One morning in November 1982, John Gobert, director of Rosebud Hospital, was having coffee in the first-floor dining room with a newly hired doctor who introduced himself as Jay Mann, a 47-year-old family practitioner from New York.
At first Gobert was impressed by Mann, a stocky, fast-talking physician who drove a Cadillac, wore a leather-fringed cowboy jacket, and was all hustle and bustle, eager to work. But when Gobert asked Mann where he had been practicing, the doctor seemed evasive and changed the subject. "Something just didn't sit right," said Gobert. He made some calls to determine whether the New York medical license Mann had listed was in fact his.
The answer came two hours later: There was a licensed physician named Mann, but it could not be this one. Dr. Mann had been "dead for four or five years," Gobert was told.
Gobert confronted the impersonator.
"He got very upset," said Gobert. "He said, 'New York is notorious for making mistakes.'
"I asked to see a driver's license. He said, 'They made a mistake on my driver's license also.' "
The fraudulent Dr. Mann "was asked to vacate Government quarters and would not be allowed to see any more patients," Gobert wrote in a memorandum to his superiors in the Indian Health Service, the federal agency that runs the 29-bed Rosebud Hospital.
For nearly four years Gobert has been writing such memos, alerting federal officials to the large number of unfit, unqualified, unsuitable and, in some cases, unlicensed physicans who have been sent to practice their medicine on the Indians of the Rosebud Sioux Tribe.
There have been alcoholics, drug addicts, an exhibitionist, doctors trying to escape from border officials, a phony doctor, a doctor who fainted at the end of a baby's delivery, doctors incapable of treating cardiac patients, doctors in trouble with the law, and foreign doctors who could not get jobs elsewhere in the United States.
There was even an elderly doctor, known around the hospital as "The Belly Button Packer," who treated patients by stuffing cotton in the navel. After receiving this "therapy," one patient with a bleeding ulcer almost died, according to another doctor who treated him later.
"I think the medical care that is being delivered there is definitely sub-par, and that it is being rationalized by a lot of the people who are responsible for it," said Dr. Robert Hoyt, who practiced at Rosebud Hospital for two years until last May, one of the few permanent physicians on the hospital staff. "The same sort of circumstances to a certain degree exist in a lot of different places in rural America. But I don't think the medical care is necessarily as poor as it is at Rosebud."
"If you view medical care as a right," added Dr. Clark Marquart, another of the reservation's permanent doctors, "then there is no justice here."
Most of the doctors have been sent to Rosebud by Project USA, a federally contracted program run by the American Medical Association that supplies physicians on a temporary basis to Indian reservations and other medically deprived parts of the country. The doctors -- known by some as "Rent-a-Docs" -- work for salaries of up to $200 a day and are offered free housing, meals, air fare and malpractice insurance. They generally stay for only a few days or weeks.
In the past three years, Rosebud has hired more than 200 temporary doctors to fill as many as five of the seven hospital slots. They come and go with such rapidity, Gobert said, that he sometimes feels less like a hospital administrator than a transit authority chief, dispatching cars and ambulances on two-hour shuttle runs to pick up the latest arrivals at the airport in Pierre.
Doctors are only part of a larger crisis at Rosebud. The hospital operating room has been closed since the last resident surgeon left in 1978. Critical cases must be airlifted to Minneapolis or Rapid City, S.D., several hours away. Infant mortality is twice the national rate. There is widespread alcoholism and much chronic illness. Accidents are a leading killer. So isolated is Rosebud that doctors cannot use radio beepers to keep in contact. So remote are some communities such as Milk's Camp that Lee Six Toes, the night ambulance supervisor, has to drive as far as 100 miles in each direction to take someone to the hospital. No suicide hotline exists because so few families have their own phones.
And death comes here prematurely: in one recent year more than 40 percent of the Indians who died had not reached their 45th birthday.
The medical emergency at Rosebud is permanent; only the treatment of it is transient. The reason, according to John Naughton, director of Project USA in Chicago, is that the reservation is especially unattractive for many doctors because of the isolation and minimal pay. "If it wasn't for Project USA in the Dakotas, many tribal hospitals would have to close down for extended periods," said Naughton. "There are very few people that would go out and perform a service way out in the sticks, work day and night, for that kind of money, whether they be attorneys or bankers. They are sure getting their money's worth."
Naughton said he rarely hears of dissatisfaction with the doctors he sends to the tribes. "I screen them so thoroughly," he said.
But at Rosebud, one hears a different story. As Gobert and others recalled the cast of temporary doctors sent to the reservation, it seemed reminiscent of the chaos depicted in the 1971 Paddy Chayefsky film, "The Hospital." Gobert said he considered it miraculous that no one has died at the hands of a temporary doctor. "Maybe," he said, "the guy upstairs is smiling on us."
"It's horrible, believe me, I have laughed and cried," said James Sutton, a nurse who worked in the Rosebud Hospital for about four years until 1983.
Consider these cases:
*The Belly Button Packer. Late in the afternoon of October 12, 1981, Cleveland Kills in Sight, 41, entered the Rosebud emergency room complaining of sharp abdominal pains. Kills in Sight, a thin, slightly hunched man, explained to Dr. Charles Scuderi, a 79-year-old Project USA doctor from Florida, that his ulcer was acting up and that he had a five-year history of internal bleeding, which was documented in his medical chart.
Scuderi, after examining Kills in Sight, stuffed the patient's navel with cotton and sent him home. He wrote in the medical chart: "Navel was packed with cotton and taped. To return next Monday to change packing."
Kills in Sight remained weak and dizzy. He decided to visit the medical clinic in nearby St. Francis. There, a medical assistant took one look and contacted Marquart, who has practiced on the reservation longer than any other physician.
Marquart immediately arranged to have Kills in Sight hospitalized -- this time under a different doctor's care. It took four days of blood transfusions and medication to stem the bleeding. "He saved my life," Kills in Sight said of Marquart.
Marquart said Kills in Sight's life was endangered by Scuderi, whose remedy he termed not only "ridiculous but incredibly dangerous."
Six leading gastroenterologists interviewed for this article, including one recommended by the AMA, said they had never heard of such a treatment for bleeding ulcers, which can be life-threatening.
"Anatomically, it's not supportable," said Dr. Joseph Kirsner, the Louis Block Distinguished Service Professor at the University of Chicago medical school, and past president of the American Gastroenterological Association. "I've been at this now for more than fifty years. I've heard all kinds of things. But I must say, I've never heard of this one."
Scuderi, reached at his home in Port Richey, Fla., said that over the years he had employed the "belly button" treatment for hundreds of patients with bleeding ulcers. He said he had been retired for 10 years when he answered the Project USA advertisement, and added: "I told some of the Indians there who were patients that they were getting very, very good service . . . the best that there is."
*The Fainter. One semiretired doctor, 66-year-old Artemio Joco, of Liberty, Ind., was sent to Rosebud by Project USA in February 1982. One morning, as he was preparing to deliver a baby, he became queasy, his hands began to shake, and he started to sweat profusely. Moments after the delivery, with the woman still on the table, her legs held up in stirrups, Joco fainted. He was carried out of the room, and the procedure was completed safely by other medical personnel.
Joco, reached at his home, said he had been working a 24-hour shift when the delivery occurred, and added: "I should have rested a little longer."
*The Operators. Some physicians have attempted surgery at Rosebud even though the operating room has been closed and some of the equipment is so antiquated that the rubber fittings are rotting away.
Gobert remembered the day a nurse called him frantically to report on a temporary doctor, saying: "He's all dressed in the gown. He's got a patient ready to operate."
Gobert had to stop the doctor.
A second physician began acting strangely and said he wanted to operate on himself for what he claimed was a hernia. Gobert said the doctor was sent home: "He was going to cut himself."
In a third case, Dr. John A. Dondero, of Mendon, Mass., decided to use the emergency room for surgery and began to operate on 23-year-old Frank Iron Heart, probing inside his chest for hours in an attempt to remove a benign growth, according to nurse Betty Hughes.
"We just didn't have the instruments and we didn't have the setting for any sort of surgical procedures," Hughes recalled. So she summoned Gobert.
"The guy was kind of propped up on the table and didn't have any IV going, no vital signs were being measured . There was an exposed rib on the patient," said Gobert. "The patient looked like he was in quite a bit of pain. Dondero had broken the sterile field -- whatever he had in there as far as a sterile field -- his finger was sticking through the end of his glove."
The wound was closed by another doctor at Gobert's direction. Iron Heart filed a $150,000 malpractice suit against the hospital.
Dondero could not be reached for comment.
*The Oddballs. In the late 1970s, the reservation was served by a doctor who claimed to be hearing mysterious voices, according to hospital clerk Lee Ann Beardt. This doctor muttered "about the world coming to an end." He told some patients they were going to die and one new mother that her baby was going to die, even though none were seriously ill. He eventually left the reservation and hitchhiked back to Oklahoma with a traveling softball team.
Beardt recalled another doctor who tried to cure her son's severe allergic reaction to a bee sting by taking her outside, picking up some leaves, and telling her to place the leaves on the child's lip to "draw all the poison out." She finally persuaded the doctor that an adrenaline shot would be preferable.
Then there was the physician who had a habit of taking his clothes off and weighing himself in the nude in the same room where embarrassed nurses were seeing patients. 'Potluck' for Patients --
To deal with such doctors, the dedicated nurses, midwives and physicians' assistants at Rosebud Hospital have developed what nurse Sutton called a kind of informal underground network to assess which newcomers were unreliable. Marquart recalled that before he would refer a patient to the hospital, he would call the nurses, asking: "Anybody there you trust now?"
"You were more or less sending the patient to take their potluck chances," Marquart said. "You couldn't verify for them that nearly all those physicians were competent and trustworthy."
Dr. Loren Petersen, chairman of obstetrics and gynecology at the University of South Dakota School of Medicine, who flies to the reservation once a week to work with pregnant patients, said that in the late 1970s one of the doctors was found to be a narcotics addict. But because of the shortage of physicians, he was kept on for a while, and on nights that he worked, the hospital pharmacy was locked. As a result, Petersen said, pregnant women in labor could not receive painkillers unless the pharmacist was roused at home and dispatched to the hospital.
Dr. Lucy Reifel, the only Rosebud Indian physician on the reservation, recalled that on several occasions she was asked to examine children who had been sent home from the hospital by temporary physicians, only to discover that the children were seriously ill. One child had meningitis; another had appendicitis.
Nurse Nancy Sazama, who supervises the emergency room nursing staff, said that at times this year she has received five or six complaints a week from nurses about temporary physicians who were prescribing the wrong medication, or the wrong dosage. Some were even failing to follow routine medical procedures, such as applying protective padding to a patient's limb before placing it in a cast. Without such padding under a cast, Sazama said, "it rips your leg up when you take it off."
One day in 1981, Sutton said, a temporary doctor "just dawdled around and didn't know what to do" when a patient was suffering a heart attack. Sutton said he had to take over the resuscitation effort. "I ordered all the medications, got the individual's airway established, called the shots the physician would generally call," Sutton said.
The patient was revived for a time, but later died.
Not every temporary doctor has been unsatisfactory. Some have been invited back five and six times and about two dozen out of the hundreds were labeled excellent by Gobert. But the impact of even the best ones has been minimized by their short stays. There is little continuity of care, and for patients with unhappy experiences, the hospital is an object of derision and fear.
Teresa Archambault, a family planning counselor on the reservation, said Cleveland Kills in Sight, the ulcer victim treated by the "Belly Button Packer," is "afraid to go to the hospital now. He doesn't trust them . . . . His whole family is terrified of going to the hospital."
Darlene Kills in Water, a tribal community health worker, said she hears complaints about the hospital from patients who say: "They're practicing on us. We don't want to go down there."
Tillie Black Bear, of St. Francis, said that some of her friends are so afraid of the hospital that they "stay away until it becomes a crisis" -- then must be admitted in far worse shape.
Marianne Brave Left Hand Bull, 36, also of St. Francis, said: "Now that I'm getting older with health problems coming on, it's scary. I can imagine how the elderly feel. You don't know if they know how to diagnose what's wrong with you."
Often, as doctors change so do treatments. Patients may receive conflicting medication for the same illness on successive visits. One man with dizzy spells and nosebleeds received so many different drugs that they began to interact and his condition did not improve until one doctor ordered all medication stopped.
Gobert, a member of the Blackfeet Tribe in Montana, blamed other tribes for failing to document and share information about unsuitable physicians. He also faulted Project USA's screening process, which consists of a license check and calls to references. But there were also times, he said, when he had no choice but to accept an unsuitable physician.
"You had to make a decision," Gobert said. "If you didn't have anybody, what do you do? If somebody's 35 percent okay, is it better than having no one?"
Naughton said since he learned from Gobert about Scuderi and Dondero, he has not sent them to other reservations.
Some temporary doctors, however, have had a second chance at the Rosebud Hospital. In the fall of 1982, Joco -- the physician who had fainted just after the delivery of a baby -- returned. "I could not believe they allowed the guy to come back," Sutton recalled. Gobert acknowledged that it had been a mistake to rehire him, saying: "We thought that he wouldn't harm anybody."
Eleanor Robertson, the federal official who supervises nine tribal hospitals including Rosebud's, said the glut of doctors in big cities has resulted in some "borderline" physicians seeking jobs in rural areas like the Dakotas. She said her office was trying to weed out the problem doctors, many of whom were in trouble with state licensing boards and who had hoped "to hide out" on reservations and practice medicine undetected. One of Robertson's assistants said 25 temporary doctors had been rejected in the past three years after routine background checks by the Indian Health Service.
The need for physicians on reservations increased dramatically when the pool of young "draft doctors" dried up after the Vietnam war, and now the reservation must also compete with other communities that can offer large sums of money for new physicians. All Rosebud can offer is a sense of mission. Recruiting the Qualified
On Jan. 11, word reached the reservation that a young physician, 31-year-old Wende Wood, a George Washington University medical school graduate from Bethesda, Md., might be available to work on the reservation to fulfill a three-year government scholarship obligation. She had expressed a desire to be sent to an economically disadvantaged area.
Rosebud officials saw the need to strike quickly. They drove four hours through a blizzard to Pierre, where Wood was attending a recruitment conference. As they waited to meet her, another hospital administrator walked over to chat. "Good luck," he said. "See what you come up with."
Wood was greeted warmly by the Rosebud recruiters, who had decided to be as straightforward as possible about the conditions on their reservation. After all, there were few places more "disadvantaged."
Gobert described the hospital: Built in 1910. Two hundred babies delivered a year. Forty thousand patient visits. No surgery. Emergency cases flown to Minneapolis from a tiny airstrip. "A lot of alcohol on the reservation," Gobert said. "Car wrecks. Rattlesnake bites."
Marquart said bluntly: "It's kind of an intense place. The poverty is intense. The violence is intense. The level of illness is intense."
The next day, Wood traveled to Rosebud. Dressed in blue jeans, suede boots, and a warm sweater, she was given a tour of the reservation, tramping through the snow of St. Francis, visiting the run-down houses outside the hospital where the staff resided. (One trailer house was so dilapidated that a nurse had twice fallen through the bathroom floor while seated on the toilet.)
Dr. Robert Hoyt, a staff physician at Rosebud, then led her through the three-story red brick hospital. A leaky X-ray machine. No major life-support equipment. The inoperative operating room. He pointed it all out. They walked into the medical library -- otherwise known as the "rare book room" because all it had was a few outdated texts from libraries in Buffalo and San Francisco that had closed down.
In one room, Hoyt found a bulky tool that had once been used to look down patient's throats.
"It's obsolete, shouldn't be used," he said. Then, recalling that some of the temporary doctors had actually attempted to use it on patients, Hoyt added: "Occasionally, you get somebody who whips that bugger out and looks around. You do get the opportunity to meet some real characters."
Several weeks later, Wood decided against going to Rosebud. She chose a non-profit health clinic serving low-income families in Salt Lake City. Rosebud had been too depressing, isolated and confining. "I feel a lot of guilt that I didn't take the position," said Wood. "I feel I could have contributed something. I felt sad because I knew if I turned it down they probably wouldn't have gotten somebody else." The search for doctors continues. NEXT: The tribal court