As Dr. Tom McClure stood in the mailroom of Haywood Regional Medical Center last April jamming copies of a scathing letter outlining his dispute with hospital administration into each doctor’s slot, he knew his days at the hospital were likely numbered.

McClure had deposited the letter with the mailroom secretary earlier that day with instructions to place a copy in each box. Not surprisingly, McClure’s letter was handed back to him and his request denied.

Determined the other 100 doctors practicing in Haywood County should know what was afoot in the orthopedics department and wanting to expose what he felt was a raw deal from an inconsiderate hospital administration, he stuffed the mailboxes himself. The letter announced that the hospital was exempting one of the three orthopedists in the county from emergency room call, thrusting the workload on the other two.

“It would seem that the administration of Haywood Regional Medical Center no longer values the contributions that have been made to the medical community in previous years. Instead, they have decided to favor the development of one physician’s practice over the others,” stated McClure, who had been practicing here since 1996. “This decision was made in secret discussions .... No consideration was given to the opinions of the other orthopedic surgeons currently on staff, as their opinions were not solicited.”

Dr. William Miller, a prized new spine surgeon, would be quitting general orthopedic work to focus solely on spine procedures. But McClure and the other orthopedist, Dr. Richard Jones, considered that an unfair move.

Few hospitals Haywood Regional’s size — and even some large hospitals like Asheville’s Mission Hospital or Duke Medical Center — allow orthopedists to focus solely on spines, hands, sports injuries or one of the numerous subspecialties in the orthopedic field. Instead everyone is required to share the drudgery of being on-call for general emergencies.

The move made McClure mad and led him to quit. It cemented Jones’ plans already in the works to move to Asheville.

The county was left without a doctor who could treat a simple broken arm. The situation continued for months, forcing Haywood County’s residents to drive to Asheville or Sylva not only for basic orthopedic procedures but hip surgery, knee replacements, torn ligaments — some of the most common injuries that lead a person to seek medical care.

The decrease in patient numbers left an entire floor of the hospital empty. Full-time nurses were sent home and forced to use up vacation time. Part-time nurses simply weren’t put on the schedule. And the number of surgeries plummeted, a factor that contributed to the November 2004 resignation of five of the six anesthesiologists at the hospital.

Ruffled feathers

The hospital’s decision to favor top-paying spinal surgery over basic orthopedics resulted in at least a $4 million loss in net patient revenue from May through November.

“We took a big hit from it. It hurt a lot of people when census was down in the hospital. But we’ve come through it and adjusted our costs and come out OK,” said Glenn White, a retired financial consultant who serves on the hospital board.

While Miller and the hospital pursued the specialized spine center that is now celebrating its grand opening, general orthopedic services have still not returned to their former level and won’t for several more months.

“I certainly do not believe this is in the best interest of our medical community,” McClure said of the scenario in his open letter to the medical community. “It clearly establishes the precedent that the hospital is comfortable with and desires the ability to manipulate the practices of physicians to their own desires and ends.”

Doctors who knew McClure weren’t surprised to find such a brazen letter distributed to every doctors’ mail slot. It was typical McClure. He was workaholic who performed 540 surgeries in 2003, bringing in more revenue for the hospital than nearly any other physician. Some referred to him as the hospital’s main breadwinner.

McClure was also a perfectionist. When the county only had two orthopedists between 2000 and 2002, he worked more hours than most people are awake rather than let the hospital bring in rotating out-of-town orthopedists to pinch hit. He said he didn’t want to be stuck providing follow-up care to patients whose surgery or initial treatment wasn’t up to his standards.

McClure’s attitude earned him a reputation as a top-quality clinical orthopedist but one who was often difficult to work with.

“If I ruffled some feathers trying to get the best possible care for my patients, then I did it for the right reason,” McClure said. “I didn’t ask anything of those around me that I didn’t demand of myself. I wanted us to be the best at orthopedics there was. It requires a high degree of self-reflection and self-criticism.”

It was perhaps too much for hospital administration. McClure was on a quality improvement committee his first year at Haywood Regional.

“They never put me on another committee the entire time I was there,” McClure said.

A fair hand

Even before McClure left, the hospital was short-handed in orthopedics. Dr. William “Bill” Owen Jr., a long-time orthopedist, had taken early retirement at the age of 59 at the beginning of 2004.

After McClure left and with Miller doing solely spine work, the hospital was left with only one orthopedist, Dr. Richard Jones. Even when Jones was one of four orthopedists, he had little time to pursue his subspecialty of sports medicine. So Jones, who was already working out a deal to join a sports medicine practice in Asheville, was soon gone as well.

The hospital administration attempted to broker a deal with Blue Ridge Bone and Joint, an Asheville practice, to send orthopedists out to Haywood County.

Blue Ridge Bone and Joint had one stipulation: Miller would have to share in the emergency room calls. Ultimately, a deal with Blue Ridge Bone and Joint could not be reached. HRMC President David Rice said the issue of whether Miller would share emergency room calls was not the deal killer, but it was a concession the hospital was unwilling to make.

Miller had landed in Haywood County by chance in 2002. Initially recruited to start a spine center in Hendersonville, Miller and his wife were driving through Haywood County when she turned to him and said she wished they could live here instead. He told her the community was too small to support the spine center he envisioned. Just then, they saw the hospital sign from the road and decided to give it a whirl.

Miller, wearing shorts and a T-shirt, walked into the office of HRMC Vice President Eileen Lipham and asked if the hospital was interested in starting a spine center. The answer was a definitive “yes.”

“They said they were short in general orthopedics and asked if I minded helping out for a year or two. I said sure,” Miller said. He was placed in an office at Mountain Orthopedic Associates with McClure and Jones.

“He announced from the very beginning he wanted to do nothing but spine, but he was nice enough to take general orthopedic call for the first two years. He was doing the hospital a favor,” said Dr. Richard Lang, a radiologist on the hospital board. “He was bending over backwards to help the patients out and the other orthopedists out.”

But when Miller learned in late 2003 that Jones was planning to leave and join a sports medicine practice in Asheville, Miller saw his vision for a spine center in Haywood County slipping away. He would be faced with picking up the slack in general orthopedic work. But worse, he would be left alone with McClure.

McClure, while a terrific orthopedic surgeon, was demanding and not a good team player, according to some. Miller worried McClure was hampering the recruitment of additional orthopedists to Haywood County.

So Miller started making plans to join a hospital in High Point and even signed a contract. But when the hospital administration found out, they made Miller a deal. They would support his initial vision for a spine center and allow him to stop doing general orthopedics. Miller said he has worked at five hospitals and has found this administration to be the most congenial and cooperative.

“This is the only hospital I’ve ever been at where a physician can walk into the administration’s office and talk to them about whatever you need to,” Miller said. “It’s a positive environment here.”

Miller points out that he has not gotten out of being on-call. He is on-call in case of spine emergencies 24 hours a day, 365 days a year.

He also has the potential for making Haywood Regional a destination for patients from surrounding counties seeking specialized spine care. He has already attracted patients from Murphy and Newport, Tenn.

“Dr. Miller’s objective was to offer us a spine center. We are committed to working with him to develop a spine center for Western North Carolina,” Rice said.

The plan fit with the hospital’s mission of marketing highly profitable procedures. Patients undertaking specialized elective surgery are often better insured and more likely to pay their bills than a patient with a broken hip who shows up in the emergency room.

Meanwhile, general orthopedic services could be restored over time. A new orthopedist started in December and more slated to arrive this summer.

“We’re quite excited. By the end of summer, we’ll have the program back in place in terms of numbers,” said Robin Tindall with the hospital marketing department.

Making changes

Before the hospital could begin recruiting new orthopedists, the on-call schedule was adjusted.

According to hospital by-laws, specialties with only one doctor are exempt from being on-call. But if there are two doctors in a specialty, they are required to take emergency room calls. The more doctors in a specialty, the more spread out the call duty.

In some specialties with only two doctors, such as gastroenterology or urology, being on-call doesn’t equate to actually getting a call, making it doable for two physicians to share call duty. But for orthopedists, being on-call more often than not means getting a call, which created an unfair burden, according to Jones and McClure.

Rice and Lipham agreed. Lipham said it would be “very difficult” to recruit new orthopedists if they had to be on-call every other night. So the rules governing call duty for orthopedists were loosened to one in every four nights, a change that was approved in June 2004 by the medical executive committee comprised of physicians.

McClure questioned why the call schedule was altered for the incoming orthopedists but couldn’t be altered for him.

“I was told under no uncertain terms I would be taking every other night call. I had every reason to believe they would enforce that and kick me off the staff if I refused,” McClure said.

A doctor who has his privileges revoked by a hospital is permanently branded when applying for future positions.

“I am good at what I do. I have worked hard to be good at what I do. I’m not going to stay there and sacrifice my reputation to fight with that hospital,” McClure said.

But others familiar with the situation say McClure was not told he would have to take call every other night, but rather that he could continue on the one in four schedule.

Regardless, McClure knows what it takes to pull call every other night. He did it for two years prior to the arrival of Jones and Miller in 2002. He worked 120 hours a week and jeopardized his family life.

“I did it before. But the thing that I wasn’t willing to do was be treated unfairly,” McClure said.

McClure’s first recourse was to take a leave of absence, which he submitted to the chief of staff, Dr. Nila Wilbur. She handed it back and refused to accept it, McClure said.

Hospital administrators said a leave of absence is either planned in advance or due to a personal emergency, not sprung upon the hospital for no legitimate reason. So McClure resigned instead.

McClure and Jones were both upset they had not been afforded the opportunity to comment before the decision regarding Miller was made.

The hospital board had discussed Miller’s scenario in closed session in late March with no advanced notice. The issue was discussed and approved by the medical executive committee shortly after. McClure challenged the chief of staff concerning the medical executive committee making a decision without Jones and himself being notified first.

“I was told that the meeting was open to the staff and that if we had anything to say on that issue we should have been there, although there was no prior notice of that issue being discussed,” McClure said. “This was basically rammed through.”

Rice and Lipham said they are not at liberty to discuss certain elements concerning what happened with McClure due to the confidentiality of personnel matters. Both did say, however, that they did not anticipate that the decision to permit Miller to become a spine-only orthopedist would prompt McClure to resign.

Tindall said the administration did not want McClure to quit, but “in the long haul, it’s probably best it happened that way. We’ll be able to build a consistent group (of orthopedists),” Tindall said.

McClure said it boiled down to control.

“They wanted control over physicians,” McClure said, and he wouldn’t give it to them.

McClure, who is fulfilling a fellowship in St. Louis, said he hopes to come back to Haywood County.

“I could practice at any medical facility in this country. I love Haywood County. There is no place I would rather live,” McClure said. “I feel like this hospital stole my life from me.”

McClure is one of four business partners developing a large medical complex of doctor’s offices adjacent to the hospital. McClure said it is against his personal financial interest to air his issues with the hospital publicly, as it could hamper recruiting and slow the sale of several buildings in the complex. McClure also said going public in the newspaper would jeopardize his chances of ever coming back to Haywood County to practice.

“The reason why I’m talking to you is because I believe the people of Haywood County deserve the best possible health care system they can have and that requires a hospital that works with physicians,” McClure said.