Passport Medicine: Five Tips from The Bakersfield Californian’s Foreign Doctor Series

The Bakersfield Californian recently took on one of the most ambitious health care quality projects I have seen attempted by an outlet outside of the really big markets. One reporter, Kellie Schmitt, wanted to answer two questions: whether most of the doctors in Kern County were from another country and whether that mattered. Schmitt did the project – Importing Doctors -- as part of her California Endowment Health Journalism Fellowship through USC’s Annenberg School for Communication & Journalism. The results are a good starter kit for anyone wanting to examine similar patterns in their own communities. One of the most valuable things Schmitt did was address stereotypes and misperceptions head-on while still asking tough questions. (In the interest of full disclosure, I am currently helping edit a project where Schmitt is one of a team of reporters. She’s doing terrific work there, too.) I picked five key lessons from the series below.

Check the boards. When writing about doctors, reporters tend to think about licensed versus unlicensed. A much bigger problem is doctors failing to achieve board certification in their specialties. Would you want a physician to oversee your pregnancy and deliver your child without having proven to her peers that she has the necessary skillset? Schmitt wrote:

In Kern County, only about 70 percent of the 634 foreign-trained physicians have ever received board certification, according to an exhaustive Californian review of ABMS physician records. That percentage, though, doesn't tell the whole story. Certification rates varied dramatically depending on which foreign medical school Kern's doctors attended. Take the most common 10 foreign medical schools graduating Kern County doctors. The certification rate among those schools' local physicians ranges from 33 to 93 percent, with an average of 64 percent.

Watch for shrugs. A common response to criticism is to blame some uncontrollable power and to act as if the true reason for some event is a mystery. Dr. Eric vanSonnenberg, chief medical officer at Kern Medical Center, shrugged when Schmitt asked him how the hospital chooses which foreign graduates get to work there. "In no way do we want to disparage foreign medical graduates, but the issue is: How do you know?" vanSonnenberg said. “If we could choose the super stars, we would, but we don't know how." Schmitt posed the same question to other hospitals, though, and received a very different answer. No shrugging at Kaiser Permanente. There they said that, in fact, you can know. You just have to do your homework.

Over at Kaiser Permanente, which has "a big portion" of doctors who received medical training overseas, the key is examining residency data. Since foreign doctors must do a U.S. residency, there is plentiful information to scrutinize, said Dr. Julia Bae, the medical director for Kaiser in Kern County. "We only hire those at the top of their programs," she said.

Map the contrasts. Just glancing at the map the Californian created for the series makes stories jump out. Why are a third or more of the doctors in Orange and Los Angeles counties from foreign schools while less than 20% are foreign-born in San Francisco? Why does the interior of the state have such a high concentration of foreign doctors while the counties along the borders have fewer?

Describe the deals. One of the most interesting pieces in the series is a story about one financial deal that provides insights into the broader trend of foreign born doctors dominating the field in Kern County.

Officials were eager to strike a deal with KMC because most Caribbean schools don't have affiliated hospitals that would offer the hands-on training; they only provide the first two years of academic coursework. For their third and fourth years, students must jockey for rotation spots in American teaching hospitals that have Caribbean school contracts. California traditionally hasn't offered as many opportunities for offshore schools. But the for-profit organizations are trying to change that. "They've been coming to California with buckets of money," said Dr. Peter Broderick, a Modesto family medicine residency director studying the movement. … Kern County officials ultimately awarded Dominica-based Ross [University School of Medicine] about 100 slots in exchange for $35 million over 10 years.

Schmitt explains how important those types of payments are to hospital budgets and how the money may be skewing the system in favor of foreign doctors.

Be flexible. Schmitt crunched data many different ways for the series, and she clearly adjusted her analysis as her reporting progressed. She explained how she did her math in a box that ran on the first day. And when questions about that analysis arose, she pivoted. For example, Joseph Flaherty, the chancellor of Ross University in Dominica, defended the quality of Caribbean schools, in part, by challenging the percentage of students who had been board certified after graduating from those schools. “He also pointed out that younger doctors might still be getting certified,” Schmitt wrote. Schmitt didn’t just let that challenge stand unanswered. She explained that her analysis was focused on doctors already advanced enough in their careers to have achieved board certification. She wrote, “The Californian excluded Kern Medical Center residents and recent residency graduates from its calculations.”

Image by J. Aaron Farr via Flickr.