Heightening the pressure on Grady hospital, the presidents of Emory University and the Morehouse School of Medicine said Tuesday that unless Grady changes its leadership, the schools might start sending their doctors elsewhere.

Grady depends almost exclusively on Emory and Morehouse for its physicians. The loss of the doctors could be devastating to Grady, a safety net hospital struggling with financial problems.

The hospital has operated in the red for 10 of the past 11 years and currently owes Emory and Morehouse $63 million, adding about $6 million a month.

The two presidents expressed concern about the quality of education their doctors are getting at Grady and about patient care standards. They emphasized that they won't pull all their doctors from Grady, but they may send new classes of resident doctors elsewhere beginning in the new year. In a few years that could cripple the hospital.

"If they make us no commitment [to change], they leave us no choice," said Dr. John Maupin, president of the Morehouse School of Medicine.

Grady is a major teaching facility for Emory doctors and virtually the only teaching facility for Morehouse. Sending these classes of new residents elsewhere could be challenging because many hospitals are already at capacity for residency programs, said Cherie Richardson, a Morehouse spokeswoman.

Emory sends about 100 new residents to Grady, and Morehouse sends about 50 each year.

"Not every place is a teaching hospital," she said. "There's so much work in setting up these agreements."

The Atlanta business community and some powerful state officials have pressed the Grady board to transfer authority over daily policy decisions to a nonprofit management corporation with a community board of directors.

Advocates assert that the new structure will help remove politics from the running of the hospital, restore faith in Grady's leadership and consequently open funding channels from the state, banks and foundations. Opponents say the change could reduce the hospital's level of care for the poor and uninsured.

The two school presidents sent a Nov. 8 letter to the head of the Grady board, Pam Stephenson, in which they strongly urged the board to overhaul its leadership structure.

The Grady board, formally called the Fulton-DeKalb Hospital Authority, is slated to vote on creating such a nonprofit board Nov. 26. The move would not change the hospital administration.

An advisory group of Grady board members and community leaders, which has been studying the issue, meets for the final time Thursday.

"Action must be taken immediately by many parties — beginning with the leadership of the Fulton-DeKalb Hospital Authority — to reorganize Grady's governance, management and funding models," said the letter, which also was signed by Emory President James Wagner.

Stephenson could not be reached for comment.

Responding to the presidents' comments, Frank Monteith, a member of the Grady board, said, "We just want to stay with the positive. It's businesslike for them to be concerned about their programs. However, I think their energies would be better spent working with us to help Grady."

Monteith added that he thought it "unrealistic" that the training that residents receive at Grady could be found easily elsewhere.

The school presidents say the hospital's dire financial predicament, which has prompted concern that it might completely close or shut down programs, along with the critical need to update equipment, has hampered the schools' ability to recruit and retain faculty and "raised concerns about the quality of our medical students' education."

Wagner said the problems are creating "the beginnings of some erosion in the standard of care."

Maupin added, "If the status quo occurs, then there will be a decline that will be inevitable, and a slow, slow erosion in the quality of service."

The letter added, "Unfortunately, we have reached a point that we cannot afford for this situation to continue into another year."

It adds that school officials already are reviewing where they might send their new classes of resident doctors next year. Emory might just recruit fewer residents for training programs at Grady.

"It's not enough for us that Grady survive and limp along. We need Grady to thrive," Wagner said in a telephone press conference Tuesday.

Maupin, of Morehouse, emphasized the urgency of making commitments and creating change quickly.

"If everybody comes to the table on [Nov. 26] and says we want to help, I hope their help is not too late," Maupin said.

Both presidents said they would prefer that their schools keep working with an "improved Grady."

"We want to be a partner," Maupin said. "We want Grady to be transformed into an outstanding hospital that continues its mission of service to indigents, to the trauma needs of this community and to the medical education needs of this community."