Foreign Medical School Grads Claim California Licensing Rules Unfair

Four years ago, the licensing of foreign-educated doctors in California was a school for scandal.

Hundreds of would-be physicians were caught cheating on basic qualifying exams by purchasing questions or whole tests in a thriving illegal marketplace.

Hundreds more were graduates of for-profit schools--located mostly in the Caribbean--that at best were providing a second-rate medical education, and at worst were little more than diploma mills.

Like medical licensure boards in many other states, California’s Board of Medical Quality Assurance responded to the wave of ill-trained foreign medical graduates by imposing, beginning in 1983, the stiffest standards in state history for obtaining a license to practice medicine.

But critics--state legislators, the overseas medical schools, public interest lawyers, immigrant community leaders and the foreign-educated doctors themselves--contend that the regulators’ prescription was too potent. The cure, they insist, has proven to be as dangerous as the disease.

In lawsuits and legislative hearings, the regulators have been accused of discriminating against all graduates of foreign medical schools, because of the faults of a few. The medical board is accused of violating state laws in the process, by holding secret meetings and imposing rules without formally adopting them.

Graduates, meanwhile, have grown frustrated by seemingly inexplicable delays in processing their applications for licenses. And questions have arisen about whether the problems of medically under-served communities have been exacerbated by the crackdown on foreign-trained doctors.

The regulators insist that the tough standards are vital to protect the public from inept physicians.

“We’re talking about medicine. We’re not talking about landscape architecture,” said Marc Grimm, a Sacramento consultant who until early this year headed the medical board’s licensing division. “Medicine is one field where people really have the opportunity to cause a lot of damage without a lot of review.”

Opponents’ Contention

The regulators’ opponents, though, contend that the medical establishment is using the scandals of 1982 and 1983 to justify a xenophobic campaign to beat down competition and preserve the hegemony of American medical schools and their graduates.

“It appears that the (licensing) division’s actions and policies have little connection to the assurance of competence, and are nothing more than a poorly disguised attempt to limit the number of doctors entering the medical profession in California,” charges the lead article in the spring issue of The California Regulatory Law Reporter, a muckraking journal published by the Center for Public Interest Law at the University of San Diego School of Law.

Vietnamese physicians who completed their training after the fall of Saigon in 1975 have had the most notable difficulties winning licensure from the medical board. But other foreign-educated doctors--whether graduates of for-profit schools in the Caribbean, Mexican medical colleges or the most prestigious universities in Britain and Europe--also have been daunted in practicing their profession by the licensure gauntlet.

Dr. Fred Kraft graduated from the medical school of the Autonomous University of Guadalajara, Mexico, in 1975. He has served as a ship’s surgeon in the U.S. Merchant Marine. He flies on medical missions to treat war refugees in Central America. He is licensed as a doctor in six states--and he shuttles among them, from Washington to Pennsylvania, to emergency room assignments brokered by physicians’ placement agencies.

Can’t Get License

But Kraft, who lives north of San Francisco in Mill Valley, can’t get a medical license in California. The medical board will not allow him to sit for one of the tests essential for licensure, citing deficiencies in clinical training he completed a decade ago at the University of California-San Francisco after his studies in Mexico. As a result, he has joined the Vietnamese doctors as a plaintiff in the class-action lawsuit filed this spring by USD’s Center for Public Interest Law.

“I think anyone in his right mind would have moved a long time ago,” Kraft said Friday in an interview from Fitzsimmons Army Medical Center in Denver, the latest stop on his medical odyssey. “I just choose to stay (in California). And I’ll fight them. I’ll fight them to the end.”

Kraft’s wife, Judith, is a flight attendant, and the couple’s travel schedules mean there are months when they see each other only once or twice.

“It’s a nightmare what it does to our family,” Judith Kraft said. “Our marriage has almost failed more than once because of the strain.”

The Krafts’ dilemma stems from a series of hotly debated actions by the medical board beginning in 1983.

Until then, the board had generally not challenged the credentials of overseas medical school graduates. If they produced a diploma, completed the required years of hospital training and passed the necessary standardized tests, they were licensed as readily as graduates of American and Canadian medical schools, according to Grimm.

But with the disclosure of the examination and diploma-mill scandals, the board got tough.

Minimum Requirements

On the recommendation of a task force, the board’s licensing division formally adopted minimum educational requirements for foreign graduates and informally began to require applicants to complete minimum weeks of hospital rotations in basic fields of medicine.

The new guidelines reflected a recognition of basic differences between North American and foreign medical education--and of the fact that, unlike in the United States and Canada, there was no organized mechanism overseas to assure the educational standards of foreign medical schools, Grimm said.

“There is no accrediting body of any type anywhere in the world,” he said.

Though historically, foreign-trained doctors had been an integral part of California medicine--they comprise about one-fourth of all doctors licensed in the state--the extent of the scandals prompted the regulators to crack down across the board on all foreign applicants.

“It’s kind of like walking through a bomb detector at the airport,” said Linda Ramsey, director of scientific and educational activities for the California Medical Assn., which generally supports the get-tough policy. “We wouldn’t have to do that if there hadn’t been terrorists throwing bombs around. The board feels it wouldn’t have to do this if there hadn’t been so many well-documented examples of diploma fraud.”

Legislative and legal critics say the new rules were ill-conceived and have been unfairly applied.

At the most basic level, they reject the notion of a two-track system of licensure. The applications of foreign graduates are nit-picked and measured against strict, numerical standards, they complain, while the board accepts the accreditation of North American medical schools as blanket evidence of the adequacy of their graduates’ educations.

“I think the standards should be such that everyone has to meet them, whether they’re American medical school graduates or foreign,” said Dr. Raymond Salman, administrative provost of St. George’s Medical School in the Caribbean island nation of Grenada.

Some Do Well

“I have seen some people who have difficulty on the licensing exam from some very fine American schools,” said Salman, formerly New York’s state director of medical licensing. “On the other hand, I’ve seen some people who’ve done extremely well from foreign schools.”

The board’s stance has been lambasted by the state Senate Committee on Business and Professions, which issued a formal “accusation” of misconduct against the agency late last year and held hearings into the board’s activities. Led by Sen. Joseph Montoya (D-El Monte), the committee charged the board with ignoring the Legislature’s intent that a 1986 tightening of licensing standards apply equally to U.S. and foreign graduates.

“It’s OK if the American doctor doesn’t have the education,” said Steven English, senior consultant to the Senate committee. “But on the other hand, we’ve got the foreign medical graduate, who has to meet the letter of the law.”

Similar allegations are raised in the USD center’s class-action lawsuit. “If the guidelines or standards were applied to all medical schools equally, more than 50 medical schools in the United States would not qualify--including the medical schools of Harvard, Yale, Stanford, Cornell, Vanderbilt and the universities of Pennsylvania and Virginia--and three-quarters of Canadian medical schools,” the suit says.

The medical board says North American medical education is so superior to that offered by many foreign schools that the criticisms are ridiculous. While some American schools’ curricula may require two weeks’ fewer surgical or psychiatric rotations than the state’s guidelines demand, their overall course of study--as evidenced by their accreditation--typically exceeds the minimums, according to Linda McCready, a board spokeswoman.

Secret Meetings?

“I would not hesitate to compare the curriculum at Harvard or Stanford or UCLA or those other medical schools with the curriculum of any other medical school in the world,” she said.

Besides their disagreement with the board’s licensure policies for foreign medical graduates, the regulators’ opponents chide the agency for the brusque and inconsistent manner in which the rules have been implemented.

Both the Senate committee and the USD lawsuit have charged the medical board with conducting secret meetings, enforcing unauthorized regulations, violating administrative procedures and taking arbitrary and unwarranted action to block foreign graduates’ licensure.

“The BMQA just basically makes up rules and regulations as it goes along, to fit each situation,” said Julianne D’Angelo, supervising attorney for the Center for Public Interest Law.

“Most of the policies under which it operates in the area of FMG (foreign medical graduate) licensing are unwritten,” she said. “The applicants have no notice, either of the criteria or the fact these criteria are being applied to them. When their applications for licensure are rejected, they are not given specific information about what is lacking in their applications.”

Robert Fellmeth, the former San Diego County prosecutor who directs the USD center, is even more forceful in his criticism. Fellmeth--echoing allegations in the lawsuit--says the board has engaged in “lying, doctoring minutes, deceiving (and) misleading”--particularly in the case of the Vietnamese applicants. Top licensure officials should be fired, he says, and the appointed board members who comprise the division of licensing should resign.

“It’s a total disgrace,” said Fellmeth, once an investigator for consumer advocate Ralph Nader.

Former board officials confirm that the agency, in the rush to tighten its standards, at times has been unfair or inept in its processing of applications.

30% Foreign Graduates

“After a period of nearly eight years of building a better system--more stringent requirements and a more standardized effort of review--it’s a shame a series of events have taken place that question the credibility of the agency, because the political backlash to that is tremendous,” said Grimm, the former licensing chief.

But the board says any statistical evaluation of its performance belies the criticisms. Foreign graduates constitute about 30% of newly licensed doctors--a number that exceeds their proportion in the established medical community, McCready noted.

“I would have to reject any claim that the board is consciously or willfully unfair or discriminatory,” she said. “Anyone would be hard pressed to prove any kind of institutionalized unfairness.”

Yet the USD law center and the Senate committee detect a nefarious motive in the board’s tightening grip on foreign-trained applicants.

English, the Senate consultant, says the tough new standards reflect the medical establishment’s desire to keep new competition for doctors to a minimum. The article in USD’s regulatory law journal, which he co-wrote with D’Angelo, describes the board as “a cartel” whose actions would be a violation of state and federal anti-trust law had the agency not been specifically created by the Legislature.

“It is not surprising that empathy for those who are now physicians, like themselves, and suspicion for outsiders who desire entry, pervade physician regulation,” the article says of the medical board. “That suspicion is perhaps exacerbated when the intruders have not gone to the same boot camp as those judging them, and who sometimes look and speak differently.”

Minority Medical Care

The strictures on physician licensure, English contends, deny medical care to minority and lower-income communities now under-served by physicians. In particular, he said, many immigrant doctors with both the language skills and desire to serve medically needy areas have been unable to practice medicine.

Grimm and others close to the licensing changes say there is no basis for the claim that the medical board has restricted the influx of foreign-trained doctors for competitive reasons.

“We made no attempt at all to keep anybody from being licensed. We bent over backwards to help people get through the pipeline,” said Dr. Maire McAuliffe, a San Francisco neurologist who retired from the board in 1985 after serving as president of the licensing division. “We were accused of trying to keep down the number of docs and protect our turf. . . . But none of us were of that mind-bent at all.”

Just as strongly, the board and its defenders say no community--even if it is medically under-served--will benefit from the licensing of doctors who cannot meet the state’s high standards.

“I am much more concerned with the question of do we want to be cast in the light of licensing untrained, incompetent people and turning them loose on any community--minority or otherwise--because of pressure from the outside,” said McCready, the board spokeswoman.

So the debate rages on. A bill by Sen. Montoya to mandate equal treatment of foreign and domestic graduates by the medical board lies inactive on the floor of the Senate, with the promise of renewed action in the months ahead. The San Diego lawyers’ suit is in the early stages of litigation in U.S. District Court in San Francisco. The licensure applications of Kraft and hundreds of other foreign-trained doctors remain mired in the medical board’s bureaucracy. The would-be doctors’ careers remain in limbo.

Grimm, from his new perch outside the system, said last week that it was time for both the board and its critics to engage in an in-depth study of the licensing system he played a central role in creating.

“There’s no intelligence to the process,” he said. “It’s all knee-jerk reaction.”