Kanter, Steven L. MD
There was a time, not long ago, when “CBC,” if uttered in medical circles, referred to a blood test. It meant “complete blood count” and everyone understood that. But now, if someone utters “CBC,” one has to pause, at least momentarily, to consider if it means “complete blood count” or “criminal background check.” This is just one indication of how commonplace criminal background checks have become in medical schools and teaching hospitals over the last few years.
In fact, in today's academic health center, faculty, residents, students, and staff are subjected routinely to a variety of background checks as a condition of employment, hospital privileging, or acceptance to medical school. Many health systems require drug testing for health care providers. Some hospitals require fingerprint-based background checks for anyone who may have contact with patients. A children's hospital may require specific kinds of background checks; for example, in the Commonwealth of Pennsylvania, an institution may require anyone who has contact with pediatric patients to complete a child-abuse-history clearance form.
At my medical school, students now must undergo—in addition to the AAMC-facilitated criminal background check for students accepted to medical school—child abuse clearance, a state-sponsored criminal background check, and an FBI fingerprint-based background check to be eligible to participate in patient care at our affiliated hospitals.
Given that criminal background checks have become an integral part of the environment at academic health centers, it is a good time to take a step back and reflect on current practices, their effects on medical schools and teaching hospitals, their implications for individuals who undergo such checks, and whether or not, ultimately, they improve the safety of patient care and the academic environment.
In this issue of the journal, there are two Point-Counterpoint essays that examine criminal background checks on acceptance to medical school—one, by Piraino et al,1 arguing that it is the right policy at the right time, and the other, by Halperin and Garcia,2 arguing that it is the wrong policy at the wrong time. In addition, there is a Commentary by Kleshinski et al3 that presents the history of the AAMC-facilitated criminal background check for students entering medical school and discusses current challenges and future considerations.
The Point-Counterpoint essays and the related Commentary raise and imply a number of fundamental questions, including: Are criminal background checks discriminatory? If a criminal offense occurred in youth, should it be viewed differently than if it occurred in adulthood? Would the answer to this question apply in the same way to a student seeking matriculation in medical school as it would to an individual seeking a faculty position in that school? What if that position were such that it did not involve patient care? How does a medical school or teaching hospital balance being fair to an individual applying for a position while maintaining public trust? To what degree should decisions at an academic health center be driven by a philosophy of rehabilitation and restoration4 versus a philosophy of retribution and a concern for recidivism?
Furthermore, I have heard important discussions among colleagues at my medical school and others about whether criminal backgrounds should influence hiring decisions for basic science faculty and acceptance decisions for students applying to graduate programs in biomedical science. For example, one colleague said, “It's not just about patient care. Certain kinds of prior criminal behavior could raise critical concerns about an individual's threshold for plagiarism, or for fabrication or falsification of data.”
Those who work at medical schools and teaching hospitals grapple daily with these and other questions about the use and value of criminal background checks. That is why it is so important for a journal, like this one, to explore penetrating questions, competing interpretations, and detailed analyses of such an issue.
Now, from time to time, someone asks me, What is the role of Academic Medicine in AAMC policy decisions? I believe that the role of this journal is to explore issues broadly and in depth, and to publish solid evidence and well-reasoned arguments on which a medical school, teaching hospital, professional association, or other institution can build robust policy decisions. So, while this journal is not involved in AAMC policy decisions, it can support the process by publishing foundational material that underpins such decisions.
In fact, the issue of criminal background checks provides an excellent example of how an association and its journal can complement each other to inform thinking and practice. The AAMC (the owner of this journal) has taken a clear position on the issue of criminal background checks for individuals accepted to medical school. The first sentence on the AMCAS Criminal Background Check Service Web site reads, “The Association of American Medical Colleges recommends that all U.S. medical schools procure a national background check on applicants upon their conditional acceptance to medical school.”5
The AAMC provides valuable guidance on a variety of complex issues—including criminal background checks—for medical schools and teaching hospitals based on its assessment of the best available information at a certain point in time. Of course, it would be a mistake to stop there. The conversation must continue. And that's why the AAMC facilitates the rigorous, in-depth, and ongoing consideration of key issues by owning and maintaining a peer-reviewed, scholarly journal. To reinforce the AAMC's and the journal's separate but complementary aims, the journal's masthead and Web site state clearly that content in the journal reflects the views of authors and not the official policy of the AAMC. This journal, by existing at arm's length from the association that owns it, and by having policies and a structure that ensure editorial independence, can explore all aspects of a controversial issue, even aspects that are antithetical to the owner's policies, practices, and recommendations. The benefit to the owner is valuable information that can inform further policy development. The benefit to the journal is that it continues to secure its reputation as a scholarly, peer-reviewed publication that promotes policy development based on solid thinking and sound evidence. And the benefit to all members of the academic medicine community is ready access to thought-provoking, rigorous, and cogent analyses of current issues that advance thinking and practice.
So, back to criminal background checks. There are simple questions, but no simple answers. Is it right to deny education in a professional school to someone with a criminal background? Does the nature of the crime matter? Even the seemingly simple question—Why did you order that CBC?—can lead to a broad and deep discussion of principles and values that ranges from recidivism to rehabilitation, from offenses in youth to the value of life's experiences, and from ensuring the public trust to creating opportunity for individuals. I hope that the Point-Counterpoint essays and Commentary in this issue enrich the conversations and inform the decisions on this topic that occur every day at medical schools and teaching hospitals.
And the next time you hear someone utter “CBC,” remember that the criminal background check has more in common with the complete blood count than just the same acronym. Both are plagued with false-positive and false-negative results that, even if very infrequent, present critical challenges for those who make decisions based on such findings and thus can affect the lives, careers, and well-being of both individuals and populations.
Steven L. Kanter, MD