King/Drew Fights to Save Its Residency Program

Born out of the Watts riots and embattled throughout its 31-year history, Martin Luther King Jr./Drew Medical Center this week faces one of its greatest challenges yet -- saving its ability to train new doctors.

On Tuesday, King/Drew and its medical school will attempt to convince an outside reviewer that they have corrected myriad problems in programs that prepare doctors to specialize in everything from delivering babies to operating on gunshot victims.

The hospital, owned by Los Angeles County, depends heavily on its group of 331 trainees to care for its patients, most of whom are impoverished African Americans or Latinos. Without those physicians, it is unclear how King/Drew would serve this population.

In 2000, the last time the Accreditation Council for Graduate Medical Education reviewed how King/Drew trains residents overall, the council gave the hospital a rare “unfavorable” rating. Nationwide, of the 374 institutions with more than one residency program, only 13 have an unfavorable designation.

If the Willowbrook hospital were to receive another negative overall review, the council would have grounds to shut down all of its 18 residency programs.

County Supervisor Yvonne Brathwaite Burke, whose district includes the hospital, called a successful review “very crucial” to the hospital’s future.

The accrediting council has never shut down all physician training at a hospital before. But experts in medical training say the council has begun issuing harsher sanctions against hospitals in the last year under pressure from politicians and physicians who felt it did not act quickly enough against poorly performing programs.

It could be several months before the accrediting body informs the hospital of its fate.

Several factors complicate King/Drew’s efforts to secure a favorable review:

* Six of King/Drew’s 18 residency programs recently have received sanctions from the council conducting this week’s site visit. The radiology program is slated to lose its accreditation in June, meaning it must be closed. Revocation also has been proposed for the surgery program, although the university plans to seek a reconsideration within the allotted 30 days.

The anesthesiology, family medicine, neonatal-perinatal and internal medicine departments either have been placed on probation or received warnings in the last two years. The accrediting council has cited problems ranging from inadequate supervision to insufficient medical research by the faculty.

* Far more King/Drew-trained residents fail the exams required to become certified as medical specialists than at other institutions nationally. Of the 25 King/Drew pediatric residents who took the boards between 2000 and 2002, for example, only 36% passed on their first try -- tied for the second-lowest in the country, according to the American Board of Pediatrics.

* The amount of work available for residents has decreased markedly. The number of admissions at the hospital has dropped 40% in the last 10 years and the number of births more than 85%. The accrediting council requires that residents perform a certain number of procedures to practice safely and independently upon completing the program.

In past reviews of several programs, including surgery, neonatal-perinatal and family medicine, the council cited shortcomings in that respect.

The Charles R. Drew University of Medicine and Science is paid $13.8 million a year by the county to run the hospital’s training programs. Officials there say they have made major improvements since 2000 and are ready for the coming scrutiny.

Program directors meet regularly to discuss areas needing improvement, officials say. Research among faculty has increased significantly. And the school plans to build a simulation center and a skills laboratory where residents will be able to practice on mannequins before they move on to patients.

“Of course, we are concerned that the possibility exists that we might not be able to have residencies, but this is something that we have to deal with,” said Dr. Charles Francis, president of Drew University. “We have, I think, successfully responded to every challenge that we’ve been faced with.”

During the last institutional review, the accrediting group cited King/Drew for a lack of commitment, insufficient supervision of residents, overworking residents and using them for inappropriate chores, according to a summary provided by the county.

If King/Drew is stripped of its ability to train residents, the hospital would lose not only a key segment of its physician work force, it also would be forced to abandon its mission of educating minority doctors to work in underserved communities. More than 90% of King/Drew’s patients are either Latino or African American.

King/Drew’s trauma center treats nearly one-quarter of the county’s gunshot and stabbing victims and 11% of those involved in car accidents, assaults and other life-threatening injuries.

The surgeons who have trained there say they can’t imagine what it would be like in South Los Angeles without the hospital, which has about 250 beds.

“Within the surgical community, you won’t find a better trauma surgeon than a surgeon from King/Drew,” said Dr. Rene Umali, a former surgical resident who now practices in Gardena. But Umali said King may never be able to escape its reputation as “a subpar” hospital.

King/Drew supporters are concerned that deficiencies in so many crucial specialties will hurt the hospital’s chances.

“How do you provide good support for a surgery residency program if your anesthesiology program is on probation?” asked Dr. James Haughton, who served as medical director of King/Drew from 1987 to 1993. “How do you supply good orthopedic training if your radiology department is withdrawn?”

“It could give them a reason for shutting down all those residency programs,” said Haughton, now the county’s medical director for public health.

Ingrid Philibert, who oversees site visits for the council, said the withdrawal of one or more training programs does not necessarily affect the overall review of a hospital. But, she added, “more often than not, issues in many programs are indicative that institutional oversight isn’t as good as it should be.”

Dr. John Gienapp, the former executive director of the accrediting council, said hospitals have long relied on residents -- “the cheapest method possible” -- to care for the underserved.

But if problems in their training persist, he said, “maybe they need to find some way to give high-quality care to those populations without simply relying upon residents who are getting a less than adequate education to do it.”

When Gienapp led the accreditation council 10 years ago, King/Drew faced the loss of its program for emergency medicine. At that time, he said, King/Drew was “pretty much at the end of their rope.... It’s up or out.” The hospital saved the program by removing the chairman and pledging to hire more specialists.

Drew Medical School Dean Dr. Marcelle Willock said the reviewers have grown increasingly tough on even the top-ranked programs. “What they have found is that a number of universities were not taking them seriously,” she said. To send a message, they’ve said, “This is not a little spanking. We’re going to take out the strap here.”

Problems at King/Drew already have caused some county officials to ask whether the hospital needs outside help to run the residencies and whether its mission remains viable.

One idea floated by both Dr. Thomas Garthwaite, the county’s health director, and Supervisor Zev Yaroslavsky is to ask UCLA or USC to assist in running the programs. That idea is likely to come up at a hearing this month of a special state Assembly committee formed to discuss the fate of King/Drew.

Assemblyman Mervyn M. Dymally (D-Compton), who heads the committee, said he hopes it can find out, once and for all, what ails King/Drew and who can best fix it.

“What is the root cause of this problem?” asked Dymally, a longtime Drew supporter. “The school points its finger at the county and the county points its finger at the school. Let’s stop the finger-pointing.”

Francis, who took over as Drew’s president five years ago, said he would be open to short-term leadership help from UCLA or USC, but only on a “very temporary basis.”

“I feel that we are a better institution, certainly, than we were five years ago,” Francis said. “But a lot of it has to do with the fact that we’ve had to deal with these crises, and coming through them has forced us to come up with new ways of dealing with things.”

Ernie Smith, a professor of medicine and clinical linguistics at the Drew school, said help from UCLA is not the answer. He and some Drew board members blame Francis for weak leadership and are calling for his removal.

“Francis was asleep at the switch,” said Smith, who also is ombudsman for the Black Community Health Task Force, an advocacy group. “It’s hard for me to see people as the source of the solution when they’ve been identified as a major part of the problem.”

The current turmoil at King/Drew is raising much larger questions about the mission of the hospital and medical school.

Garthwaite said Drew has trouble attracting enough high-quality minority faculty willing to work at an institution with relatively limited resources and research opportunities.

“My assessment is that the applicant pool is not deep enough to get enough educators in all specialties at all times to make these programs more stable. And what we’re seeing is the result of that.”

Haughton, the former King/Drew medical director, said he believed Tuesday’s institutional review by the accrediting body is the biggest challenge facing the hospital since it was conceived after the Watts riots of 1965. At that time, a commission headed by John A. McCone, the former director of the CIA, found one of the biggest needs in the community was local access to health care. King/Drew opened its doors in 1972.

“If that hospital should suffer seriously because of this action, we’ll be back to the McCone report,” Haughton said. At that time, he said, people only got medical care when they were “$25 sick,” because that’s how much it cost to take a taxi from Watts to Los Angeles County-USC Medical Center.

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Key facts

Martin Luther King Jr./Drew Medical Center

Opened: 1972

Licensed beds: 537

Staffed beds: 233

Residents: 331

2001 Trauma visits: 2,560 (second-highest in Los Angeles County)

Race of emergency room patients: 49% Hispanic; 43% black, 3% white, 1% Asian, 4% other

2002-03 Admissions: 13,927*

2002-03 Hospital births: 807*

2002-03 Emergency room visits: 49,096*

2002-03 Outpatient visits: 206,963*

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SOURCE: Los Angeles County Department of Health Services*Estimated