21 October 2011

Bitch-Slapping Yocasta Brugal, The SJBullshitters And The LCME

Here's what I said about the San Juan Bautista School of Medicine losing its accreditation on October 3rd: that it was the result of negligence and incompetence; furthermore, that Yocasta Brugal and the School's administration was lying.

As I posted yesterday: I was fucking right. On all counts. And more.

I could be pedantic and insufferable and even more condescending than I have been with these idiots by defining the simple terms I used. So I will:

            negligence  Noun: (1) Failure to take proper care in doing something. (2) Failure to use reasonable care, resulting in damage or injury to another.

            incompetence  Noun: (1) not possessing the necessary ability, skill, etc. to do or carry out a task; incapable. (2) marked by lack of ability, skill, etc.

            lie  Noun:  (1) a false statement made with deliberate intent to deceive; an intentional untruth; a falsehood. (2) something intended or serving to convey a false impression; imposture. (3) an inaccurate or false statement. 

On October12th, the SJBullshitters filed a lawsuit seeking injunctive relief from the loss of accreditation by the Liaison Committee on Medical Education (LCME; due for their own bitch-slap further ahead). As reported by Me in News Is My Business, Judge Gustavo Gelpi of the U.S. District Court in San Juan postponed the decision until October 31st,directing both parties (School and LCME) to invite amicus curiae (friends of the court) to provide briefs concerning the potential impact of granting or denying the injunctive relief on health care and medical education.

That decision, made public on the 20th, provided access to documents related to the case. Although some 20 documents were filed by the LCME in its plea for rejection of the injunctive relief, only two are needed to prove Me right on all counts. The first is listed as Case 3:11-cv-02014-GAG, Document 33, with filename15913217945.pdf, the 44-page LCME Response. I'll quote it as "LR" with the case page number included.

The second is Case3:11-cv-02014-GAG, Document 33-20, with filename 15913217965.pdf, a 12-page document titled "Exhibit Q." I'll quote it as "EQ" with case page number.

Here We go.

The LCME stated in its October 3rd letter to Yocasta Brugal MenDacious that the withdrawal of accreditation was due to "inadequate clinical resources." 

The School, in its public and very limited utterings about this devastating decision, said it was "shocked" at this result. Waffling and wasting time, their petition for injunctive relief, though, was based on the following three points (LR p.28):

            (1) That the LCME failed to provide SJB adequate notice and opportunity to be heard concerning the specific accreditation standards cited by the LCME in withdrawing accreditation;
            (2) That the SJB should have been afforded an opportunity to cure any deficiencies prior to withdrawal of its accreditation; and
            (3) That the LCME denied SJB its “fundamental right” to an unbiased decision maker by appointing a current LCME member to the independent appeals panel.

Point 1A: What accreditation standards, besides "inadequate clinical resources," were used to come to the accreditation withdrawal decision?

Quoting Me, concerning the Survey Report (Exhibit L in the case; not in hand...yet) and the SJBullshitter's refusal to make it public:

"The Report has not been released--and will not be for now--because the Report proves that the SJB was most likely negligent and possibly incompetent in dealing with the LCME's findings, thus leading to the sudden fulminating loss of accreditation."

In a nutshell, the Report found deficiencies in USMLE results (licensing exams), the SJB's income profile and yes, "inadequate medical resources," with far-reaching implications.

About the USMLE results, the LCME found that "Between the 2008 and 2010 academic years, the first-time pass rate of SJB students on Step Two of the United States Medical Licensure Examination (USMLE) dropped from 94% to 71%, whereas the national pass rate for that period was over 95%. The first-time pass rate of SJB’s students on Step One declined from 33% to 32% over the same period, as compared to the national average exceeding 90%." (LR, p.2)

Furthermore, "(T)he LCME cited the precipitous decline in percentage of students who passed Step Two of the USMLE, which tests for clinical knowledge and skills – from 94% in 2008 to just 71% in 2010, compared to the national average of 95% and above throughout the time period." (LR, p.20)

More data about these deficiencies are found in EQ page 9, with the LCME citing the "downward trend" as a sign of a "precipitous" drop in education quality. In brief, the SJB was not preparing its students to be anywhere near passing range on the very basic licensing exams all U.S.-accredited medical students must pass. The School knew this, for medical schools are judged on this very aspect (rightly or wrongly, it's part of the rules of the game) and follow-ups in 2008 and 2009 by the LCME made this a key concern. To pretend otherwise, as Yocasta Brugal MenDacious and the SJBullshitters have done, is ludicrous. Or stupid. Especially when the published LCME's Rules of Procedures, that the SJBullshitters knew about since at least 2007, (see below) state: 

[R]apid and precipitous deterioration in the quality of an educational program may be sufficient grounds for withdrawal of accreditation, whether or not a limited visit or probationary period had preceded the decision to withdraw accreditation. (Quoted in LR p.35 & EQ p.2).

The SJBullshitters lied.


The SJB's income profile was also a major concern for the LCME. As noted in EQ page 8, the average private medical school relies about 4% on tuition for its operational budgets. The SJB was deemed to have a reliance of 70%. From EQ page 9:

Comments: As noted, the number of enrolled students (and visiting students) put pressure on the already stressed clinical resources of the institution. The medical school is heavily dependent on tuition as a revenue source. Data provided by the institution (pages 18-21) showed very limited support from grants and contracts (less than $100,000), no revenue from a practice plan, and no revenue from gifts and endowments. Visiting students contributed significant revenue ($172,000 in 2010-2011, as stated in the survey report).

Those additional foreign students were also a finding against the SJB by the LCME, as admitting them exceeded a 10% increase in the number of 3rd-year students, a change the SJB was supposed to notify the LCME about and didn't. (LR p.3 & p.18). The SJBullshitters claimed that they may have "misinterpreted" the rule, saying that the 10%+ increase didn't happen in one semester, but over an academic year. 

But. The whole core of the LCME's case against the SJB was its very limited clinical resources. As We shall see, the SJB knew it was on a razor's edge with these critical educational resources. How bad was it? One example suffices, from LR page 2:

The lack of such resources was dramatic. Thus, for example, a student at SJB can be expected to have on average no more than 6 surgical experiences during a 12-week surgical rotation – as opposed to an average of 15-75 experiences during such rotations at other LCME-accredited schools.

SJB students were getting 60-1,200% less experience than the average medical student elsewhere, and yet the SJB went ahead and placed an even greater load upon their very limited clinical resources, to the extent of denying their own students access to clerkships and experience in order to take in monies from outsiders. In the words of the LCME (LR p.19):

Specifically, the LCME found that the addition of eight students in the third year class reflected a violation of ER-3 in that “[p]ressure for institutional self-financing [had] compromise[d] the educational mission of the medical education program [and] cause[d] it to enroll more medical students than its total resources can accommodate.

The SJBullshitters were negligent.


Now for the big tumor.  The San Juan Bautista Hospital is affiliated with the SJBSOM and serves as its primary clinical resource, but it does not own or operate it as such (Exhibit N, p.3; in hand.). The SJB likes to boast that it is the only medical school in Puerto Rico with such an arrangement. The LCME's increased interest in the Hospital and its effect on the School began in October 2010, as indicated in LR page 14:

In October of 2010, the LCME learned that the Puerto Rico Electric Power Authority had threatened to shut off power to the Medical Center because the utility claimed that the Medical Center owed more than $21 million in unpaid electric power bills.

The LCME requested a report on this situation; the SJB submitted its report on December 13, 2010. (LR p.14)

As the electric bill and other problems (cash flow, labor, services, safety) piled up in the Hospital, the SJBullshitters decided to "protect" the Hospital by declaring bankruptcy. Even though the Hospital was and is the key component in the School's clinical education services, here's what happened:

On March 24, 2011, the LCME learned from press reports that the Medical Center had filed for bankruptcy on March 18, 2011. (LR p.14) [Emphasis Mine].

Although nearly a week had elapsed since the filing, the LCME received no notice from SJB of the bankruptcy of its principal teaching hospital. (LR p.15) [Emphasis Mine.]

            negligence  Noun: (1) failure to take proper care in doing something.
            incompetence  Noun: (1) not possessing the necessary ability, skill, etc. to do or carry out a task; incapable.
            lie  Noun: (2) something intended or serving to convey a false impression; imposture. In this case, lying by omission.

How crucial was the Hospital? From LR page 17:

The decline in occupancy was most dramatic in the areas of pediatrics and surgery, for which SJB relies on the Medical Center to provide “almost all of the pediatric experience and approximately half of the surgical experience” for its students.

Even if SJB students had participated in each of the 211 surgeries that took place, students would have had, on average, just six surgical experiences during their rotation at the Medical Center. Id. That figure is vastly below the 15 to 75 surgical experiences per rotation that medical students have, on average, at other LCME-accredited schools. Id. Likewise, it would appear that, on average, each SJB student on the inpatient pediatric rotation would have available approximately 2 to 3 patients – while students at other LCME-accredited schools would be able to select from 12 to 18 active pediatric cases and be the primary care-giver to 3 to 6 hospitalized children at any given time.

From another part of LR, page 25:

Moreover, even these dismal figures fail to account for the fact that SJB students had to share the School’s scant clinical resources with 7 to 23 visiting students who paid the School to join rotations.

In short, the SJBullshitters played fast and loose with what amounted to at least 40-45% of their clinical education resources when they had no room to spare. They were trying to cover a king-sized bed with barely queen-sized sheets--and then they cut the sheets almost in half.

And how do these findings tie together: The LCME explains, LR page 8:

A medical school whose clinical program offers too few patient encounters or too few teaching physicians (ER-6), because it has admitted too many students (ER-1) due to pressure to finance the school through tuition payments (ER-3), will leave its students unskilled in the practice of medicine and poorly prepared to succeed on the USMLE (ED-11 and ED-15).

Too few patient encounters, too few teaching physicians, over-reliance on tuition payments leading to taking in "outside" students for cash flow, thus reducing patient encounters and experiences for all students resulting in decreased pass rates on the USMLEs. The whole SJBullshitters fiasco wrapped in a neat shit taco shoved down their students' throats.


Point 1B: How much notice, if any, was provided by the LCME to the SJB?

I'll cut to the chase. From LR page 2:

SJB was given a fair opportunity to set forth its position. The initial decision to withdraw accreditation – based on the facts set forth in paragraphs 2-4 and many others – was conveyed to SJB by letter of June 13, 2011. [Emphasis Mine.]

June. 13th.

While some 250+ students were already enrolled. While a new class of first-year students were being wooed into the SJBullshitters Lounge. While the whole fucking ball of fetid earwax known as the administration and Trustees of the San Juan Bautista School of Medicine fiddled and faddled, the SJBullshitters were aware--at every moment for almost four fucking months--that their accreditation was for all intents and purposes, gone. And they didn't day a fucking word about it.

But Yocasta Brugal MenDacious and the SJBullshitters cried--literally--that this was simply unbelievable. From page 3 of the LR, proof that they lied...brazenly:

As part of its accreditation, the President and Dean of SJB, Yocasta Brugal Mena, M.D., signed a Letter Agreement with LCME on June 15, 2007 expressly agreeing as follows: “I further acknowledge and expressly agree that the LCME may revoke or withdraw the program’s accreditation, place the program on probation, or take any other action deemed appropriate by the LCME, at any time, if the LCME continues to have strong concerns regarding the program’s ability to comply with LCME accreditation standards, or determines that the program is not in full compliance with the terms and conditions of this letter.”  In other words, SJB explicitly consented to the withdrawal of its accreditation “at any time” if “LCME continues to have strong concerns regarding [SJB’s] ability to comply with LCME accreditation standards. [Emphasis Mine.]


And furthermore, from the same Letter Agreement, signed by Brugal and quoted in LR page 12:

Notwithstanding anything to the contrary that may be stated in the LCME’s published materials, including but not limited to its policy document Rules of Procedure, I agree that the above terms and conditions are acceptable and enforceable. I further acknowledge and expressly agree that the LCME may revoke or withdraw the program’s accreditation, place the program on probation, or take any other action deemed appropriate by the LCME, at any time, if the LCME continues to have strong concerns regarding the program’s ability to comply with LCME accreditation standards, or determines that the program is not in full compliance with the terms and conditions of this letter. [Emphasis Mine].

Yocasta Brugal MenDacious signed that letter, almost four years to the day before the loss of accreditation. Could she have forgotten about it? Yes, if she was mentally incompetent, an alcoholic, drug abuser, severely-concussed, disease-addled, amnesiac, senile or a willfully stupid dunce. If she was any of those, then what was she doing running a medical school? If she isn't any of these, and simply forgot, then she is demonstrably incompetent and the SJBullshitters around her equally so, and negligent as well. And if Yocasta Brugal MenDacious didn't forget this Letter Agreement, then her saying she was "shocked" at the decision is a fucking barefaced lie. The only way she could be "shocked" is if her grasp of reality is so tenuous as to be practically non-existent...in which case, she should have resigned or been kicked out long ago.

The Letter Agreement also contains an additional salient indication fully applicable to this situation (LR p.13):

Accreditation is awarded to the program of medical education based on a judgment of appropriate balance between student enrollment and the total resources of the institution, including faculty, physical facilities, and the            operating budget. If there are plans to significantly modify the educational program, or if there is to be a substantial change in student enrollment or in the resources of the institution so that the balance is distorted, the LCME expects to receive prior notice of the proposed change. Substantial changes may lead to re-evaluation of the program's accreditation by the LCME. [Emphasis Mine].

Now why is all this so significant? Well, for one, the SJBSOM's accreditation was not granted outright, but on appeal (LR p.12). The LCME's decision was overturned by an Appeals Panel, but the situation was so borderline, the LCME placed a restriction of only four years on the term of accreditation and presented the Letter Agreement to Yocasta Brugal MenDacious. The ground rules were set then, accreditation was always under review, but more so in 2011 (when the original term was close to expiring) and the SJBullshitters failed miserably to live up to the required standards.

As the LCME states (LR p.27):

Thus, by its own admission, SJB knew that it remained under close scrutiny and that its accreditation could be withdrawn “at any time,” including as a result of the April 2011 site visit. If SJB believed otherwise, the fault lies with it, not the LCME.


As for Points 2 and 3 of the SJB's injunctive relief defense, Let's dismiss them quickly, shall We?

Point 2: That the SJB needed time to correct the deficiencies before the withdrawal of accreditation. Simple question: what the fuck were the last four years for? Rehearsal? From June 15th, 2007, the SJB was put on notice and acknowledged such notice, that it was being judged continuously. Toss the Hospital you rely on for clinical resources into bankruptcy, strain those same limited resources in a rush for cash (and parenthetically: Why doesn't the SJB get as much federal funds, or any kind of funds, as other private medical schools? Hmm?), thus undermining the students you are supposed to serve and after screwing up a 30-year march to accreditation in 4 years, you want more fucking time?! For what? Your Swiss bank retirement accounts? Just say you don't have any: We'll """""believe""""" you.

Point 3: That the decision was biased against the SJB because there was a current LCME member to the independent appeals panel. First of all, the three-person panel voted unanimously to uphold the withdrawal of accreditation. So one vote didn't matter at all (simple majority was enough.) The person in question, Linda Golodner, was the public member of the Appeals Panel and had no prior connection to the Review, the Survey Report or the SJB in any way (LR p.37). The LCME's Procedures do not forbid her participation on the panel (LR p.38). There was no possible conflict of interest (LR p.39) for she also was only able to base her decision on the information presented at the appeal, i.e., she had no prior knowledge of the SJB's situation (LR p.37).

If anything, this made Ms. Golodner the truest acid test of whether the LCME proved its case or the SJB did, based solely on the merits of the information presented. How this person could be deemed biased against the SJB would have to include the other two Panel members as well.

More SJBullshit.

There's plenty more to dissect, but the overall proof is overwhelming: I was fucking right. Yocasta Brugal MenDacious and the SJBullshitters Horde lied to the students and employees, were negligent in their duties and responsibilities to meet the LCME's standards and acted with rampant incompetence in ways that have been shown and in many ways that will be revealed (financial malfeasance, anyone?)

But.

The LCME stated, in public and in private communication with the SJB students, that their role also incudes protecting them. Here is their version of this responsibility, from LR page 43, where they ask Judge Gelpi to uphold their withdrawal of accreditation and deny the SJB injunctive relief from that decision:

"Even if SJB and its students have been harmed to some degree by the loss of accreditation, the balance – as Judge Garcia Gregory rightly recognized – weighs in favor of the accreditation organization and the public interest."
  

This self-serving smarmy mouth-fart makes the LCME a hypocritical bag of horseshit. They bring to mind the vile doublespeak exemplified by "We had to destroy the village in order to save it." 

Did the SJB deserve to have its accreditation yanked? Certainly. But did the LCME properly fulfill its role as "protector of students" by not forcing the SJB to announce what was going on, or by not providing some sort of warning system to alert students that their time, money, effort and talent could be shat upon by its own decision? Fuck no, they didn't.

As a good friend pointed out: maybe not hypocritical...maybe disingenuous. Okay, Let's try that:

            disingenuous  Adjective: Not candid or sincere, typically by pretending that one knows less about something than one really does. Synonyms: insincere - false - devious - hollow-hearted

Ah, Good Friend, good call. The LCME was not candid, pretended to know less than what it knew to avoid upholding a reasonable interpretation of their self-stated responsibility to the students. Fuck the LCME as well, then. For after all, they seem to have forgotten the very basis of the physician's role: First do no harm.



The Jenius Has Spoken.

6 comments:

Anonymous said...

You are totally right on the money about the LCME's obligation to the students, I would tell the students legal reps to stress that.

Gil C. Schmidt said...

Thanks for reading all the way to the end. I have been stressing it, indirectly, through the students. Just as I'm suggesting the current SJB defense have a plan to be given a provisional accreditation through May 2012, provided the current administration is dumped in favor of a multi-agency monitoring Board (Health, Education, Justice, Medical Association) charged with addressing the clinical rotations and income issues as top priorities. I don't see the SJBullshitters staying in their positions and the School staying open past June 2012. Brugal and the rest of the lying herd had long overstayed their welcome.

Anonymous said...

Myriam Ramos and Yocasta Brugal, should be the principal defendants in the lawsuit.

Gil C. Schmidt said...

I agree. They should lead the parade to punishment. But the parade is L(CME)ong.

Anonymous said...

Absolutely, the whole steering committee for preparation for the LCME visit had to know as of at least June 13, 2010:

Alvaro Perez
Marta Garcia
Shirley Valentin
Sandra Chinapen
ALL of the DEANS

and likely more characters..

Gil C. Schmidt said...

Reply in post of 23 October. Thank you.