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September 1, 0205

Community profile: Cleveland, Ohio

When the health-care industry employs more people than any other in the city, you know that’s a place to which doctors gravitate.

But what if we told you we’re talking about Cleveland, Ohio?

This is the city once dubbed the "mistake by the lake" after the Cuyahoga River tributary of Lake Erie caught fire and burned in June 1969, thanks to the petrochemicals dumped there by Ohio cities. But Cleveland has cleaned up its act and its reputation. Today, just as many other Midwestern cities, it’s chugging along in relative obscurity.

"People aren’t just going to look at a map of the United States and say, ’Well there’s a place I’d like to be,’" admits Andrew S. Bowers, the director of recruitment and credentialing at Kaiser Permanente. Indeed, he recruits his fair share of BLTs - code for "born, licensed, or trained in Ohio" - because "obviously those people have ties to the area and know something about it already. But when people do not, they’re very pleasantly surprised about what they see here," he says.

Cleveland Lakefront

The centerpiece of Cleveland’s shimmering lakefront is the Rock ’n’ Roll Hall of Fame and Museum.

That’s why Amy Georgalis, the administrative director for medical management and physicians’ services at Marymount Hospital, recently landed a recruit who chose Cleveland over the sexier Orlando, Florida. Bowers likes to troll for candidates in California and New York because "there are so many people in those two states who aren’t from there anyhow and jobs aren’t as plentiful there." In other words, they’re ripe for the picking.

Gerard Isenberg, MD certainly represents that population. He and his wife arrived from southern California for his residency in gastroenterology and fell in love with the city. "It’s quite a secret jewel," he says. "Housing is extremely affordable, many neighborhoods have mature trees, manicured lawns and quiet streets."

"This is an old community - and I speak for the Detroits, Pittsburghs, Clevelands of the world," says Robert Coulton, the administrator of professional affairs at The Cleveland Clinic Foundation. "Residents have been here for a long time, so they’re stable. They’re insured. They’re working and they value quality health care, value the practice of medicine the way it’s been practiced for a long time."

Tuning up

University Hospitals Health System and The Cleveland Clinic Foundation are the largest systems in the city. The Cleveland Clinic alone encompasses nearly 1,000 beds across 10 hospitals, employs more than 1,700 physicians, and supports one of the largest graduate medical education programs in the country with more than 800 students currently enrolled. Modeled after the Mayo Clinic - in fact, the Mayo brothers attended the grand opening in 1921 - the clinic is essentially a group practice that owns its own hospital, research institute, medical school, and graduate program. "The idea was for a group practice of physicians to teach younger colleagues and conduct research. They each drew a salary and the rest of the proceeds go back to building the practice," says Coulton "That’s continued for 80 years without any real change."

University Hospitals Health System looks remarkably similar:  One of its trustees, Samuel Mather, visited Johns Hopkins hospital and medical school in 1981 and returned home fired up to follow in its footsteps. So today, UHHS’s tertiary medical center, University Hospitals of Cleveland, is the primary affiliate of Case Western Reserve University. Together, they claim to form the largest center for biomedical research in Ohio. UHHS has approximately 25,000 folks on its payroll (including physicians) who operate 11 hospitals and "centers of excellence," such as the Rainbow Babies and Children’s Hospital, Ireland Cancer Center, and MacDonald Women’s Hospital.

Last decade, these two organizations were in acquisition high gear, scooping up a majority of the other players in the area. The result, insiders report, is the typical survival-of-the- fittest fallout - weaker institutions either closed their doors or merged with these systems, while stronger players like Kaiser Permanente - a not-for-profit health plan and physician shareholder medical group with 40-year roots in the region - used the situation to carve distinct niches. Bowers’ group, one of eight in the country, has 150,000 members.

Georgalis’ hospital, which now belongs to both The Cleveland Clinic and Marymount Healthcare Systems, recently broke ground on a state-of-the-art, 28-bed ICU, a 30-bed emergency department, and a new radiology facility, which should be completed in 18 months. "We lost a good number of hospital beds with the closings - some inner city, some more suburban - so we’ve seen our emergency volume and inpatient volume increase," she notes.

Now it seems the competition centers on who can stack up the most accolades. Take a look at UHHS’s list:

  • 4 Out of the more than 6,000 hospitals in the nation, U.S. News and World Report recognizes University Hospitals of Cleveland among the top 50 hospitals in 14 of the 17 clinical areas rated in 2005, up from 13 areas in 2004. Here are some of the details:
  • 4 Rainbow Babies & Children’s Hospital continues to hold its position as the number one pediatric program in the Midwest and number six among all pediatric programs in America. Child magazine places it among the top three children’s hospitals in America.
  • 4 University Hospitals’ Ireland Cancer Center ranks 18th among all cancer programs in the nation, as do the geriatrics and psychiatry programs.
  • 4 Other UHC clinical programs ranked among America’s best include digestive disorders, ENT, gynecology, heart and heart surgery, hormonal disorders, kidney disease, neurology and neurosurgery, orthopaedics, respiratory disorders, and urology.

As for The Cleveland Clinic, U.S. News and World Report rates it the fourth best hospital overall in the United States, and ranks its programs in the top 10 in 11 areas, and the top 30 in 5 more. It ranks first in heart and heart surgery, and second in both digestive disorders and urology.

"When you look at an opportunity in a group like ours, it’s the potential for collaboration, both clinically and research-wise, that is just phenomenal," says Coulton. "And in a salary-based organization, the ability to collaborate on all kinds of clinical care is excellent.

"Physicians from out of state are recruited to a job as opposed to the region," he adds. "We can dazzle people because the opportunities are broad and attractive."

Gettin’ down

Generally speaking, Isenberg says that if you work for a larger institution, thereby avoiding malpractice insurance problems, the Cleveland lifestyle is wonderful. "It’s easy to balance work, family, and personal obligations if you choose the right job," he says.
Physicians certainly don’t lack cultural stimulation. In 1920, Cleveland was the fifth largest city in the United States, and the entertainment pillars from this social standing remain. For starters, the city supports a major league team in every professional sport:  the Browns (National Football League), the Cavaliers (National Basketball Association), the Indians (Major League Baseball), and the Barons (American Hockey League). The city also is home to grand prix racing, international boxing events, and soccer competitions.

Row Houses on Cleveland’s Prospect Avenue

Row houses along Prospect Avenue in downtown have nearly all been renovated.

Travel Smart newsletter deemed Cleveland one of the 10 safest and culturally most fascinating cities to visit in 2004, no doubt thanks in part to its wide artistic base. After all, this is the city that landed the coveted Rock ’n’ Roll Hall of Fame and Museum, which means locals strolling along the Lake Erie waterfront on their lunch breaks stand a good chance of bumping into celebrities such as Meatloaf, Kevin Bacon, Red Hot Chili Peppers, Eddie (the dog from Frasier), Sheryl Crow, Take Six, Al Green, or Faith Hill - all of whom have dropped in for a visit.
Of course, the Cleveland Museum of Art pulls its share of regional visitors, as does the Cleveland Symphony Orchestra and the Cleveland Ballet. All of these pieces add up to give Cleveland physicians a well-rounded culture.

Meanwhile, professionals also make the most of the lakefront community lifestyle, Georgalis adds, by enjoying boating, swimming, skiing, and other beach activities. Many families make an annual summer trek to Cedar Point Amusement Park in nearby Sandusky, home of the world’s tallest and fastest roller coasters. It’s famous with the thrill junkies. Add it all together, and named Cleveland one of Americans’ top 10 summer vacation destinations two years in a row.

Simpler pleasures of hiking, jogging, and biking lie in nearly everyone’s backyard, thanks to the city’s park system, officially called Cleveland Metroparks, but affectionately known as the Emerald Necklace, which graces the city. More than 42 million people pass through the 20,000 acres of these14 parks annually, many of them at the Cleveland Metroparks Zoo alone.

Cleveland’s downtown is a vital, evolving entertainment center. To date, approximately $1.7 billion has been pumped into projects like the Rock ’n’ Roll Hall of Fame, the Great Lakes Science Center, and the theaters in Playhouse Square. The effort is paying off:  Officials report nearly 16 million people flood downtown for events and attractions every year. City planners are looking at a long-term plan to reconstruct the interstates to create more of a boulevard feel along the lakefront, a la Lake Shore Drive in Chicago, to give folks more access points to the lake.

Housing has followed the downtown entertainment scene, with the number of market-rate units from the Flats to the Quadrangle doubling to 5,175 in the past few years. Retail has begun to swing hammers and rev up the power drills to support this potential population, but the area better suits singles than families. Physicians Coulton works with haven’t been persuaded to buy into the idea. "The area has always had very nice suburbs and public schools," he says. "I wouldn’t have my kids in the public schools within the city limits."

Families prefer the suburban neighborhoods, where $200,000 buys a lot of house. According to Georgalis, the hot spots on the east side of the Cuyahoga River are Aurora, Bainbridge, Zoland, Twinsburg, and Hudson, while Rocky River, Strongsville, and Westlake attract professionals on the west side. Of course, the river’s divide is merely a technicality. Commuting times are quite reasonable for a large city. Bowers, for example, lives 24 miles from the Kaiser Permanente office, and budgets less than 35 minutes to get there. "In some cities, that would be an hour and a half," he says.

"You don’t have to fight to live in Cleveland," Coulton agrees. "You don’t get on a lot of different freeways to go to work. We’re just an easy place to live." It’s also a convenient place to leave:  Cleveland is within 500 miles of 43 percent of the U.S. population, less than a day’s drive from major cities along the East Coast and Chicago on the west.

No wonder Cleveland is a cosmopolitan city that attracts a variety of ethnic groups. Its sister cities include Alexandria, Egypt; Bangalore, India; Cleveland County, England; Taipei City, Taiwan; Ljubljana, Slovenia; and Segundo Montes, El Salvador. "And we have an Orthodox Jewish community, so Orthodox physicians are automatically attracted here," Bowers adds.

But when asked, residents proudly declare themselves Midwesterners, through and through, Coulton says.

A couple of flat notes

Both UHHS and Cleveland Clinic have openings in a majority of specialties. According to spokesperson Julie Phillips, UHHS is currently on the lookout for dermatologists, emergency physicians, radiologists, family physicians, and orthopaedists. Bowers adds gastroenterology, hematology, oncology, and cardiology to his wish list. Marymount Hospital is in the market for primary care physicians, although that’s an area where Bowers sees a healthy supply.

"We were recently recruiting for primary care positions, and I didn’t even have to run an ad. I just saved all the CVs and inquiries I’d received over the past two years. We contacted those names, and out of the 12, all but three were available and still interested," he says.

"Hey, the medical marketplace adjusts very quickly. Young people see what’s happening in the marketplace for jobs and adjust their specialties, so the flow of people seems to balance out quite well," Coulton says. He’s always willing to meet with physicians in this moment’s red-hot niches, which include MD’s qualified to do invasive procedures in cardiology and gastroenterology.

Everyone agrees Cleveland needs ob/gyns. That’s because this specialty has suffered the most casualties from a poisonous medical malpractice environment in Ohio that mirrors the headline-making situations in neighboring Pennsylvania, West Virginia, and nine other states the American Medical Association has labeled "crisis" states. It’s been severe enough to give Michael Nowak, MD, a surgeon who grew up in Cleveland, second thoughts about living in his hometown.

"There was a statistic on one of the billboards in town that said 40 percent of the docs practicing in northeast Ohio have left or retired in the last five years," he says. To underscore this fact, competing billboards, Yellow Pages covers, posters in the airport concourses, television, radio, and any other advertising spaces are plastered with messages from lawyers.

Such a litigious environment meant insurance companies either fled the state or stopped writing new policies until the handful remaining jacked rates through the roof. To add insult to injury, physicians left high and dry without coverage then had to contend with soaring rates for tail coverage. One health-care system says it paid as much as $400,000 just in tails to bring on three obstetricians with clean records.

The malpractice insurance problems combined with the fact that the acquisition fever eroded Nowak’s referral base have caused him to worry. He readily admits the situation over the past five to 10 years kept him nervous and eyeballing other cities.

Today, he and other doctors are breathing a bit easier, thanks to new state tort reform legislation that took effect on April 7, 2005. Of course, as Isenberg points out, "It’s expected lawyers will subsequently challenge the law with the Ohio Supreme Court with time, as they have done previously. But currently, malpractice insurance rates have stabilized and two new insurers have entered the Ohio marketplace."

Nowak found a more solid answer to both of his worries by joining Kaiser Permanente and scooting underneath its self-insured umbrella. "It’s been a pleasant experience working with a larger organization," says Nowak. "I’ve been very satisfied with the change I made. It’s made living here very comfortable.

"But the pendulum does tend to swing. I think in the next five to 10 years you’ll see some sort of revival or renaissance as the malpractice and insurance issues subside somewhat," he adds. "It means you’ll probably see more opportunities in the future."

And, in the plus column, physician recruiters across the city say potential recruits don’t get hung up on the salaries offered, and Medicare reimbursement levels are reasonable. "During tough times, the practice patterns, the community involvement, the resources available to them keep doctors in the area," Georgalis says. "For the most part, our medical staff is stable and doing well."

Count Nowak among those staying. "You have to ask yourself what’s important to you. If you’re young and ambitious and want to take on the world and some risks, there’s that opportunity for an entrepreneur everywhere. There are always opportunities in Cleveland for people who are knowledgeable and willing to work," he says.

Julie Sturgeon is a freelance writer who regularly contributes features and community profiles to UO.

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