifo has since filed a $1 million whistle-blower suit against the PBC, contending that he was fired for criticizing the hospital management, which he alleges retaliated against him, even going so far as to revoke his reserved-parking privileges. “When you give your whole life to a service and you end it with a kick in the pants, it hurts,” he says.

Oriaifo says he was only looking out for patient care, calling attention to the administration’s failure to respond to doctors’ complaints about a CT scanner that broke down twice a week, defibrillators that malfunctioned regularly, and incompetent nurses in the trauma center. He says the hospital has seen its patient count dwindle by 20,000 since 1995 because the emergency room has been closed down repeatedly for lack of beds. “Is it your fault when people say you’re not productive? The problem is not the employees. The problem is leadership and management,” Oriaifo contends.

To make his points, he has charts he sent to the PBC board outlining a proposed reorganization of the emergency department and memos with long lists of complaints about poor management. In the course of an interview in which Oriaifo talks almost nonstop for three hours, it becomes clear that he believes that he personally should be running the hospital. “I, Paul Oriaifo, was one of the doctors who received [Capitol shooter] Russell Weston! I was running the service of excellence!” he says, gesticulating wildly. “We [staff doctors] are the main engine of the PBC. We revolutionized that hospital. We are victims here.”

Since Oriaifo’s departure, the PBC’s medical staff has directed its attacks at Newton. On July 3, Dr. Michal Young, the new president of the medical/dental staff, wrote to the PBC board complaining that Newton had, among other wrongdoings, ignored Oriaifo’s request to volunteer in the trauma unit. (Oriaifo has offered to volunteer 20 hours a week in the trauma unit because of his “deep commitment” to the hospital. He also admits that by doing so, he would be able to keep his leadership job with the elected medical staff.)

Perhaps Newton’s biggest offense in the eyes of the doctors, however, was her support for legislation in the D.C. Council that would have designated the doctors “at-will” employees—which would have made them much easier to fire. (The legislation was withdrawn after a flurry of lobbying by the medical staff.) Late last month, the medical staff staged a vote of no confidence against Newton.

Meanwhile, all the complaining by the medical staff has had an effect in one respect, at least: Former CEO John Fairman has been removed, and now everyone from the General Accounting Office to Congress is scrutinizing the PBC. But the end result may not be exactly what the doctors had in mind.

The PBC is preparing to lay off hundreds of workers, including doctors, to avert a shutdown of the hospital entirely. Services to the poor will likely be severely curtailed. Trauma surgeons are in all likelihood going to be phased out altogether. Their special designation as an independent unit within the emergency department—which has other surgeons on which to draw—was always an anomaly, and outside consultants found them to be vastly inefficient.

And in the end, the people who are going to suffer the most are the city’s poor and uninsured—the very people the medical staff has claimed to be standing up for all along. CP