The replacement of two fired UA dermatologists is a chief priority for the UA College of Medicine, as the short-staffed dermatology department struggles to train medical students and serve the community in a state blistering with the nation’s highest skin cancer rates.

The shakeup – triggered by alleged violations of Medicare billing rules – has jeopardized the once top-notch department’s ability to train medical students and provide care for low-income patients, said Tucson dermatologist Dr. Alan Levin, who spent three years as an assistant professor in UA dermatology.

“”This department had a very positive effect on the level of care in the community,”” Levin said. “”We don’t yet have a full handle of all the negative consequences of what’s happened.””

Longtime UA physicians Dr. Norman Levine and Dr. Jerry Bangert were fired in July following an investigation by University Physician’s Healthcare, the doctors’ group that runs the dermatology clinic in conjunction with the medical school, at 535 N. Wilmot Road.

Levine was the UA’s chief of dermatology from 1986 until 2003, while Bangert had worked at the UA since 1984. Neither physician could be reached for comment.

“”These were excellent doctors, very ethical,”” Levin said. “”It’s a true loss for the university.””

Dr. Roland Wheeland, who was demoted from the chief of dermatology position by UPH as a result of the investigation, was left as the clinic’s lone surgeon, despite a patient load that requires appointments to be made months in advance, said UPH dermatology registered nurse Debbie Hansen, Wheeland’s assistant.

“”This is like a cancer; it’s destroyed people’s lives,”” Hansen said. “”It was totally unnecessary that (UPH) took steps this drastic.””

Dr. Keith Joiner, dean of the UA College of Medicine, was quick to counter that Wheeland is not the clinic’s sole physician, although he was unable to provide specific names of other doctors working there.

“”Any implication that we’ve just closed up shop is wrong – the sky has not fallen in,”” Joiner said.

The department is running under Dr. Robert Rietschel, who is filling in as the interim head alongside his normal duties at Tucson’s Veterans Administration Hospital.

Rietschel was unavailable for comment. Wheeland declined comment for the story.

The firings stemmed from a 1996 federal law that prevents attending physicians from billing Medicare unless they are present for the entire procedure – despite the relative simplicity of some procedures, like freezing warts, which can be performed by residents while their instructors are out of the room.

Several medical schools have been slapped with fines because of the law, notably the University of Washington School of Medicine, which was charged $35 million by Medicare in 2004.

There is no word whether the actions against the doctors will prevent any similar actions by Medicare against the UA College of Medicine, said UPH CEO Norm Botsford.

Much criticism has erupted within the fractured department over UPH’s actions against the dermatologists – which was a case of overreaction and heavy-handedness executed to escape federal inquiry about their own billing practices, Hansen said.

“”In the 36 years I’ve been a nurse, I’ve never seen anything like it,”” Hansen said. “”This is something you see in a movie.””

Short-staffed dept. unable to handle patient load

An “”eerie”” scenario of empty rooms and dark hallways has developed from the understaffing of the clinic, as indigent patients head to Phoenix for timely treatment, Hansen said.

A month’s calendar of appointments can be filled within three hours in her office in Phoenix, said recent UA dermatology school graduate Dr. Xuan Nguyen, who trained with the dismissed physicians and now practices at Phoenix Children’s Hospital.

The overflow of Tucson patients is causing her office’s receptionists to take up to 70 calls an hour, Nguyen said.

“”For a major university to not have the capability to serve their local patients is beyond belief,”” Nguyen said.

The patient load for the dermatology department has also decreased. Last summer, UA dermatologists attended to about 1,400 patients. However, this summer, since the firings, around 400 patients were seen, according to UPH records.

Meanwhile, with 300 sunny days each year, Arizona had 1,278 skin cancer incidences in 2000, making it the second-highest in the world behind Queensland, Australia, said Sharon Mckenna, SunWise Program Coordinator with the Arizona Department of Health Services.

However, bringing more dermatologists to the College of Medicine is difficult, Hansen said.

The fired doctors’ prestige within the medical community and abrupt departure from their UA posts has complicated efforts to recruit new physicians and brought sluggish results, Hansen said.

“”The calls we’re getting, people are looking at the UA medical school like ‘what the hell is going on over there?'”” Hansen said. “”We’re being made to look stupid.””

However, President Robert Shelton said that while the program is in a “”low spot,”” he anticipates no major problems with restaffing efforts and expects to have the program back to full strength within six months.

“”Any time you have a departure of well-known people, whether voluntary or involuntary, questions will be raised,”” Shelton said. “”That means the field is ripe for rumors that can’t be squelched.””

“”Personnel issues”” leading to the investigation and subsequent dismissals would remain sealed, but there are “”several pieces in place”” toward rebuilding the UA dermatology program, Botsford said.

“”I’m sure what happened here will be something people will consider when coming for a new job,”” Botsford said. “”We’ve done what we should do, we have a great program and we will reestablish it.””

Underserved community members who depend on the college’s medical programs should not confuse personnel issues with the university’s commitment to Tucson, Shelton said.

“”I would just remind people of the track record that we have in serving the community, and we’re not abandoning that,”” Shelton said. “”We’ll find ways to make sure they’re served.””

Local dermatologists have stepped up to assist the UA program with temporary instruction at their clinics, which Levin termed “”preceptorships.””

However, many patients who shell out fees for private-practice physicians often insist on treatment from those doctors as opposed to the resident – resulting in a lack of hands-on experience for students, Hansen said.

“”That training amounts to minimal, at best,”” Hansen said.

Future dermatologists proving difficult to train

Training new dermatologists – and physicians in all areas – is critical in Arizona, where population growth has outstripped the number of new doctors. The state recruits 90 percent of its doctors from out-of-state medical schools, according to the Arizona Physician Workforce Study conducted by Arizona State University and the UA.

While the dermatology department is struggling, UPH and the College of Medicine are working to find ways for residents to keep their educational experiences meaningful, Botsford said.

“”We have an excellent group of residents and work very hard to ensure that they have a good experience and that standards are maintained,”” Botsford said.

The commitment of Tucson’s dermatologists to keeping the program afloat is admirable and will prove valuable to resident’s education, Joiner said.

“”I think that one has to distinguish between the qualities and quantities in education, but that doesn’t mean we think the situation is optimal,”” Joiner said. “”We have a commitment to have a world-class dermatology department, and I’m being quite direct when I say that’s our mandate.””

Joiner said he wants to look beyond the dermatology department’s problems and shore up other areas of the college that are in need of improved staffing.

“”There’s many areas that we don’t have sufficient depth,”” Joiner said. “”Because our mission quintessentially includes service to the underserved, we need to build in lots of areas.””

But the situation will have repercussions on medical training across the country, Nguyen said.

“”If the government is going to be so hard about having the attendings being there, you’re going to have residents that are going to be less experienced because you have to limit the number of patients coming through the door,”” Nguyen said. “”If we can’t train primary care physicians about the basics of derm, how horrible is that?””

Without oversimplifying the issue, the best thing for the dermatology department is to make the most of the College of Medicine’s reputation and create a solution as great as the need, Shelton said.

“”I’m not ready for the premise that the education is suffering,”” Shelton said. “”The college is going to make sure – by whatever method necessary – to keep the program strong.””