Major Hasan--How Did He Do It?

Our local fishwrap, The News and Messenger (January 12, 2009) carried an article that pondered how it was that Major Nidal Hasan was able to get through medical school and a psychiatry residency despite the fact that his performance all along the way was substandard.

Oh, if you only knew!

Let’s start with Major Hasan’s education at the Uniformed Services University of the Health Sciences and the F. Edward Hebert School of Medicine, our nation’s military medical school. Medical students entering the F. Edward Hebert School of Medicine are commissioned as at the entry level (2nd Lieutenant/Ensign) in the Army, Navy, Air Force and Public Health Service. They are paid at this grade for the four (or more) years they attend school but they pay no tuition, laboratory fees, etc. while they attend school. Once they complete school, they are advanced to Captain/Lieutenant and begin their internship and eventual payback for their “free” medical education. At this point, the government (the Armed Forces) has something approaching $500,000 invested in each graduating student. This does not count their pay and allowances. At the current pay scale, new students pay and allowances for four years comes to just over $271,000. Of course, this investment is greater for the student who doesn’t finish in four years as was the case for Major Hasan—the six year tally comes to more than $470,000. So the government has somewhere between three-quarters and nearly a million dollars invested in a new physician before they begin their internship and any specialty training. Hasan was promoted to Captain upon graduation and his annual income for the next four years was more than $385,000 (again, based on the current pay scale). This includes another year of training for master’s degree in public health—the cost of that schooling has not been calculated in this figure.

The Uniformed Services University has never been able to fully quantify just how much it costs to train a medical student because the school does much more than just train physicians. There are numerous PhD programs, research programs and other training courses that impact the cost of operating the medical school. But conservatively the government had something over $1.25 million invested in Major Hasan when he was transferred to Fort Hood.

Despite his poor performance in medical school and his residency program, those in charge of Major Hasan equivocated repeatedly on his Officer Evaluation Reports and on reports regarding his performance during his residency.

On May 17, 2007, Major Scott Moran, an Army psychiatrist and director of Major Hasan’s psychiatry residency training program wrote the following memorandum:

"Consortium Participating Instructions: Uniformed Services University of Health
Sciences, Walter Reed Army Medical Center, National Naval Medical Center,
Malcolm Grow USAF Medical Center

May 17, 2007

Memorandum for: Credentials Committee

Subject: CPT Nidal Hasan

1. I am the program director for NCC Psychiatry Residency Training Program. I
took over as PD in MAR 2007 and was Assistant PD from July 2006. I have
been a faculty member of the residency since July 2004.
2. This memo is based on my personal knowledge of and the documented
incidences in CPT Hasan’s Resident Training File.
3. The Faculty has serious concerns about CPT Hasan’s professionalism and work
ethic. Clinically he is competent to deliver safe patient care. But he
demonstrates a pattern of poor judgment and a lack of professionalism. In
his PGY-2 year, he was counseled for inappropriately discussing religious
topics with his assigned patients. He also required a period of in-program
remediation when he was discovered to have not documented appropriately an
ER encounter with a homicidal patient who subsequently eloped from the ER.
He did successfully remediate this problem. At the end of his PGY-2 year,
he was placed on administrative probation by the NCC GMEC for failure to
take and pass USMLE Step 3 and to obtain an unrestricted state medical
license by the end of his PGY-2 year; as a result he was not promoted to
PGY-3 on time. He did eventually complete step 3 and get a license and was
promoted to PGY-3. He was counseled for having a poor record of attendance
at didactics and lower than expected PRITE scores. One year he failed to
show for his PRITE examination at all. During his PGY-3 year, he was
counseled for being consistently late to NNMC morning report. During his
PGY-4 year, he was discovered to have only seen 30 outpatients in 38 week
of outpatient continuity clinic. He was required to make this missed clinic
time up using his elective. He failed his HGT/WGT screening and was found
to be out of standards with body fat % and was counseled on that.

Lastly, he missed a night of call for MGMC ER and then did not respond to
numerous pages by my office the next day.
4. Take together; these issues demonstrate a lack of professionalism and work
ethics. He is able to self-correct with supervision. However, at this point
he should not need so much supervision. In spite of all of this, I am not
able to say he is not competent to graduate nor do I think a period of
academic probation now at the end of his training will be beneficial. He
would be able to contain his behavior enough to complete any period of
probation successfully. My purpose in writing this letter is to give the
credentials committee the benefit of full disclosure and the opportunity to
modify CPT Hasan’s plan of supervision following initial privileging.
5. I did discuss this memo with CPT Hasan and informed him I would be adding
it to his initial credentialing paperwork.
6. POC is the undersigned and may be reached at 202-XXX-XXXX or email at XXX/

Sincerely,
Scott Moran, MAJ, MC
Program Director
NCC Psychiatry Residency Training"

Despite all of his reservations, Major Moran failed to stop then Captain Hasan from graduating. A careful read of paragraph 4 tells the story. It is this paragraph that lets Major Hasan off the hook as well as the author Major Scott Moran. It equivocates, back peddles, is wishy washy, waffling or whatever name you wish to assign to someone who is protecting himself and is obviously concerned about possible litigation--one of the biggest crimes I believe we face in our society. It keeps us from being candid just when we need to be.

Graduating, promoting and transferring Hasan were major leadership failures from medical school through residency training. I have said it before and I will say it again, physicians don't like to "rat out" other physicians. It is much like the Blue Wall of Silence found among police officers--fellow police officer don't "rat out" fellow police officers and physicians don't "rat out" other physicians.

There is plenty of room for blame here and I, for one, hope that is spread around on those responsible that they are appropriately disciplined. But I'm not making any bets on it--our leaders have become politically correct wimps--always concerned about litigation and their public persona. Where are the George Pattons, Chesty Pullers, and Bull Halseys when we need them? Gone to graveyards everyone.

There have been other instances over the years since the University was opened that medical students did not graduate in four years. How many? I don't know, but unless someone steps in and carefully reviews the procedures at the F. Edward Hebert School of Medicine that are used to determine whether a student graduates, is “rolled back” or is removed from training, there will be other Major Hasans—it is only a matter of time. The University had a major shakeup some fourteen years ago; perhaps it is time for another bottom to top examination.