3 of Navy Hospital’s Training Programs Placed on Probation

Three of the 15 residency training programs at the Navy Hospital in Balboa Park have been placed on probation by national accrediting bodies--a greater proportion than at any other major teaching hospital in Southern California--according to official documents released to The Times under the Freedom of Information Act.

All three of the probation terms are still in force. One was ordered after the American Board of Thoracic Surgery sent a special evaluator into the Navy hospital last year, and the specialist found deficiencies in the training of surgeons to perform heart operations on infants and children, according to the documents and the San Diego regional office of the Naval Medical Command.

Overall quality of care problems at Southern California Navy medical centers were detailed in a report Sunday by The Times.

In addition to the Balboa hospital’s cardiothoracic surgery training program, sequences training resident physicians in anesthesiology and radiology have also been placed on probation, according to a file of reports to the Navy by the Accreditation Council for Graduate Medical Education. Administered by the American Medical Assn., the council is the central agency that enforces quality standards for physician training programs nationwide.

The reports were supplied by the Navy with virtually all detailed criticisms expunged. The Navy said the specific criticisms were withheld because they were intended for internal Navy use only. All three programs were cited for substantive deficiencies that could impair the quality of medicine practiced by their graduates--as opposed to strictly technical violations--a Navy spokesman confirmed.

The programs on probation must comply with a requirement that they warn in writing each doctor applying to them of the action in force against them.

There are 4,748 residency programs in hospitals across the country, the AMA said. A spokeswoman said she was not authorized to release information on the total number on probation or the number whose accreditation has been withdrawn. Actual disaccreditation is an exceedingly rare step, said an AMA official speaking on the condition he not be identified.

The Times found that UC San Diego; UC Irvine Medical Center in Orange; Harbor-UCLA Medical Center in Torrance; Martin Luther King Jr. General Hospital in Compton, and County-USC Medical Center in Los Angeles all have one program each on probation. UCLA, Loma Linda University and Cedars Sinai Medical Center in Los Angeles have no programs on probation.

The Navy said the cardiac surgery and radiology programs hope to be reinspected late this year or in 1986 and that the hospital believes deficiencies have been corrected. The Navy said the anesthesiology program has already been resurveyed and is awaiting results of its application to be restored to fully accredited status.

The action taken against the cardiac surgery program appeared to represent the most serious problem facing the Navy hospital, because the probation resulted from questions about the adequacy of training in pediatric cardiac surgery, a spokesman said. That area has been such a critical problem for the Navy hospital that Capt. Harold Koenig, who took over as commanding officer of the hospital last summer, issued a blanket ban on performance of such surgery there, the spokesman added.

In November of 1982, a few months before the special examiner was dispatched to look into the residency program, Navy hospital surgeons botched a heart operation on an infant. The failed surgery was detailed Sunday in The Times in stories reporting the results of a four-month inquiry into malpractice and quality of care at Navy hospitals in San Diego and Long Beach and at Camp Pendleton.

In the operation, two Navy surgeons--including one resident in training--failed in their attempt to repair a heart defect in Mathew Titus, the infant son of a Marine Corps private first class. Instead of sewing shut the defect--called a patent ductus arteriosis--the Navy surgeons mistakenly tied off the boy’s left pulmonary artery.

It took Navy physicians nearly three weeks to discover the mistake. By that time, the Titus boy had lost the use of his left lung. The Navy settled a malpractice case filed by the boy’s family for $300,000. The boy is alive but has recently required additional corrective heart surgery and his chances of surviving past age 10 are uncertain.

In November, 1983, the Navy documents indicate, accreditation officials ordered the comparatively unusual step of sending a heart specialist to the Navy hospital to reevaluate the cardiac surgery program, which had notified the accreditation council it was entering into a close affiliation with UC San Diego, Children’s Hospital and Health Center and Sharp Memorial Community Hospital.

In September, 1984, the council, led by representatives of the American Board of Thoracic Surgery, the American College of Surgeons and the AMA, moved to formally put the program on probation. Several paragraphs in a letter to the Navy hospital explaining the action were deleted by Navy officials in Washington.

When the probation term was imposed, the accreditation agency found that only UC San Diego still had a close affiliation with the Navy training program. A separate Naval Investigative Service inquiry now nearing completion was launched a few weeks ago to look into allegations the Navy hospital may have inappropriately steered heart surgery referrals to a cardiac surgery group operating mainly at UC San Diego. UC San Diego said late last week that its single residency program on probation is in cardiothoracic surgery.

Dr. Judy E. Schwartz, chairman of the Navy hospital cardiac surgery program at the time of the special review and subsequent probation action, has since been relieved and transferred to a position in the quality assurance department at the Navy hospital.

The Navy hospital’s therapeutic radiology residency program was placed on probation in December of 1983, and the anesthesiology program was ordered onto probation status in September, 1984. Friday, the Navy said it hoped the cardiac surgery program would be reviewed by an accrediting team again next year. Lt. Gene Elliot, the spokesman, said Navy commanders believe deficiencies in all three programs have been corrected.

Elliot said the anesthesiology department was cited because it did not have enough senior doctors to teach younger residents and because the instructional curriculum was weak. The program has now been resurveyed, Elliot said, and, “quite frankly, preliminary results indicate that program will be off probation.” The censored documents released by the Navy indicated the program had been cited for three major deficiencies.

The radiology department, Elliot said, was cited because it lacked some needed equipment and at least one senior doctor. The program is scheduled for a new review by evaluators later this year. Documents released by the Navy showed the radiology program was cited for four deficiencies.