Re: Med Schools: Four That Flunk
From: art fougner, md (evsono@pipeline.com)
Tue Jul 1 07:50:21 2003
well ... we still call the person who graduates last in his class ...
doctor. am still waiting for the day when a residency program director
will be named party to a suit since he/she signed off on a bad actor as
qualified... bound to happen one day.
art
At Mon, 30 Jun 2003, rmodugno@aol.com wrote:
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>From: Robert Modugno MD
>Bitter Medicine got some great discussion going,what about thos
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>Med Schools: Four That Flunk
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>By JACK DOLAN And ANDREW JULIEN
>Courant Staff Writers
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>June 29, 2003
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>Idaho regulators investigating complaints involving 12 patients revoked Dr. Brent E. Woodfield's license after concluding that he didn't understand "the basic principles of the practice of medicine."
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>For Dr. Anacleto Capua, accused of misdiagnosing fatal conditions in three patients, refresher medical courses were recommended by Florida authorities concerned about his medical skills.
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>Hitting the books might have helped Dr. Narpat Panwar, who flunked the U.S. medical licensing exam seven times before passing - only to be accused later in New York of botching a childbirth so badly the newborn suffered brain damage.
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>Besides a slippery grasp of the basics, these physicians share another bond: They graduated from a handful of medical schools that produce troubled doctors at about 10 times the rate of the best schools, an eight-month Hartford Courant investigation has found.
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>The schools - the Autonomous University of Guadalajara in Mexico, Howard University in Washington, Manila Central University in the Philippines and Meharry Medical College in Nashville - ranked at the bottom in separate analyses of three databases containing records of disciplinary actions against thousands of physicians across the United States.
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>Other medical schools also fared poorly in The Courant's review, but only Guadalajara, Howard, Manila Central and Meharry appeared in the bottom 5 percent of 200 or so schools ranked by rates of disciplinary actions against graduates in each analysis. Together, these large, well-established schools have produced more than 600 doctors cited by licensing boards for negligence, incompetence, sexual assault, drug abuse, fraud or other problems.
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>Within the medical profession, some of these schools have long been eyed with concern. Howard and Meharry ranked at the bottom of a National Science Foundation-funded survey of U.S. medical school quality in 1977, and questions have been raised about Guadalajara for years.
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>While it is difficult to draw conclusions about individual doctors based on where they went to school, The Courant's findings - for the first time - point to a link between medical schools that have raised red flags in various settings and troubling behavior by some of their graduates.
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>"This is incredible information," said Dr. Rebecca Patchin, chairwoman of the American Medical Association's council on medical education. "This could shake up the whole community and force people to take another look at the licensing criteria."
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>The precise reasons for the poor showing of these schools is unclear, but most have one thing in common: A practice of admitting students with lower grades or scores on standardized tests who might have trouble being accepted in many other places.
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>At least one school, Guadalajara, has accepted would-be doctors who never completed college.
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>"There is no excuse for students being allowed into medical school if they aren't adequately prepared," said Dr. Sidney Wolfe, director of health research for Public Citizen, a Washington-based consumer group.
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>"Maybe this means that it's worth requiring that anyone practicing medicine in this country had adequate preparation before medical school."
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>Even when evidence of incompetence or poor training is strong, troubled doctors are typically viewed as isolated cases and rarely do authorities look for hints of deeper problems within the educational system that produced them.
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>Additional information that could help further explain The Courant's findings is guarded closely by the medical establishment. Not one of the official bodies that keep exhaustive data on medical licensing exam pass-fail rates and doctor disciplinary records acknowledges checking its own files to see if some schools are, indeed, producing too many troubled doctors.
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>When the possibility of doing so, in a limited fashion, was raised two years ago by the AMA's medical education council, the plan was shelved.
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>The newspaper's findings drew a sharp response from the head of the trade group representing U.S. medical schools, who said it was impossible to pin the performance of physicians on the schools they graduated from because too many other variables determine success or failure.
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>"I think it's kind of an irrational approach to analyzing a very complex set of issues," said Dr. Jordan Cohen, president of the American Association of Medical Colleges, who also characterized the effort as "simplistic" and "foolish."
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>"I don't think there are any bad medical schools" in the United States, Cohen said. "That's a null set."
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>Loose Admissions
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>The Courant's investigation centered on an analysis of national and state-level databases containing the type of disciplinary information consumers can get through "physician profile" websites, which are run by state licensing boards and are becoming increasingly common across the country.
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>The disciplinary actions ranged from a simple citation against doctors, to permanent revocation of their rights to treat patients, for offenses that included negligent or incompetent surgeries and misdiagnoses of fatal conditions. Others were prompted by ethical lapses, such as having sex with a patient, or criminal behavior, such as using prescription privileges to peddle narcotics.
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>The broadest database, compiled by Public Citizen, contained information on more than 19,000 physicians disciplined between 1990 and 1999 by state licensing boards, the federal Medicare and Medicaid programs, the Food and Drug Administration and the Drug Enforcement Administration.
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>In addition to the national data, The Courant also obtained "physician profile" databases from two large, geographically distinct states, California and Ohio, which together contain the records for some 240,000 doctors who have held licenses over the last 50 years. The California database also contains a small number of malpractice payments made by physicians.
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>The schools represented were then ranked according to rates of disciplined graduates. After eliminating small schools with insignificant numbers of graduates, only Guadalajara, Howard, Manila and Meharry consistently stood out among the schools with the highest rates of disciplined doctors in all three databases.
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>In California, approximately one of every 10 graduates from each of the four schools has faced disciplinary action. For most schools, less than half that many graduates have been disciplined.
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>The four schools differ in many ways, but the clearest common denominator is that most accept candidates who might have had trouble getting into other schools. For a variety of reasons - some noble, others more pragmatic - the schools have more flexible admissions standards than other institutions.
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>The two U.S. schools, Howard and Meharry, have played a critical role in the history of American medical education, training generations of African American physicians when the doors to most schools were largely open only to whites. Doctors trained at these schools have gone on to provide care for many who were being turned away by hospitals or physicians that refused to treat minorities.
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>They are also among a handful of historically black institutions that attract students who often come from underprivileged backgrounds and may score lower on standardized tests.
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>"Many, although not all, of our students come from disadvantaged backgrounds and therefore have not had the same educational advantages as other students in their formative years," Meharry spokeswoman Jill Scoggins said in a written statement.
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>Howard officials declined to comment for this series.
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>According to "The Complete Medical School Preparation and Admissions Guide," the average Medical College Admission Test score of a successful applicant at Howard is 7.0, and at Meharry, 7.5. Those numbers are on the lower end of the spectrum. At Johns Hopkins, the average score is 11.3 and at Harvard it is 11.5, out of a possible 15.
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>But Scoggins said the school's graduates score well on traditional quality measures. Meharry graduates have a 98 percent pass rate on the United States Medical Licensing Examination and typically are placed in their first or second choice for a residency program at a rate that equals or exceeds the national average, she said.
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>"We hold all Meharry students to the same standards as any of the nation's other approximately 125 medical schools," she said.
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>But consumer advocates said it's probably unrealistic to expect that a medical school, no matter how lofty its goals, can compensate for poor preparation in high school and college. The rigorous academic demands leave little room for remedial education.
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>"It would be nice to think that disadvantages can be compensated for by the medical school, but that's just not the real world," Wolfe, of Public Citizen, said.
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>The Courant's analysis is not the first to raise questions about Meharry and Howard. Both schools have a history of recognized concerns about educational quality and financial stability.
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>A 1977 study of 94 U.S. medical schools, funded by the National Science Foundation, placed Meharry and Howard last and sixth from last, respectively, in reputation and perceived quality. Similar concerns have been raised by accreditation committees or internal school reports over the years.
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>Although difficult to prove, several experts also theorized that racial bias by state medical boards and other regulatory agencies might lead to black physicians being viewed more skeptically than whites when disciplinary actions are meted out, skewing the results for both Howard and Meharry.
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>Outside the U.S.
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>The Autonomous University of Guadalajara also has more flexible admissions standards, but for a different reason. The school draws U.S. citizens south of the border by catering to college students who do not have the grades, or the MCAT scores, to win admission to a medical school in the United States.
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>And because the number of vacant residency positions at U.S. hospitals outpaces the number of graduates from U.S. medical schools by about 3,000 a year, there is a constant demand for medical students from beyond the nation's borders.
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>With that demand have come periodic bouts of concern about the quality of doctors educated outside the United States, where norms and standards vary widely from one country to another. Manila Central, on its website, warns applicants not to give cash "to anyone who asks for money as a condition for admission."
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>"Some persons may approach you to offer help and ask for certain sums," reads a statement. "Do not believe them or give them money. They cannot influence admission and you will simply lose your money."
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>Manila Central officials declined to answer questions about The Courant's findings.
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>In Central America and the Caribbean, Guadalajara is only one of more than a dozen schools that cater to aspiring doctors unable to win admission to U.S. schools.
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>Two years ago, Patchin, the chairwoman of the AMA's medical education council, wrote a report calling on the AMA to take a hard look at the safety records of certain American doctors who were trained in Mexico.
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>Those graduates participated in a program known as the Fifth Pathway, a unique arrangement that allows Americans to avoid the final year of the Mexican curriculum, which is typically spent caring for that country's rural poor. Instead, the American students find a medical school in the United States to sponsor a yearlong clinical internship, after which they are granted a degree from Guadalajara.
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>Guadalajara produces many of the participants in the Fifth Pathway program, which over the years has drawn scrutiny from the medical profession.
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>A 1985 study in the Journal of Medical Education found that Fifth Pathway graduates were less likely to find jobs in primary-care fields and that some were "unable to engage in the practice of medicine." A federal health department report found that many Fifth Pathway students completed their training in hospitals that were viewed as providing medical education "of a less than desirable quality."
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>Acknowledging that the AMA had almost no data on the real-world performance of Fifth Pathway graduates, Patchin's council suggested tracking the "general outcomes" of the program, including a study of how often the graduates are disciplined later in their careers. However, the study was never done.
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>Instead, the AMA simply recommended that all state boards continue treating the Fifth Pathway graduates like any other recently minted doctor looking for a license.
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>Med School Matters
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>The Courant's findings challenge a traditional maxim among doctors. Most experts in academic medicine insist there is little, if any, connection between where a doctor goes to school and how competent a physician he or she becomes.
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>"I think it's difficult to draw meaningful conclusions because there are so many factors involved that have nothing to do with the origin of [the doctor's] medical training," said James Thompson, who runs the Federation of State Medical Boards, the national organization of licensing authorities.
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>In fact, a number of experts said that post-graduate training, including residencies and fellowships, has more to do with a physician's competence than medical school. After medical school, graduates can spend anywhere from three to eight years in hospital-based programs honing skills in their chosen specialty.
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>"Most people believe that, ultimately, graduate medical education influences physicians more than undergrad," said Kenneth Ludmerer, an expert on medical education from Washington University in St. Louis.
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>But as malpractice insurance rates skyrocket and concern over medical errors continues to grow, the role played by medical schools in producing quality doctors is coming under sharper scrutiny.
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>At the University of California at San Francisco, researcher Maxine Papadakis is conducting a two-year study to see if unprofessional behavior in medical school can predict disciplinary problems further down the road.
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>The theory behind the study is that a sizable number of the physicians who end up in trouble with regulators had some sort of problem in medical school. Researchers are hoping to single out key issues so admissions committees can weed out potential problem doctors.
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>Another piece of evidence pointing to the critical role of medical education was a 1997 study that found a relationship between the extent of an aspiring physician's knowledge of basic science early in medical school and his or her ultimate success as a clinician.
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>The study, published in the journal Advances in Health Sciences Education, looked at a pool of students over a 20-year period and found that those who did poorly early in medical school tended to receive lower ratings during residency programs, and were less likely to win board certification in their specialty.
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>"Does a medical school play a role in shaping the future of these people?" asked Dr. Joseph Gonnella, the study's author and a professor at Jefferson Medical College in Philadelphia. "The answer must be yes. Otherwise, why would we require medical school?"
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>Gonnella said the younger a doctor is, the more likely it is that the doctor's problems are directly linked to flaws in his or her medical education. As physicians spend longer in the field, they are subjected to other influences, from the type of patients they treat to the hospital where they do their post-graduate training.
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>But Gonnella said that doesn't mean medical schools can simply write off any problems that are the result of inferior students being allowed to go out into the world and treat patients.
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>"It is possible for wine to become vinegar, but I've not seen vinegar become wine," Gonnella said. "I do think all schools should pay more attention to the product. Once we put out a product, we need to take responsibility for both the good and the bad of that product."
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>Shrouded In Secrecy
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>When Florida regulators looked into the case of Anacleto Capua, they concluded that the St. Petersburg doctor essentially needed to go back to school.
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>Hours after being sent home from the emergency room, a patient who'd been complaining of chest pains collapsed from a massive heart attack - one of three patients who died after Capua failed to diagnose their fatal conditions.
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>The regulators ordered that Capua, a graduate of Manila Central University in the Philippines, take refresher courses in medicine, and they put his license on probation for six months.
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>If they'd checked further, state officials would have learned that Capua was hardly the only Manila Central graduate in their midst with a questionable record. But the authorities rarely, if ever, take such steps.
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>The Federation of State Medical Boards, for example, has access to the most comprehensive and up-to-date database of doctor disciplinary actions in the country, but the organization has never scrutinized the data for a correlation between medical schools and sanctions against the doctors they produce.
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>And even though the information in the database is taxpayer funded - it's provided by public licensing authorities from all 50 states - the federation is a private organization and therefore not obliged to share the data with the public.
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>"The medical profession has historically taken that position: `It's no business of outsiders what's going on among us. We take care of our own,'" said Daniel S. Greenberg, a Washington-based author who has written extensively on medicine and science, and is critical of the medical establishment.
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>Another private council, the Liaison Committee on Medical Education, is in charge of reviewing U.S. medical schools to ensure they are complying with accreditation standards. Despite the fact that a healthy chunk of medical education in the United States is financed by government-backed loans, the committee's reports are unavailable to the public.
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>Cohen, the head of the association of medical colleges, acknowledged that schools have periodically been placed on probation for failing to meet committee standards, but said that "each of those schools emerged from probation with much improved programs and an even greater commitment to the quality of their graduates."
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>When asked for the names of those schools, the AAMC said its policy is not to identify specific institutions. Cohen said that probation for medical schools is not an issue requiring public scrutiny.
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>Even if all else fails, a critical safeguard that is supposed to protect the public against the prospect of an under-trained doctor finding his or her way into practice is a series of tests known as the United States Medical Licensing Examination. Theoretically, the tests weed out any doctor whose training was inadequate.
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>But troubled doctors still slip through. Thompson, whose organization administers the exam, said steps are being taken to address known shortcomings. In its current form, the exam amounts to a written science test but does not demonstrate whether the doctor can take a competent patient history and draw the right conclusions, Thompson said.
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>So a new component will be added soon in which the doctor has a face-to-face consultation with an examiner posing as a patient. The examiner will grade the doctor on how well he communicates in English and whether he comes to a reasonable conclusion given the patient's complaints. Foreign medical graduates have already begun taking this new "clinical skills" test.
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>"The societal benefit of having a national standard is so substantial, we really think it's going to help," Thompson said. "I hope 25 years from now people will see we've had less litigation and fewer disciplinary actions as a result of the clinical skills test."
>Copyright 2003, Hartford Courant
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art fougner, md
ich bin ein New Yorker
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