Doctors Leave Levees and Lassitude Behind

NEW ORLEANS, Aug. 31 -- For Robert Perrillo, M.D., it could have been worse. When the levees broke here in the face of Katrina's surge, his house was inundated by waters that were only waist high.

Nevertheless, after the Ochsner Clinic hepatologist and his wife spent many months sleeping on an air mattress in his office, they decided they'd had enough of a city that no longer functioned like one.

They managed to get their house repaired with the help of a contractor, who was one of Dr. Perrillo's patients, and in June they sold out and moved to Texas, like so many physicians who had thought that would spend their lives in this community.

Dr. Perrillo, who now practices at the Baylor University Medical Center in Dallas, had simply given up hope that New Orleans could bail itself out of the politics of paralysis.

Six months after Katrina, the Orleans Parish Medical Society estimated that there were 1,200 practicing physicians in the New Orleans metropolitan area, down from approximately 4,500 in the days before Katrina.

About 1,200 of the pre-Katrina complement included medical residents and post-doctoral fellows, many of whom have returned with the reopening of the Tulane and Louisiana State medical school campuses.

But new student enrollment is still off by about 33% at Tulane Medical School, and Louisiana State University has found it hard to attract graduate students to fill basic science openings.

A year after Katrina, it's unclear just how many physicians have left New Orleans for good, according to an Orleans Parish Medical Society spokesman. Many were able to find a new home at the Oschner Clinic Foundation in Jefferson Parish, which lost about 40 physicians in the immediate aftermath of the storm, but is now staffed well above pre-Katrina levels.

But Ochsner is one of only three hospitals that never closed following the storm, and although more acute care facilities are reopening, there is still a critical shortage of nurses and of support personnel, including technicians, housekeeping staff, cafeteria workers, and maintenance personnel. Many hospital staff workers lived in areas of the city heavily damaged or destroyed by the floods, and are living with relatives or friends elsewhere.

Nurses appear to have found the grass greener well beyond the levees. According to the American Hospital Association, there are nearly 120,000 vacant positions for registered nurses across the United States, and many facilities are offering incentives to lure them in.

For some physicians the decision to leave New Orleans behind may be straight forward -- losses of practices, homes, and patients. But others, like Dr. Perrillo, cite a complicated mix of reasons for leaving.

"We had, as many others also witnessed, the opportunity to see the poor governance of the disaster event," Dr. Perrillo said. "We felt very low confidence in the government's progress in that area, and the efforts to bring money and business back."

And even though the re-election of New Orleans Mayor Ray Nagin occurred long after Dr. Perrillo and his wife had made the decision to pull up stakes, the people's choice to return to office a man whom many people blame for the inertia of recovery efforts just reinforced their decision to leave, he added.

A third factor in his decision to decamp from the city once called "the Big Easy" was that his practice had changed, he said. As one of only three major hospitals open in the city, Ochsner had taken on patients from the shuttered Charity Hospital and Louisiana State University Medical Center. The patients often came in without records, and many didn't have the resources they needed for adequate self-care or follow-up visits, Dr. Perrillo said.

Donald Palmisano, M.D., who has stayed in his native New Orleans, sympathizes with the plight of his colleagues.

"Right now," he said, "one of the problems for the hospitals that are open and for the doctors who have found a place to practice, or those who were fortunate enough to be on those hospital staffs, is that you may not get paid. Thirty to fifty percent of the patient population may not have any insurance, or the insurance they have doesn't pay you."

Those doctors who lost their practices (Dr. Palmisano's private surgical practice in New Orleans East was damaged, and is still closed) face daunting challenges, he said. These include uncertainty about insurance and financing, and whether they will be able to attract enough paying patients to sustain a practice.

There are also basic problems of infrastructure that remain unsolved, such as a lack of land-line telephones and sporadic power outages in parts of the city, Dr. Palmisano said.

"How can you have a medical practice without something as basic a land-line telephone?" he asks. "It's impossible."

In a recent survey, the American College of Emergency Physicians, which will hold its annual meeting in New Orleans in October, polled its members in hurricane-damaged areas of Louisiana and Mississippi. A total of 59 physicians out of 142 who were e-mailed surveys responded.

More than one-third of the 59 doctors who participated in the survey said they would consider leaving the area to practice elsewhere if the system has not sufficiently improved by this time next year.

Of these, 92% still practiced in the same areas they were in before Katrina, but more than a third said they'd consider relocating if things haven't improved by the second anniversary of the storm.

About half of the respondents said there was little or no recovery of the emergency care system where they practiced, and 60% said their emergency departments had not recovered, in terms of functioning, to pre-storm levels.

In addition, 65% said that patients were being harmed by long waiting times, and more than 75% said that the emergency response system was not prepared to cope with another hurricane or other form of disaster, natural or otherwise.

Two physicians who made the difficult decision to put down roots elsewhere were Tyler J. Curiel, M.D., former chief of hematology and medical oncology at Tulane, and his wife Ruth Berggren, M.D., a former associate professor of medicine and infectious disease specialist, also at Tulane.

Dr. Curiel, who made headlines when he staged a rescue mission to protect irreplaceable research samples that were in danger of perishing in his lab at Tulane, has moved his research to the University of Texas Health Science Center at San Antonio, where he will head the San Antonio Cancer Institute. Dr. Berggren is joining the faculty in the division of infectious diseases.

Dr. Curiel said in an interview this week that the decision to leave New Orleans was one of the most difficult choices he has ever had to make.

"I really love New Orleans," he said. "It's one of the greatest cities in the United States, if not the world. New Orleans is going to be a place of special memories for me, but for doing the research that I do, I can't see any time in the foreseeable future where it would be possible to do there what I do."

The city no longer has the facilities or the specially trained staff needed to run a research laboratory, and the patients needed for clinical research have vanished, Dr. Curiel said.

"It's one thing to run the risk of losing your cell samples -- they'll thaw out and be gone," he said, "but it's a much different story when you lose contact with your patients. I lost contact with every single patient in every clinical trial. They were gone."

Last April, Dr. Curiel and Dr. Berggren co-authored an article in the New England Journal of Medicine, in which they characterized the state of health care in New Orleans as "unacceptably primitive," a view apparently shared by their New Orleans colleagues.

Michael Ellis, M.D., a clinical professor of otorhinolaryngology at the LSU Medical Center, whose practice was destroyed in the hurricane, is a passionate advocate for health care reform in Louisiana.

He said that he's hopeful about the chances for reinventing what all seem to agree is a failed health care system. But if proposed reforms should fail, he may join the New Orleans medical diaspora for good, he said in an interview.

"I just got back from five weeks working locum tenens in Charlotte, N.C.," Dr. Ellis said. "I'm going back there to work for several more months, and who knows whether I'll decide to permanently relocate there."

"But if we get the 'same old, same old' in this state, I'm out of here," he continued. "An awful lot of other doctors feel exactly the same way, and many have just picked up their marbles and gone, because they don't see any hope for the next couple of years."

Related Katrina Coverage:

• New Orleans Now -- Few Doctors in the HouseA Multimedia Special Report
  This special report from Zach Wise, a MedPageToday contributing photographer, presents the sights and sounds of New Orleans medicine a year after Hurricane Katrina.