Common themes in the reviews of UCI include a failure to demonstrate adequate supervision, to support research, to provide enough experience with various procedures, to have an adequate number of faculty members and to provide adequate classroom and lecture experience.

The repetition of these troubles throughout the school "suggests to me there's some systematic issues in the medical school," Gienapp said.

Medical school dean Dr. Thomas Cesario said most of the problems are "easily soluble."

"I don't think anybody should walk away with the notion we're failing in our educational responsibility. A lot of these probations, with minor corrections, will be taken off."

Nationwide, an average of 4 percent of medical school residency programs receive council warnings; at UCI, 25 percent of the programs have.

Word of the school's problems is the topic of discussion among medical educators across the country, said Dr. Dade Lunsford, professor of neurosurgery at the University of Pittsburgh.

"The buzz is that it's in trouble," he said.

Cesario said he expects to be able to improve all the probationary programs and prevent any loss of accreditation.

Nine specialties are on probation or have received warning _ they amount to the same thing, Gienapp said _ and the council has proposed adding Neurosurgery to that list, saying the school failed to give graduates adequate surgery training, among other things.

"I think it's fair to say the situation is pretty bleak" in the neurosurgery department, said Dr. Clarence Greene, associate clinical professor of neurosurgery and pediatrics at UCI.

The school is working to make sure that neurosurgery and other graduates get adequate experience, Cesario said. Those who have graduated with "inadequate" surgical experience are not a danger: "We expect they're going to find a way to develop enough experience (through continuing education) or not do the procedure," he said.

Because of drops in patient volume due to increased competition for patients, officials are looking at whether to close some programs, Cesario said.

Fewer patients make it hard for students to get sufficient training, and the school has cut the number of students to improve the situation. Some residents are being sent to other hospitals for training.

"In this era, you have to make some choices," Cesario said. "Maybe every medical school shouldn't do everything."

In a recent memo, Cesario proposed partnering with other schools for the neurosurgery, neurology and ophthalmology programs _ all departments in need of a chairman.

"We've had a decline and we've had to adjust," Cesario said.

Increased workloads and changes in how doctors are compensated have caused a loss of faculty, he said.

He said many of the school's problems are "paperwork" _ a failure to document training and supervision that was done. Rules now require more documentation than in the past, and the school is working to comply, he said.

And ACGME is getting more strict about what it requires: In the past, for example, medical education was very loose and informal. Now, the council expects better documentation about what training students are getting, he said.

"They're asking you to develop a curriculum," Cesario said. "In the past, they didn't do that."

He said most faculty are doing good research, but until recently, there hasn't been as much of a requirement that residents do research.

Dr. Kenneth Waxman, former professor of surgery at UCI, said the troubles can be blamed only partly on UCI Medical Center's dwindling patient load, which makes it hard for students to get experience and for doctors to do research.

Waxman also blames problems on "a weakness of leadership. The leadership has not successfully emphasized the priority of teaching, research and optimal patient care. You have to look at the institution and say, `Are they setting the standards high enough? Are they managing their teaching programs?' "

Cesario said departments have been given a great deal of autonomy in how they conduct their education programs, but that's changing: Five weeks ago a new system-wide policy was put in place requiring that all attending physicians review the work of their training residents at the end of each month.

Attending doctors are now required also to see every resident's patients every day and, if there are problems with the care provided, they will be expected to review the case with the resident.

The school is now developing standards governing what each resident is expected to do in each year of training. "That's going to be very uniform," Cesario said.

WHERE THE UCI MEDICAL PROGRAMS STAND

Ten of UCI Medical School's 39 residency programs have been warned that if they don't fix problems, they may lose their accreditation. "Warning" and "probation" both mean that the program is on notice that it can lose accreditation if problems aren't fixed:

CHILD AND ADOLESCENT PSYCHIATRY STATUS: Accredited "The program does not have adequate leadership." Director of outpatient clinic "unreceptive to the needs of the child and adolescent residents and their patients." Lectures "poorly organized." Grand rounds "not consistently held. Key seminars . . . are not provided." Some areas of experience inadequate. Teaching staff not doing research in this area. "Residents received little support for their required research." Not enough current texts on the topic in the library. "The committee expressed strong concern . . . adverse accreditation decision will be considered . . . if the program does not" improve.
NEXT: Site visit in July.

CHILD NEUROLOGY STATUS: Warned The number of inpatients seems to be less than adequate. Resident experience with outpatients inadequate. Resident experience in the various subspecialties of neurology deficient.
NEXT: Site visit in September.

EMERGENCY MEDICINE STATUS: Accredited No evidence faculty members have time for scholarly activity. Volume of patients necessary for training six residents marginal. "The committee warns the program director that the areas of noncompliance . . . are very serious. Should these persist . . . adverse accreditation may be proposed."
NEXT: Site visit September 1998.

ENDOCRINOLOGY STATUS: Warned "All major dimensions of the curriculum are not structured educational experiences for which written goals and objectives, a defined method of teaching and explicit method of evaluation are documented." "Insufficient" clinical and lecture experiences in pediatric endocrinology. No evidence teaching doctors review performance of residents at the end of each rotation.
NEXT: Site visit in September.

GASTROENTEROLOGY STATUS: Warned "Program may not be organized to provide training and experience at a sufficient level for resident to acquire the competency of a specialist in the field within the two accredited years." "All major dimensions of the curriculum are not structured educational experiences for which written goals and objectives, a defined method of teaching and explicit method of evaluation are documented." Residents doing too many procedures; "excessive reliance on service, as opposed to education." No evidence teaching doctors review performance of all residents at end of each rotation.
NEXT: Site visit in September.

HEMATOLOGY STATUS: Warned "All major dimensions of the curriculum are not structured educational experiences for which written goals and objectives, a defined method of teaching and explicit method of evaluation are documented."
NEXT: Site visit September 1999.

INFECTIOUS DISEASE STATUS: Warned Failed to demonstrate that teaching attendings review the performance of residents at the end of each rotation. Program did not ensure meaningful, supervised research experience. Failed to demonstrate that faculty members adequately participate in conferences with students. Training doctors assigned to Loma Linda University Medical center, where "it appears that the assignment only meets the service needs of the institution and not the educational needs of the residency."
NEXT: Site visit in September.

INTERNAL MEDICINE STATUS: Accredited "The program did not demonstrate all residents have sufficient experience in psychiatry . . . gynecology" and other areas. No evidence all residents have adequate experience and lectures in adolescent medicine. Failed to teach residents basic legal principles, "specifically issues of informed consent."
NEXT: Site visit September 1999.

MEDICAL ONCOLOGY STATUS: Warned "All major dimensions of the curriculum are not structured educational experiences for which written goals and objectives, a defined method of teaching and explicit method of evaluation are documented." No evidence that there are enough qualified teaching faculty.
NEXT: Site visit September 1999.

NEPHROLOGY STATUS: Accredited Dwindling number of renal transplants. Program doesn't ensure meaningful, supervised research experience.
NEXT: Site visit September 1999.

NEUROSURGERY STATUS: Probation proposed Residents get "insufficient" training _ and in some categories no training _ in intracranial vascular surgery, occlusive vascular surgery, removal of plaque from carotid arteries, epilepsy management, peripheral nerve surgery, some spinal surgeries, pituitary tumor surgery, pediatric neurosurgery. "The operative cases in the program do not allow the residents to participate in the care of patients suffering the full spectrum of diseases," the March report states. "The committee judged . . . these cases to be inadequate and not representative of the operative procedures necessary for residency training in neurological surgery." Two doctors graduated from the program in 1996 with insufficient training, the report said.
NEXT: Probation being considered; no deadline set.

NEUROLOGY STATUS: Probationary Accreditation Department graduates fail national exams at a much higher rate than the national average. Insufficient number of qualified faculty for teaching and supervision. The range of faculty expertise is inadequate. Resident experience is inadequate. Research in the program is inadequate.
NEXT: Site visit May 1999

OBSTETRICS AND GYNECOLOGY STATUS: Accredited Resident experience with genetic amniocentesis is "inadequate." Experience with neonatal resuscitation is "inadequate." Experience with fine needle breast aspiration is "inadequate."
NEXT: Survey in 1999

OPTHALMOLOGY STATUS: Accredited "The program did not adequately offer each resident a graduated supervised experience with the entire spectrum of opthalmic diseases." Supervision levels questioned.
NEXT: Review planned, no date given.

PAIN MANAGEMENT STATUS: Accredited Inadequate support for research. "No publications or evidence of research by full-time faculty in past five years. None of past or present trainees have ever participated in or published research projects." "It is questioned whether the pain-management lecture series actually occurs."
NEXT: Review Spring 1997

PHYSICAL MEDICINE STATUS: Accredited Faculty don't always participate regularly in training program. No supervision available in some areas.
NEXT: Review in 1998.

RHEUMATOLOGY STATUS: Warned "All major dimensions of the curriculum are not structured educational experiences for which written goals and objectives, a defined method of teaching and explicit method of evaluation are documented. The program does not ensure a meaningful, supervised research experience.
NEXT: Site visit in September.

SURGERY STATUS: Accredited "The operative experience of individual residents who recently completed the program was inadequate." Supervision and feedback were lacking: "Attendings did not make regular organized ward rounds with the resident team."
NEXT: Site visit February 1997.

SURGICAL CRITICAL CARE STATUS: Warned Faculty staffing levels questioned.
NEXT: Site visit February 1997.