For Profit Medical Schools
 
The Composite standards which have served as the source of the International Association of Medical Schools standards have little reference to for profit medical education. The Liaison Committee on Medical Education (LCME) standards state;

“IS-2. A medical school should be part of a not-for-profit university or chartered as a not-for-profit institution by the government of the jurisdiction in which it operates.” 

During the twentieth century many countries had tried government controlled central committee investment and planning policies. These not for profit enterprises were designed to remove them from competition and market forces. They were tested extensively for about 100 years. After that experience it has been painfully concluded by most observers that for profit schools, established and sustained by private investment, should be permitted. 
 
The standard cited above does not mandate exclusion of for profit schools, but it does endorse not for profit of ownership. Such endorsement is especially inappropriate in this instance because it is incorrect. The origin of the concept found in the LCME standard above may be found in a report on medical education in the United States in 1911. At the time it was published there were battle lines between unenlightened, unrestrained capitalism, communism and socialism. Following the inevitable decay of the apprentice system as a way to train doctors, small for profit medical schools proliferated. Abraham Flexner evaluated those medical schools and found most schools were very small, for profit schools that provided a poor medical education. He believed the source of the problem was that there was an inherent evil in profit. More recent analysis may be found in Kenneth M. Ludmerer’s, “Time to Heal”, Oxford University Press, 1999 and in a text edited by Barbara Barzansky and Norman Gevitz entitled, “Beyond Flexner, Medical Education in the Twentieth Century”, Glenwood Press, 1992. Suffice to say, many of today’s scholars, enlightened by the experience of the past 100 years have come to different conclusions.
 
Regardless of one’s bias for or against for profit education, the result of eliminating for profit medical education in the United States is clear. An illustration may be found in the State of California medical school data. According to the AAMC Curriculum Directory eight not for profit California medical schools (Five government owned, three privately owned) had a 1981-1982 enrollment of 4,141 students and in 2001-2002 the enrollment was 4,429 students. A seven percent increase in student population over the twenty years was entirely in the three private schools. The five government schools lost four students! But the population of California increased by fourteen percent or four million people during the same period. Today the population is estimated to be thirty six million people, while California medical schools have approximately the same student population!  

Compare the data from two small Caribbean islands, Dominica and Grenada. The combined population is approximately 190,000 people. Each has one for profit medical school that was barely starting in 1981. Today their combined medical schools enrollment exceeds that of the entire State of California. Safe to say for profit schools, serving the public market forces of supply and demand have a different investment and growth rate. See further analysis that had presented to the California Board of Medical Quality Assurance, entitled, “The System’s Broke” on this website.  

Global accreditation standards should not ignore for profit education but should establish a baseline for a quality education, regardless of the type of ownership. None of the standards used as the basis of the consolidated global standards provides standards to govern for profit schools. Thus IAOMC has developed and added a new educational standard that it will use in evaluating any for profit medical school. 
 
Every form of medical school ownership should be considered before developing standards. For profit medical schools should not be an exception...It must be conceded that there is always a risk that a, “for profit” school could compromise the quality of the education it provides to pursuit greater profits. Similarly, there may be a risk the politically driven budget process could also result in an under funded government medical school. There is also a risk that a private not for profit school may suffer from an inept and/or entrenched bureaucracy. However, when appropriate standards are in place and a transparent accreditation process verifies compliance with those standards, the public may be assured that a quality education is being provided regardless of the type of ownership.  

The existence of private for profit medical schools is not even recognized in the standards that form IAOMC composite standards. Thus no standards are directed to insuring the potential conflict between investing money to provide a quality education and providing a return to investors. IAOMC has dealt with this omission. 
 
It should also be noted that the market place works. It establishes which schools provide a quality education. Should one consider the record of for profit schools over the past thirty years they will discover, over time the poorer performing medical schools have failed. This provides a contrast to the better schools. The tuition paying students and their families have determined which schools will flourish and grow and which ones will disappear. In brief, the marketplace does works. 
 
Many of the founding members of IAOMC are for profit institutions and are fully aware of the strengths and weaknesses of different types of ownership. They are dedicated to founding and overseeing transparent accreditation by independent experts. This type of public accountability or open review cannot be found elsewhere. 
 
For reasons previously stated this Association recommends the following standard be publicly discussed and adopted at the next IAOMC meeting; 
 
“ The primary commitment of any for profit medical school must be to attempt to accept fully qualified students to become a practicing physician and then to provide a quality medical education.” 

1. The following recommended data base document questions concerning admissions acceptance are recommended. Following each question is an acceptable response is indicated. Any unacceptable answers require a written explanation that will be considered by the evaluator before the site visit. 
    
   Do shareholders influence or control the choice and/or appointment members of the admissions committee? A yes answer is unacceptable. However, a written explanation will be reviewed and considered. 
   
   How are the admission committee members’ elected or chosen? . Faculty choice by democratic means is preferred. Appointment by senior faculty is adequate. How is the Chairperson chosen? Committee member choice is preferred. Appointment by senior faculty is adequate 
   
   What is the length of term that the committee members are chosen/elected? Staggered terms are preferred. 
   
   Do teaching faculty members comprise the majority of the admissions committee members? A no answer is unacceptable. 
   Does the admissions committee: 

   • Independently establish its standards? A no answer is unacceptable If yes; detail how the committee determined its standards? 

   • Publish its standards? A no answer is unacceptable. If yes, state the standards used. 

   • Vary from its published standards? A no answer is preferred. If yes, explain the circumstance. 

   • Maintain detailed minutes? A no answer is unacceptable. If yes, provide a copy of the last years minutes. 

   • Independently establish it’s operating and decision making process? A no answer is unacceptable. If yes, detail how the committee arrived at this process. If no, how was the process determined? · Has the committee varied from its established procedures? A no answer is preferred. If yes explain. 

   • Make the final acceptance/rejection decision? If no, detail the appeal process. 

   • Accept students provisionally or conditionally? If yes, describe the categories of acceptance and the standards governing each. 

   • Independently determine the entering class size? A no answer is unacceptable. If yes, what factors determine their decision? Document their formulating and monitoring these factors. 

   • Monitor the students’ success/ failures? A no answer is unacceptable. If yes, what do they monitor? What changes have been made as a result of monitoring? · Are applicants interviewed before acceptance? A yes answer is preferred. If yes how are the interviewers chosen? 

Questions concerning providing a quality medical education are the same for all types of ownership. 

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 

This paper was presented to the Medical Board of California, Division of Licensing at its meeting January 31, 2003 in El Segundo California.

The System's Broke And Three Suggestions On Where To Begin Improving It

Introduction

Provided herein is an overview of the failing U.S. health care systems and their need of modification. Initially, the focus will be centered on the current quality of medical education that forms the foundation of our physician supply. This is followed by a review of the origins and structures of the little known, and poorly understood private institutions responsible for governing the quality and output of our medical education system. The review goes on to discuss why these controlling private institutions have not only failed to adopt to change, but also why they cannot solve even the basic causes of these existing problems. Lastly, three specific recommended solutions to the Licensure Division of the Medical Board of California are mentioned to address some of the problems of the proposed Section 1314.1.

OVERVIEW

Here are the principal facts illustrating many of the health care system's serious failures and where our present course will take us. The purpose here is to establish that the Medical Licensure Board can and must address our fundamental systemic problems. The status quo is unsustainable. Thereafter, the focus is on but one part of the problem, medical education. These facts also form the recommendations for change, which will assist in implementing proposed section 1314.1. 

COSTS

1. Out of Control 

• The Centers for Medicare & Medicaid Services (CMS) estimated that for 1999 government share of the total U.S. health spending as 45.2% ($548 billion) was directly paid. Including the indirect cost the total reported in one study was $723.8 billion or 59.8%. Between 1965 and 1999 the government share of tax-financed health expenditures rose more than 5700% while overall health costs increased 2,900%. JAMA, 3/5/03 Vol. 289, No 9 pg 1165
  

• "Health-Care Spending Rises 8.7%, Fastest Expansion in 10 Years." "Health-care spending in the U.S. soared to $1.42 trillion in 2001, as across-the-board increases fueled the fastest annual growth in a decade." "Rising health spending, coupled with the softening economy, caused health as a percentage of the GDP to swell to 14.1% in 2001 from 13.3% in the previous year." "Private health-insurance premiums rose 10.5% in 2001, as employers are starting to scale back coverage and shift more of the cost-burden onto employees." Wall Street Journal 2003

  • A Few Reasons 

    • CMS officials noted that although physician payments were cut 5.4% in 2002, lowered costs did not result in 2003. Preliminary estimates for 2004 have pegged physicians for a cut of 4.2%, as improved senior health and longevity comes at a price of more services. AMA News 4/7/03, Pg. 1

  • Discovery Enhances Care, Increases Treatment

    • · "We will discover more biology in the next 10 years than has been discovered in the last 100 years," says Dr. David Baltimore, President California Tech., Nobel Laureate, interview 3/18/02, Charlie Rose Show, Public Broadcasting System. 
      · In 2002 of the top 100 institutions receiving federal research and development expenditures were: The University of California-San Francisco, Stanford University, University of California-Los Angles, University of California-San Diego and University of Southern California totaling $1,256,000,000.00. U.S. News & World Report, 4/14/03, Pg. 76

  • The Ability to Pay

    • "The National Academy of Sciences has confirmed what most citizens already know: The nation's health care system is confronting a crisis. The cost of private health care insurance is surging upward by more than 12% a year, as patients are required to pay more out of pocket and are receiving fewer benefits. More than 41 million Americans lack health insurance. Malpractice premiums are soaring and quality problems are rampant. Indeed tens of thousands of patients die each year as a result of medical errors. These and other disturbing trends have only been getting worse, with no clear solution in sight." N.Y. Times, 11/22/02, A26

    • "Medicare Plan B Premiums to Rise 12.4% Next Year." Recently, Medicare's trustees reported that Medicare will run out of funds by 2013 -- four years earlier than predicted last year." Wall Street Journal, 3/27/03

    • "Indeed medical bills are now the second biggest cause of personal bankruptcies," according to a study by Elizabeth Warren, who heads Harvard University's Consumer Bankruptcy Project. Wall Street Journal 3/13/2002 pg b1

  • Where Are We Going?

    • "Representative Jim McCreary, Republican of Louisiana, said the surge in health spending was alarming. 'If we don't find a way to reduce the rate of increase in health costs,' Mr. McCreary said, 'we'll end up with a government-controlled health care system in which we control costs by rationing'." N.Y. Times, 1/7/03 

    • Health-care spending in the U.S. is expected to double within a decade -- from $1.3 trillion in 2000 to $2.6 trillion in 2010. Wall Street Journal, 11/17/2002, Pg. B2 

    Summary: Patients and their governments have nearly reached their limit in their ability to pay ever growing health care costs. A review of these increases over a period of years demonstrates the projections for the future. It is time to begin to question. It is time for a fundamental review and analysis. It is time for REAL change.

     

• Painful Cuts 

  • States Respond

    • "Grim Choices Face States in Cutting Medicaid to Balance Budgets." State legislatures look for ways to cut benefits and reduce payments to hospitals, nursing homes and pharmacies. Medicaid spending grew 11% last year, prescription drugs is rising at a rate of more than 20%. Medicaid has had a catastrophic increase in health care costs. The need for Medicaid goes up just as the states' ability to pay goes down. Medicaid provides health insurance for one-fifth of all children and is the largest source of federal grants to states, accounting for nearly one-fifth of state budgets. NY Times 1/14/02 

    • "Rather than ration people, ration services." States Look to Ration Health Care Wall Street Journal 11/14/2001

    • "Within the System of No-System, "an ER doc wrote of hospital conditions for the uninsured. "The safety net does not provide a soft landing the failures are not random 'accidents' from a missing net. This is a system of exclusion that denies care to the uninsured. It is a netherworld of closed doors and shrinking services. The paradox of the system of no-system is that it is becoming increasingly systemized." "*** Clinicians yield principals to realities." "What is practiced is the art of the minimal." JAMA11/28/01 Vol. 286, No 20

    • "Employers Group to Unveil Plan to Reduce Medical Errors." Ninety-six of the nations largest employers have formed the Leapfrog Group to reduce medical errors to save lives and money. "Leapfrog was formed in 2000 in response to a disturbing government report which found that medical mistakes result in between 44,000 and 98,000 deaths a year and produce more than $20 billion in added costs." "The theory is that better care, not cheaper care, will save money in the long run." Wall Street Journal, 11/17/2002, Pg. B2

    Summary: The limited public and private budgets will be balanced. Medical licensing boards will govern licensing and oversee appropriate administration of medical education and physicians delivery of services. Thus, an adequate number of well-trained, licensed physicians able to treat the public are a Board concern.

Medical Education - One of the Problems 

• Background 

  • A Flawed Blueprint 
    Abraham Flexner laid down the blueprint for medical education in a 1910 report to the Carnegie Foundation. During his times the communist philosophy of Marx and Engle were calling for the complete elimination of the marketplace. The belief in 1910 was that for-profit education was but a form of exploitative capitalism. It would deprive medical students of an adequate education to permit owners to gain greater profits. Flexner was a product of his times. After he saw inferior for-profit medical schools, he endorsed and expressed this belief. Others chose a different path, believing that government oversight and/or the marketplace could modify exploitative behavior or excessive pursuit of profit. The experience of the past century has resolved the issues surrounding competition, profit and governing business behavior. The central planning committees' elimination of profit and control of a nation's physicians supply has proven to be flawed. Flexner's conclusion was wrong and so far, history's lessons are lost on some of Flexner's followers today. These individuals continue to call for controlling the supply of the number of doctors and the elimination of for-profit education. Recent experience has shown, that when a marketplace is free, the good for-profit medical schools will continue to prosper and flourish while the bad ones will be forced to close. The marketplace works.

  • The Fox Minds the Chicken Coop 
    Every state medical licensure board requires U.S. graduate applicants to have attended an accredited medical school. This has allowed an accrediting body to determine the number of U.S. medical schools and students that will be permitted to learn medicine. Responsibility for physician supply rests with the Liaison Committee on Medical Education (LCME), which is jointly owned and operated by two membership associations, the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC). The AMA is Chair one year and the AAMC is the next. 
    
    Each association maintains separate staff members, files and office space. One is in the AMA building in Chicago and the other in the AAMC building in Washington, DC. These few staff members are employees of the AMA and the AAMC who also work on the LCME. Being a private Committee, it may establish its own standards, review schools as it chooses, demand such information as it feels relevant, keep its operations and records secret and even restrict its review to the US and Canada. After the medical school completes a lengthy form, the committee conducts its regular accreditation medical school review every seven years. Each association selects from its members the names of those who will be chosen to visit a medical school for a few days every seven years. Schools may choose to seek accreditation from the LCME, a medical school program-accrediting agency recognized by the U.S. Department of Education (DOE). This set up permits federally guaranteed student loans, which are essential to medical students. Practically then, U.S. medical schools must seek accreditation of their programs by the LCME. For the DOE to recognize an accrediting agency it must either be "separate and independent" of its sponsoring organizations or obtain a waiver of the "separate and independent requirement." The AMA and AAMC sought and obtained a waiver. The AMA, AAMC, and LCME all deny using the accrediting process to control the number of physicians.
    The LCME standards are contained in a thin pamphlet entitled, "Functions and Structures of a Medical School." These principals are broadly stated; their meaning rests on the subjective judgments of different staff members, site visitors and the Committee members. Individual opinions differ. St. George's University considered an application to the LCME and attempted to learn how the broad standards were applied. A copy of that correspondence is attached. 
    Would it be lawful for the California State government to deal with an applicant in this way? How can it delegate, authorize and/or recognize a private committee to do the things that it could/would not do?

Blind Reliance on the LCME 

• The "LCME Guarantee?" 
  At the Division of Licensure meeting on January 31, 2003, Dr. James Thompson, Chief Executive Officer and Executive Vice President of the Federation of State Medical Boards, addressed the need for CSE examination. He said, "There has been a suggestion the LCME has education requirements and impose these so that medical schools can progress students. Well, I spent nearly five years on the LCME when I was Dean at Wake Forest. The LCME, and in fact the Secretariats of the LCME, have attested to this publicly -- that the LCME is not capable of doing this, the LCME simply accredits programs. They do not attest to the fact that every single student has passed minimal standards for clinical and communication skills." He continues," ***I can assure you there is widespread variability in how much of this has been done at different medical schools." "Twenty percent of our medical students who had completed their primary rotations in medicine, surgery, Ob-gyn, psych and pediatrics state they have been observed by faculty either zero, one or two times. There is a wide variability among schools." A transcription of Official Tape 
  
  The LCME does not require a standardized curriculum; individual schools are free to develop their own curriculum. In the preface to the Curriculum Directory of American Medical Schools the former President of the American Association of Medical Schools referred to the schools curriculum diversity as a "strength." Speaking more broadly, the present President to the Association testified before the VA Capital Assets Realignment for Enhanced Services Commission on April 2, 2003, and said, "There is a common saying amongst medical schools that if you've seen one medical school, you've seen one medical school."
  
  "Wide variation in how doctors treat patients with similar ailments is epidemic in American medicine, reflecting a large gap between medical knowledge and clinical practice. "Doctors are creatures of their training, and typically don't learn how to use care-management techniques in medical school." Wall Street Journal, 2/4/03, pg. D5
  
  An unpublished 1986 statistical review of medical malpractice suits brought in Queens County, New York during 1982, 1983 and 1984, reported the numbers of physicians by: sex, the state or country of undergraduate medical education, medical school, the year of licensure and their medical specialty. This study demonstrated there were significant statistical malpractice differences in every category -- noting there were the remarkable differences between U.S medical schools. Medical Malpractice, A Statistical Review, 3/12/86, by Bernard Ferguson. (Copy forwarded to Neal D. Kohatsu, M.D., M.P.H.)
  
  Summary: Blind reliance on the LCME without Board oversight is an error. A State Medical Licensure Board should routinely have copies of the documents where the LCME has reached its judgments to determine concurrence. . This resource library should be available to scholars, to any Board member who wishes to review the documents or to any expert or Committee reporting to the Board. It might be reasonably anticipated that most medical schools would willingly participate in providing their schools' reports. 

The Legacy of Blind Reliance - How The System Fails 

• The Record
  The United States is the most affluent, powerful nation the world has ever known. The educational facilities here are acknowledged as being among the finest in the world. "U.S. system helps educate the world, yet fails at home. More than 50% of the degrees in engineering are granted to foreign nationals." USA Today, 11/8/2001 pg. 15a. 
  
  More than one half of a million foreign students travel to the U.S. to attend our colleges and universities; however, medical education is an exception. Of the 125 schools allowed to teach medicine, there are only 50 private schools. Not only are there almost no foreign students in our medical schools, there are also not enough openings for our own qualified citizen students to learn medicine! Six states don't even have a single allopathic school of medicine. Fully qualified American students must travel abroad in large numbers to have the opportunity to study medicine. They are, in effect, exiled by the system in their own country! How could this have happened in the land of opportunity? The United States has even become dependent on citizens of foreign countries. It is these medical schools that supply physicians to make up for our country's shortages. The major suppliers are India, Pakistan and China. AMA data tells us that the Philippines alone has provided over 14,000 doctors up to 1998. 

• Too Few Doctors
  "Survey Forecasts Doctor Shortage. A survey by the San Diego County Medical Society found that 35% of area doctors plan to stop practicing in the next three to five years. A year ago, a study in Health Affairs projected a nationwide deficit of 200,000 physicians by 2020. "San Diego and other major counties in California are firing the warning shot to the nation," said Rod Munoz, society president. "The American health care system is on the verge of collapse." AMA News 2/3/03

• School's Desperate Search for Revenue

  • To establish a claim under the False Claim Act it must be established that Washington University knowingly submitted a false or fraudulent claim to the federal government. The complaint is sufficient. U.S. ex rel. Schuhardt v. Washington University, 2002WL 31161905

  • "Johns Hopkins U. Agrees To Pay Government $800,000 Following Medicare Audit," The Chronicle of Higher Education Today's News, 2/17/03 (see also U. of California will repay $22.5 Million, 2/16/2001, U. of Chicago to repay $10.9 million, U. of Texas to repay $17 million, U. of Virginia to repay $8.6 million, Thomas Jefferson U. to repay $12 million, and Penn. to repay $30 million.) 

  • "Supreme Court backs U.S. in Dispute Over Payments to Teaching Hospitals"
    The Chronicle of Higher Education, 3/6/1998

• Medical Student Debt

  • Student tuition and fees are but 3.7% of medical schools revenue. AAMC Data Book: Statistical Information Related to Medical Schools and Teaching Hospitals 1/01, Pg. 40

  • On average, medical-school graduates now owe $115,000. In the past decade the number of residents who chose to become general practitioners has decreased from 36% to 14% as financial considerations have played an increasing role on training subspecialties. The most competitive fields also are the highest paying. The debt for graduating medical students has risen 211% from 1981 to 2000. A recent study in the Annals of Internal Medicine shows a direct link between increasing resident debt and increasing cynicism and depression. Debt has also caused the number of medical school applicants to decrease for in the past six years, the number has fallen from its peak of 47,000 in 1996, to the current level of 34,000. The Chronicle of Higher Education 2/14/03 PG B16.

• Quality of Training

  • "Clinical Directors said managed care was having a negative effect on faculty participation in teaching, faculty availability for education administration, directors morale, amount of director's clinical responsibility and volunteer faculty participation. If doctors need to see patients every 10 minutes instead of every 30 minutes, the perception is they don't have as much time to discuss with students that [patient] encounter." We're all focused on money, and what gets lost is the student. When education suffers, your going to graduate people who are less qualified," "Medical School Faculty Struggle to Find Time for Students and Research." AMA News, 12/9/02, Pg. 16

• Need for Change
  The Institute of Medicine of the National Academies began a quality review in 1996. It has documented the serious and pervasive nature of the quality problem. "The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering." It determined the system must be "radically transformed in order to close the chasm that exists between what we know to be good quality care, and what actually exists in practice." It also says that reform around the margins would be inadequate "just as the health system must be transformed in order to advance quality, so must health professions education." (Emphasis added.) Health Professions Education: A Bridge to Quality, Institute of Medicine, The National Academies Press, Foreword, March 2003

Secrecy Has Not Served The Public Interest 

• The Solution, Accountability/ Openness 
  Over the years our ever-evolving democracy continues to refine the governance of our society. The debate on the advantages/disadvantages of policies to open governance has been resolved. Every state government has added Notice of Meeting and Freedom of Information laws that guarantee public rights to listen to debate that forms policies, while also having access to background information on the policies that affect their lives. Taxpayers, consumers and even some interest groups welcome the benefits from this innovation. Today, in California the responsibility for medical school approval is being delegated to a private accrediting organization, which reaches its decisions in secrecy and will not share the basis of its determinations. This is the delegation of a public responsibility to an association that has no public accountability - even to the California State Board of Medicine. The AMA/AAMC's dedications are to serve its members. When the public interest varies with that of the association, it may elect to serve its members interest to the detriment of the public interest. When it operates in secrecy, the public will never know when it has chosen its own self-interest first.

• Flexner Report on Openness
  In the almost one hundred years since his report, we can now judge with the benefit of hindsight which of his conclusions were correct and which were incorrect. Earlier discussion dealt with his error of rejecting for-profit education and noted his followers today have not learned from the lessons of history. However, Flexner had correctly embraced the concept of medical school openness and/or public accountability. His message is especially true today.
  "A considerable number of colleges and universities take the unfortunate position that they are private institutions and that the public is entitled to only such knowledge of their operations as they chose to communicate. In the case of many medical schools the aversion to publicity is quite as marked as it is reputed to be the case of certain large industrial trusts. ******* All colleges and universities, whether supported by taxation or by private endowment, are in truth, public service corporations, and the public is entitled to know the facts concerning their administration and development, whether those facts pertain to the financial or to the educational side. ****And furthermore, that only by such publicity can the true interest of education and of the universities themselves be sub served. In such a reasonable publicity lies the hope for progress in medical education." (Emphasis added) MEDICAL EDUCATION IN THE UNITED STATES AND CANADA, A report to the Carnegie Foundation for the Advancement of Teaching by Abraham Flexner, with an introduction by Henry S. Pritchett, President of the Foundation. Bulletin Number Four (1910), Pg. IX

Recommendations
"Even the longest journey begins with a single step"

• Assemble a bank of LCME approved medical school documents that \relate to their LCME approval

  • The present medical school evaluation systems, governed by private institutions operating in secrecy, have clearly failed. Today's ever-accelerating dynamic of change in society has exceeded their capacity to appropriately adopt and/or modify.
    
    California's Business and Professions Code Section 2084 states "Medical schools accredited by a national accrediting agency approved by the Division and recognized by the United States Department of Education shall be deemed approved by the Division under this section. Nothing in this chapter prohibits the division from considering the quality of the resident courses of professional instruction required for certification as a physician and surgeon." 
    
    This section does not direct unquestioned approval of whatever the LCME should decide in perpetuity. Indeed, the LCME changed its standards since the legislature that authorized recognition. The legislature could not have accepted the present standards. Further, this delegation of recognition by the U.S. Department of Education first requires approval by the Department. Thus, the Division may withdraw recognition at any time. Indeed the record presented here raises serious questions concerning the effectiveness of LCME governance. The delegation of the accrediting function to a private entity, foreign to the state of California, in perpetuity, conducted in secrecy without oversight or accountability also raises serious legal questions. Quite simply, the public is not served.
    
    The regulation stated in Title 16, Article 4. Section 1314, "Approved Schools" states: "(a) Those medical schools accredited by the Liaison Committee on Medical Education of the Coordinating Council on Medical Education or the Council on Medical Education of the Canadian Medical Association shall be deemed to be approved by the division for the giving of professional instruction in medicine."
    
    Clearly, as the Department may decertify the LCME then the Department is not barred from review of the basis of LCME decisions. The very purpose of proposed section 1314.1 is to establish standards to be used to determine an International Medical Schools equivalency to approved, LCME accredited schools. However, LCME standards are extremely broad. Their meaning may only be found in how they have been interpreted and applied. The LCME maintains secrecy, claiming that this is done for the benefit of medical schools. However, 75 medical schools are public. The taxpayers pay their expenses. Their records cannot --or should not -- be secret from their taxpayers. Public schools might be expected to cooperate with any staff inquiry for a copy of their LCME documents. This would be especially true of the California medical schools but staff may lack the time and possibly the expertise to analyze and interpret massive amounts of new information. However, this information bank would be available to researchers, interested Board members, legislative committees, foreign schools being held to subjective standards and sections 2089 and 2089.5. The mystery of what the standards mean should end!

• Require an annual report providing significant output measures from all approved domestic and foreign medical schools.
  
  In current times the LCME's seven-year cycle does not provide public assurance of the medical education being offered. There are but few output measures that will demonstrate to the Board if there is a need for further inquiry. . The practical way to deal with this would be to monitor but a few outcome results that provide real insight into the quality of the educational program.
  
  The LCME provides an annual report in the educational issue of JAMA. The reason this is insufficient is that it provides averages for all U.S. schools. These averages mask the poorer performers and provide no assurance about individual schools.
  
  Some of the information requested here is provided on an annual basis to the U.S. News & World Report and is published in a special Edition entitled, "America's Best Graduate Schools." This edition lacks reports on some schools and some of the significant information requested below is not included. Therefore, I am recommending the following:
  
  Medical School Annual Report 
  
  Provide information for the current year and the two previous years.
  
  Quality of Applicant Pool
  1. Number of applicants
  2. Acceptance rate
  3. Number of matriculating students
  4. Matriculating student average MCAT scores by subject
  5. Matriculating student average GPA
  6. Applicant undergraduate and graduate degrees 
  
  Quality of Student body
  7. Attrition rate by reason
  8. Enrollment by year
  9. Diversity: men, women, and minorities by state or country
  
  Quality of Training Program
  10. Full time faculty by department 
  11. Curriculum length by year, hours 
  12. Length of required clerkships
  13. Clinical sites with/without graduate training programs
  14. Patient - bed to student ratio
  15. Resident to student ratio 
  16. Step 1, 2, 3, & CSA average pass rates, range of scores
  17. Percent completing program in four years or less
  18. Five years or more (reasons for the delay) 
  19. Match rate
  20. Report on graduates' evaluation by residency Directors of Medical education 

• Authorize an advisory committee comprised of foreign medical schools approved to conduct clinical training in California.
  This committee will not be the "fox that minds the chicken coop" as it would be advisory only. The licensure Division may accept and/or reject, in whole or in part the committees' recommendations. Further, the open meetings act and other California laws of disclosure will govern it. Its recommendations will be public record. Be assured, the advice provided will be without expense to the State. Each school is proud to be approved by the State and its representative will be interested in being certain any new school has equal standards. It should be noted that St. George's University, Ross University and American University of the Caribbean collectively have a student body of more than 4,000 medical students. Each has been in operation for approximately 25 years and will bring to the committee a level of expertise in medical education.