Dr. Halperin is Ford Foundation Professor of Medical Education, professor of radiation oncology, pediatrics, and history, and dean, School of Medicine, University of Louisville, Louisville, Kentucky.
Dr. Garcia is professor of medicine and associate dean of medical school admissions, Stanford University School of Medicine, Stanford, California.
Correspondence should be addressed to Dr. Halperin, University of Louisville, Abell Administration Center, 323 East Chestnut Street, #217, Louisville, KY 40202-3866; telephone: (502) 852-1499; fax: (502) 852-1484; e-mail: firstname.lastname@example.org.
The Association of American Medical Colleges (AAMC) is implementing a national system of criminal background checks for entering medical students.1 Over 2,200 background checks have been conducted in a pilot trial. To date, “33 misdemeanors, 11 dishonorable military discharges, and no felonies have been detected.” The chair of the AAMC background check advisory group said that
I asked students about privacy concerns, and one said they underwent a criminal background check when they applied to be a camp counselor. Another one had one when they wanted to work at a child-care center ... so this is old news for them. ... You can't mop the floor in a hospital without undergoing a criminal background check .... It has become so common and ordinary that no one seems bothered by it.1
The perceived “ordinariness” of criminal background checks, however, does not make them the right choice for medical schools.
Criminal background checks are based upon a criminal justice system that is discriminatory. It is likely that the most common “offenses” identified in criminal background checks of potential medical school matriculants will be related to possession of alcohol or drugs by minors and associated behaviors such as public intoxication. Since the probability of incurring a criminal charge for drug offenses is a function of race, socioeconomic status, and location, criminal background checks will disproportionately target socially disadvantaged groups already underrepresented in the medical profession. If a wealthy young Caucasian is arrested for possession of a small amount of marijuana in a suburban community, it is highly likely that his or her parents will identify an attorney experienced in these matters, that supportive letters from prominent community leaders will be brought before the judge, and that he or she will be given a few hours of community service or have the charges dismissed. The alleged offense will never show up in a criminal record. In contrast, if a poor African American is arrested in an inner city for alleged possession of a small amount of drugs, he or she is far more likely to end up with a criminal record because there will be no wealthy parents with a lawyer in tow to come to his or her aid.2–4 African Americans make up 15% of the youth population and account for 26% of the youth arrested, but of those arrested, African Americans make up 44% of those detained, 46% of those judicially waived to criminal court, and 58% of youth in prison.5 Members of minority groups are therefore more likely to have a criminal record than Caucasians—not because they are more likely to have committed a crime but because they are more likely to be victims of an inequitable criminal justice system.
There is no consensus of state or federal law or in the risk management literature regarding the culpability of health care employers for ensuring a safe work place, what entities must conduct criminal background checks, which potential students or employees should be checked, what crimes bar someone from being a health professions student, whether it is possible to establish remediation, what the penalty should be for failure to conduct a check or for providing false information, what should be included in the search, and who should pay for the process. Medical schools will have to develop processes for case-by-case review of positive criminal background checks—an attempt to fix, post hoc, our compromised criminal justice system.
What will be the impact of requiring criminal background checks for medical school admissions? Will patient safety truly improve? Will we reduce the incidence of unprofessional behavior by physicians? There is no evidence that routine criminal background checks of medical students or any other professional student will improve patient or workplace safety or efficiency. Proponents of a policy for criminal background checks should at minimum support definitive studies to determine with confidence that the safety and efficacy of medical education are augmented by criminal background checks. They should be concerned that evidence from the relative inefficacy of preemployment drug testing strongly suggests that criminal background checks will be no better.6
The issue is not whether the system is relatively inexpensive, nationally administered, or meets no significant opposition from anxious and compliant young people who are seeking entrance into medical school, but whether the widespread deployment of an expensive and unproven intervention is justified. Studies are necessary to determine that the desired impact was reached; if not, we should all have the good sense to abandon criminal background checks.
Other disclosures: None.
Ethical approval: Not applicable.
1 Harris S. AAMC expands criminal background check testing. AAMC Reporter. July 2008;1:4.
2 Schlesinger T. Racial and ethnic disparity in pretrial clinical processing. Justice Q. 2005;22:170–192.
3 Ziedenberg J, Colburn J. Efficacy and Impact: The Criminal Justice Response to Marijuana Policy in the US. Washington, DC: Justice Policy Institute; August 25, 2005.
4 Yates J, Fording R. Politics and punitiveness in black and white. J Politics. 2005;67:1099–1121.
5 Yates J. Racial incarceration disparity among 47 states. Soc Sci Q. 1997;78:1001–1010.
6 Halperin EC, Andolsek KM, Jackson GW, Weinerth J. Pre-placement screening of resident physicians by substance abuse testing: Efficacy, cost, and physician opinions. Drugs (Abingdon Engl). 2008;15:77–91.