Some weeks ago, heart surgeon Don Williams wrote a letter to the chairman of the board of the Mount Sinai Medical Center, complaining about the institution where he's worked for almost 20 years, much of that time as head of the department of surgery:

"I grew disheartened with hearing the CEO described as 'dictatorial, ' 'autocratic, ' 'ruthless, ' 'despicable' . . . Many members of the medical staff are angry and disengaged with some of our best doctors leaving and more to follow. There has been a cascade of bad, costly decisions. The hospital remains filthy. Yet the CEO and his executive staff are exorbitantly compensated."

That a prominent surgeon would write such a scathing letter about his boss is a testament to the extent of the problems and discord at Miami Beach's Mount Sinai, a once-thriving institution that now persistently loses money ($11.5 million last year), has only two of every five of its licensed beds occupied and carries more than $250 million in junk bond debt.

Some of Sinai's difficulties can be seen in many hospitals around the country: Rising numbers of uninsured streaming to the emergency room and not paying their bills; shorter hospital stays; and growing numbers of procedures performed at outpatient centers. Many stand-alone hospitals, such as the nonprofit Mount Sinai, lack the clout of larger chains to negotiate healthy rates.

CEO IN HOT SEAT

But increasingly some doctors are looking for reasons behind Mount Sinai's woes and are pointing to its chief executive, Steven Sonenreich, who took over in 2001.

Sonenreich says he has taken many actions to turn the hospital around and that the personal criticism is utterly unfair.

"We're very proud of the tremendous accomplishments we have made over a short period of time, given the challenges left by the previous administration and the challenging environment we face." He points to the latest quarterly results, which show a smaller loss and an increase in patient admissions.

He says not everybody can be happy with all the decisions he makes. "I'm the CEO of a $500 million institution. We take care of 24,000 patients and have over 3,000 employees with over 300 physicians in offices here."

Three doctors who lead the medical staff say they support Sonenreich. So does Board Chairman Michael Adler. "He's doing a very competent job, " says Adler.

All say the decline of Mount Sinai reflects the changing demographics of Miami Beach. Once the retirement haven for Northeasterners, the city is now home to hordes of young South Beach hipsters. Old folks use hospitals a lot. Young folks do not. Of the four hospitals that once served Miami Beach, only Mount Sinai is left.

As its losses have mounted, so has patient unhappiness. A federal survey released earlier this year showed Mount Sinai ranked 18th of 22 South Florida hospitals for patient satisfaction. The hospital responded that in recent months, after implementing several initiatives, its satisfaction scores have increased substantially.

FINANCIAL WOES

For more than a decade, Sinai has been trying to climb out of its financial mess. In 2000, Bruce Perry, the previous chief executive, decided the key was purchasing another money-losing Miami Beach hospital, the Miami Heart Institute. The price: $75 million.

"It was a terrible decision, " says Jack Turken, a Miami Beach internist connected with Sinai for more than two decades.