States Accept Suspect M.D.s
By ANDREW JULIEN And JACK DOLAN
Courant Staff Writers
December 14 2003
In a cavernous nursing home on a narrow spit of land in the middle of New York's East River, Yonnette Humphrey lies quietly, her head pitched sharply to the side. Her husband leans over to whisper a few words, not expecting a reply.
She has been silent for more than four years now, since the day she went to St. Mary's Hospital of Brooklyn to have a baby. As complications set in, Humphrey was rushed to the operating room for an emergency Caesarean section, where the anesthesiologist, Dr. Lyonel Paul, was supposed to keep her breathing.
But a lawsuit settled for more than $5 million accused Paul of committing a fundamental medical error: mistaking Humphrey's esophagus for her trachea. Deprived of oxygen, Humphrey's brain shut down, and the woman slipped into a coma, never having seen her little girl.
The lawsuit against St. Mary's, which outlined a number of possible scenarios for the incident, raised a key question: Was Paul equipped to handle the critical task required of him that day?
His educational resume, in fact, included a worrisome entry: He attended Spartan Health Sciences University, a Caribbean medical school that has sparked such serious concerns about educational standards that its graduates are banned from practicing on its home island and in six states.
But not New York.
A Courant investigation has found that nearly 900 doctors practicing across the country are graduates of schools banned in states including California and Texas because of questionable educational standards.
Inconsistent licensing rules from state to state allow these doctors to pursue lucrative careers after graduating from offshore medical schools that would be hard-pressed to win accreditation on U.S. soil. Thirty such doctors are practicing in Connecticut.
The four most widely banned schools are Spartan in St. Lucia; the University of Health Sciences in Antigua; and two in the Dominican Republic - the Universidad Tecnologica de Santiago and the Universidad Eugenio Maria de Hostos.
While it can be difficult to draw a direct connection between any given medical school and a specific incident, what happened to Humphrey is the type of event feared by regulators who have banned these schools.
"We have to protect the patients," said Pat Park, foreign schools liaison at the Medical Board of California. "That's why we have to look into every aspect of how these people are trained and where they are trained. They can pose a serious danger to the public."
With an estimated 6,000 U.S. citizens attending foreign medical schools, some state officials say it's time to eliminate the haphazard patchwork of regulations.
"We would really like to see a national organization do this," said Jill Wiggins, a spokeswoman for the Texas medical board. "The standard should be national, not left up to the individual states."
A Twilight World
The findings are part of an ongoing Courant series investigating links between problems with medical education and preventable injuries and deaths. An analysis published earlier this year ranked major medical schools by the proportion of their graduates disciplined for negligence, incompetence and other problems.
The medical establishment denies that such a link exists, arguing that most medical errors are the result of flaws in health care delivery systems, not flawed doctors.
But the consequences are staggering. While estimates of the number of Americans who die each year from medical errors vary widely, even the most conservative experts theorize it's in the tens of thousands.
Gavin Humphrey understands the personal pain behind those statistics. For the past four years, he has lived in a twilight world, his 34-year-old wife technically alive but tragically out of reach.
"She's here - but I cannot talk to her," said Humphrey, who is raising a family while holding down a full-time job as a track maintenance worker for the New York City Transit Authority.
Humphrey's 4-year-old daughter, Rashanda, never met her mother. His oldest daughter, now 16, still needs counseling to help deal with her loss. Gavin profoundly misses his wife.
"After they rolled her out of the emergency room and I saw her lying on the bed, my knees buckled," Humphrey recalled. "It was like she was dead at that point."
"I'm still angry," he added. "I would do anything to have her back; if not for me, for the kids. They need their mother."
His anger is understandable. Paul, the doctor accused of sending Yonnette Humphrey into her coma, had been hired by St. Mary's just a month before. At 53, it was his first job as a fully licensed physician, court records show.
Paul spent the previous four years in a post-medical training limbo. The stretch included time spent building a house in Haiti, working as an administrative assistant in Queens and tutoring students back at Spartan, Paul testified. It did not, however, include treating patients or gaining experience in the delicate procedure he needed to perform on Humphrey.
The incident led to his discharge from St. Mary's within a week.
Paul, in a telephone interview from his home in Uniondale, N.Y., vigorously denied any wrongdoing. He said if he had made a mistake, the baby would have been harmed. She was born healthy.
"This was a case that I did according to the book," said Paul, whose license is currently under suspension in New York. "Something unfortunate happened."
But Cheryl Bulbach, the attorney who questioned Paul in a deposition as part of the Humphrey lawsuit against St. Mary's, said she was surprised by how little he knew.
"I've done hundreds of these things over the years, can't tell you how many I've done with anesthesiologists. But, generally, they give the impression that at least they have some grasp of the anatomy, the physiology, of what's supposed to be going on in the operating room," she said. "I definitely did not get that impression."
Disorder And Disarray
Spartan Health Sciences consists of a single building with four classrooms, a couple of bookshelves and six computers with shaky Internet access. The "campus" sits in an industrial park near a brewery in a hardscrabble port town, far from the posh tourist centers on St. Lucia.
After a scandal over falsified diplomas at a Dominican medical school in the early 1980s sparked broader concern about the quality of Caribbean schools, regulators in California dispatched inspectors to visit a number of schools, including Spartan.
The nine-page report following the team's 1985 visit was a blistering indictment of the island school, concluding that the primary mission of most students was to spend as little time as they needed on St. Lucia to get a passing grade on the standardized exams required for earning a license as a physician in the United States.
The report took particular aim at the Spartan faculty, characterizing it as an unorganized collection of part-time instructors who had questionable qualifications and whose comings and goings were hardly tracked by school administrators.
Many of the professors had not completed approved postgraduate training programs, the report said. Some were simply spending time at Spartan while waiting to be accepted into a residency program.
"The faculty is grossly underqualified and does not meaningfully participate in the operation of the school," the report concluded.
The Universidad Tecnologica de Santiago, or UTESA, did not fare much better when a team from California was dispatched in 1996 to the Dominican Republic for a visit to the school's Santo Domingo campus, which includes the English-language program. The school has a second campus in Santiago.
The inspectors found a school characterized by disorder. The laboratories were antiquated and stocked with out-of-date equipment. The library consisted of "a few thousand very dusty volumes shelved at random" - including many shelved upside down. The registrar's office was "heaped with files both loose and boxed, with files falling out of shelves and everything in complete disarray."
The visit led to a clear and unequivocal conclusion:
"The deficiencies at UTESA are broad in scope and deep in extent," the report said. "Only a complete reorganization could adequately prepare its graduates to enter the mainstream of the continuum of medical education, and then medical practice, in the United States."
Officials from UTESA rejected the assessment of the California authorities, saying the school has hundreds of graduates who have passed U.S. licensing requirements and passed the necessary examinations.
"The quality of graduates can be determined ... by the high number of those who, having achieved their licenses, practice in the United States," said Pedro Gil Iturbides, a UTESA official, in a statement.
Officials from Spartan and the University of Health Sciences declined to comment for this story. The Universidad Eugenio Maria de Hostos closed in 1998.
In addition to protecting patients, the site visits are seen by California officials as a means of letting students know that they might have problems being licensed in the U.S. if they are thinking of studying in the Caribbean.
"A lot of times it's the lack of admissions criteria that attract people to certain schools," Park said. "If you've got this 2.0 GPA and for some reason you still think you should be a doctor, these schools are waiting to take your money."
After reviewing California's methodology and deciding that schools such as Spartan failed to deliver a reliable medical education, officials in Texas decided earlier this year to adopt California's list. High among the concerns was the fact that Spartan has no teaching hospital where students can do their clinical training under faculty supervision.
"They don't do their clerkships on campus; they are not even done at one place," said Wiggins, of the Texas medical board. "It all seems very scattered."
But that sort of tough action remains the exception. In addition to California and Texas, only a few states either ban graduates of certain schools or restrict their practice: Alabama, Indiana, Idaho, Kansas, New Mexico and Vermont.
The severity of the bans, which have been instituted over the past two decades, vary from state to state. In some states, such as California, the ban is absolute. Other states permit exceptions and allow individual applicants to petition for a review of their experience and training.
Licensing directors in several states said that keeping up with the changing spectrum of offshore medical schools would be impractical and that dispatching inspection teams to the Caribbean would be costly.
"Without an international accrediting organization, the data would change from year one to year two," said Margaret Anzalone, deputy director of the Maryland Board of Physicians.
Instead, to assess the legitimacy of an overseas medical school, many states turn first to an international directory compiled by the World Health Organization in Geneva.
"They feel that is a type of credential. We start there, then we look at the individual scores and that type of thing," said Peggy Cryer, executive secretary of the Arkansas State Medical Board.
The directory, however, has limited value. It is little more than a listing of medical schools that are recognized by the country in which they are located. Even the World Health Organization warns against relying too heavily on the listing, pointing out at the beginning of the guide that the organization does not formally recognize or accredit medical schools.
"It is not fair nor accurate to believe that WHO ensures the quality of a medical school by the simple fact that it is listed in the WHO directory," said Charles Boelen, the official at the organization who was in charge of the directory for many years.
Dr. James N. Thompson, who heads an umbrella group that represents state medical boards, acknowledged that there is "no good system for accrediting all international medical schools."
But he insisted that the measures used by state boards to assess the knowledge and skills of individual applicants were thorough, weeding out those without the ability to perform at the level expected of doctors in the U.S.
"I think it does a remarkably good job of protecting the public," said Thompson, president of the Dallas-based State Federation of Medical Boards.
To check on the skills of aspiring doctors, many states look to the Philadelphia-based Educational Commission for Foreign Medical Graduates. To win certification, applicants must show proficiency in English, undergo a clinical skills test and pass the same national licensing examination required of U.S. medical graduates.
The commission also verifies that applicants actually graduated from a medical school listed in an international directory that, like the World Health Organization guide, is little more than a listing of schools approved by local authorities.
It is also typical for states to require two or three years of post-graduate medical training in an accredited U.S. residency program.
"There's remarkable uniformity across the states in establishing that competency," Thompson said. "All require graduation from medical school, residency training, credentials verification, and require passage of licensure examination."
Still, there is quite a bit of variation from one state to the next. In New York, Spartan is not on the list of schools whose students are permitted to undergo clinical training or residency training at the state's hospitals, but they can become licensed physicians if they are trained in another state.
Connecticut, like many other states, uses the World Health Organization directory. But, by statute, it relies on an edition published in 1973, before schools such as Spartan and UTESA existed. Graduates of schools not in the book who want to be licensed in Connecticut are reviewed on a case-by case basis, an approach also used by regulators in Oklahoma.
"We don't have a list of schools we just flat don't accept. We look more at the individual," said Lyle Kelsey, executive director of the Oklahoma State Board of Medical Licensure and Supervision. "If we have a question about a school, we'd contact California or New York to see what they know."
But Kelsey said it can be hard to sort good eggs from bad in cases of marginal schools, because they can attract the medical equivalent of con artists.
"Those are usually the guys who are hard to catch because they're so convincing. They are obviously intelligent in some way, and they can slip by."
Nine Months At Spartan
If medical regulators needed a lesson in the hazards of leaning too heavily on standardized tests, they got it when Spartan graduate Michael E. Holton launched a career in medicine.
His story is laid out in disciplinary files and medical school records in Iowa, Indiana and Alabama obtained by The Courant.
When Holton applied for a license to practice medicine in Iowa, regulators there were under the impression that he'd spent three years studying at Spartan's satellite campus in El Paso, Texas, a facility that has since been shut down.
But when Iowa regulators checked, they learned that during that same period, Holton was employed full-time as a supply clerk at Baptist Hospital in Nashville, Tenn., and was living at home with his parents at the time in nearby White Bluff - about 1,300 miles from El Paso.
Holton later admitted he was only physically present at Spartan for a total of nine months, during which he completed three trimesters of basic science courses, although he denied misrepresenting his status at Spartan. Most medical schools devote two years to the basic sciences.
Despite his short tenure on campus, Holton graduated from Spartan with honors in August 1986.
An evaluation of his performance during a clinical rotation at a Tennessee hospital pointed to potential trouble: "Ability to perform limited by lack of basic knowledge," it said.
Holton's shortcomings became more evident when he was suspended from a residency program at the University of Alabama in Huntsville after a series of evaluations sharply critical of his skills.
Holton eventually passed all the required tests and won board certification in family medicine. Despite graduating from Spartan, he was licensed in Indiana - which officials say is most likely because he had previously been licensed in Iowa.
But, when regulators in Indiana began looking closely into Holton's background in 1993, they became alarmed.
They learned that during Holton's medical training at Spartan there were no laboratories, no autopsies, no tissue samples and no library to speak of. One professor taught 11 classes. During Holton's clinical rotations, Holton had no contact with Spartan "other than payment of tuition."
The regulators concluded that Holton was essentially self-taught and that his formal education at Spartan was both "substandard" and "inadequate."
The board suspended Holton's license and sent him back to medical school, where he was required to repeat the classes he'd supposedly taken already.
Holton, whose license was reinstated in 1996 after two years at Indiana University, declined to comment, although a letter written by one of his teachers in support of his reinstatement praised his "earnestness as a student" and "his mature outlook."
But the Indiana board's run-in with Holton led to a conclusion that calls into question the widespread reliance on standardized tests as a means of protecting the public from untrained physicians:
"Passing ... examinations, alone, is not adequate assurance of a competent medical education to receive or retain an Indiana license," the board said.
Any Doc Will Do
There is a reason schools such as Spartan exist.
Every year, the number of first-year residency positions at hospitals across the country exceeds the number of new doctors being turned out by the nation's medical schools by about 3,000.
The gap has been caused by a variety of factors, including the fact that U.S. hospitals - arguably spurred by the generous education subsidies available under the federal Medicare program - increased the number of residency slots while medical schools were holding their numbers steady.
"It was about the mid-'80s that hospitals realized there was almost this bonus payment for having residents," said Edward Salsberg, director of the Center for Health Workforce Studies at the State University of New York at Albany.
At the same time, while the competition for jobs in high-end specialties is fierce, positions often go begging in more bread-and-butter fields such as internal medicine and pediatrics.
"The practice environment for generalists is not as friendly as it once was," said Dr. Munsey Wheby, president of the American College of Physicians, Internal Medicine.
"Reimbursement has been declining. The regulatory hassles the physicians have to deal with virtually increase every year."
This imbalance, between the demand for new doctors on the one hand and the number of U.S. medical graduates on the other, has led to a tremendous dependence on graduates of medical schools in other countries.
While many of them are doctors from other countries who studied medicine in their homelands, there is also a large contingent of Americans who gained their medical degrees at schools in Mexico and the Caribbean.
"Yes, there are some of them ... perhaps they are not sufficiently qualified to enter a U.S. medical school, and perhaps some of them are sub par," Wheby said.
"And that's of some concern."
Dr. Richard Cooper, director of the Health Policy Institute of the Medical College of Wisconsin, published a paper in 2002 that showed that if medical training is not beefed up, by the year 2020, America will have a shortage of 200,000 doctors.
"The failure to keep up with sufficient physician training in America has led to several adverse unintended consequences," Cooper said.
`A Little Slap'
Corey Fuller had been battling a fever and vomiting for two days in 1990 when his mother decided to take him to the emergency room at Lawnwood Regional Medical Center in Fort Pierce, Fla.
The doctor on call that morning was Maureen Zelinka, who Florida records show had received a medical degree in 1984 from the Universidad Tecnologica de Santiago, a school whose graduates are restricted from obtaining licenses in six states, but not in Florida.
Zelinka examined the 13-year-old, diagnosed a virus, gave him a shot of an antihistamine and sent him home with orders for painkillers and fluids, according to records of the case.
"She gave him some aspirin and Gatorade and sent him back home," Corey's mother, Peggy Fuller, said. "She just pushed him out the door."
The next day, Corey was back in the emergency room, almost in a coma, according to his mother. Another doctor conducted an examination of the boy and ordered laboratory tests - which uncovered the fact that Corey was suffering from diabetic ketoacidosis, a complication of diabetes. He died about 10 days later. "I can still remember as it was yesterday," Peggy Fuller said.
State regulators in Florida sharply criticized Zelinka's handling of Corey, accusing her of failing to perform an adequate physical examination, failing to order necessary tests and failing to take a complete medical history. She was placed on probation for two years, fined $1,500 and ordered to attend an additional 20 hours worth of classes on pediatric care.
Zelinka declined to comment, but newspaper accounts at the time quoted her attorney as saying experts who reviewed the case said Zelinka had performed a proper assessment.
But Fuller said that she was surprised at the "little slap on the wrist" the regulators handed Zelinka and that it was pretty clear she didn't learn everything she needed to during her tenure at medical school. "I really don't think she got the knowledge she needed to get from them," Fuller said.
A discussion of this story with Courant Staff Writer Jack Dolan is scheduled to be shown on New England Cable News each half-hour Monday between 9 a.m. and noon.