Diverging with its plan to shore up the U.S. physician shortage, the American Medical Association recently decided that as of July 1, 2009, it will no longer sponsor the Fifth Pathway program. This move could have an unfortunate impact on how many physicians start practices in the United States, especially those who speak Spanish.

Fifth Pathway, which the AMA has sponsored since 1971, permits entrance into U.S. graduate medical programs to U.S. citizens and residents studying in a medical school outside of the country who meet specific academic requirements. The AMA MasterFile reports that the program graduates approximately 100 physicians each year, and that these physicians generally end up in office-based practices, primarily in large states, such as California and New York.

There is "a great deal of uncertainty regarding the eligibility requirements for Fifth Pathway programs among [medical] program directors and various licensing jurisdictions," wrote Richard Pan, MD, chair of the AMA Council on Medical Education, in a report discussing why the AMA had decided to no longer support the program. "Neither the Council on Medical Education nor the AMA is in a position to undertake responsibility to ensure that only eligible individuals are allowed to enter graduate medical education through the Fifth Pathway."

Dr. Pan also contends that the program has further deficiencies, including: vague eligibility criteria that are probably not enforceable; a lack of supervision or quality control in the admissions process; no external accountability; a lack of clearly defined standards for successful program completion; and no consistent method to verify Fifth Pathway participants' educational credentials from primary sources.

In an analysis of Dr. Pan's report, Francisco Martinez-Sandoval, MD, dean of the School of Medicine at Universidad Autonoma de Guadalajara (UAG), a private university in Mexico, concluded that it contained several discrepancies and lacked concrete evidence to support the AMA's decision. For example, the UAG points out that eligibility criteria and standards for program completion are clearly established in the Graduate Medical Education Directory.

Concerning Dr. Pan's contention that the program lacks quality control, it is only necessary to point to particular Fifth Pathway hosts such as New York Medical College, Mount Sinai School of Medicine, and Ponce School of Medicine. Are not these Liaison Committee on Medical Education- accredited schools sufficient and valid enough to operate these programs?

And at a time when bilingual physicians are in high demand, discontinuing the Fifth Pathway program is likely to damage their future supply. Graduates of the UAG School of Medicine, who are largely bilingual and bicultural, make up about 75% of Fifth Pathway participants, and have helped ease the U.S. physician shortage. Since the program's 1971 inception, the school has graduated over 7,500 physicians who practice in the U.S. Many of these are now professors, residency directors and chiefs of departments of prestigious American medical schools. Some have served on state medical boards and others are researchers on the international level.

Ending Fifth Pathway also seems contradictory to the AMA's own policies. In its U.S. Physician Shortage policy, the AMA recognizes the existing shortage of physicians in many specialties and areas of the U.S. and it supports current programs to alleviate the problem. The AMA's Resolution 807 notes the need to increase minority representation in medical schools and in the physician workforce to improve access to care for underserved groups.

According to the AMA Masterfile, 30% of Fifth Pathway graduates entered primary care specialties. Of these, approximately 46% of the internists and 11% of the pediatricians sub-specialized. Fifty-four percent of these graduates are certified by the American Board of Medical Specialties, and they experience disciplinary actions at about the same rate as the general population of physicians.

"As of January, Latinos are less than 5% of the state's 79,000 licensed physicians," says Christina Gonzalez, executive director of the California Latino Medical Association. "Of those Latinos licensed, we are at an equal dead heat-51% are U.S.-trained, 49% are [international medical graduates]." California has a Hispanic population of approximately 35% and there is a clear need for Spanish-speaking physicians.

Any deficiencies found in the Fifth Pathway Program must be addressed, but the program should not be discontinued. California cannot afford such a setback.

A native of Whittier, Raul Herrera is a second-year medical student at the Universidad Autonoma de Guadalajara.