
A large nonprofit system of low-income clinics in Washington state has sued a national accrediting agency after a denial of certification threatened state and federal funding and sparked an exodus of 30 doctors-in-training.
The federal lawsuit — and a judge’s initial ruling against the clinic chain — sheds light on the powerful role of obscure nongovernmental accrediting agencies, as well as the efforts by safety net clinics known as federally qualified health centers to provide residency programs that provide medical education for doctors-in-training to complete their degrees.
It comes at a time when the Pacific Northwest, and the United States in general, face a wave of retirements among doctors and other health care professionals, sparking access-to-care concerns as well as efforts to boost training for the retirees’ replacements.
Named for its roots in Seattle and Marysville, Sea Mar Community Health Centers operates about three dozen clinics as well as pharmacies across the state of Washington, including in Vancouver. It was founded to provide “medical, dental, and social services to some of Washington’s most marginalized communities,” the safety net clinic chain’s lawyers wrote in a court filing. “Tto help remedy the persistent shortage of practitioners in rural and underserved areas, Sea Mar created a Family Medicine Residency Program … to train the next generation of community-focused family medicine doctors.”
On June 21, Sea Mar sued the Accreditation Council for Graduate Medical Education, an Illinois-based nonprofit that oversees education and training for medical and osteopathic doctors in the U.S, including residency programs and internships.
Filed in the Western District of Washington at Seattle, the suit challenged the council’s decision to strip Sea Mar of its accreditation saying it was not given a chance to respond to a negative inspection or appeal the decision before it took effect.
Council a financial ‘gatekeeper,’ suit says
The council acts as a gatekeeper for state and federal funding, according to the suit, and “Sea Mar’s residents have already started leaving, institutional relationships are already unraveling, and government funders of the program have taken initial steps to address the public-funding implications.” In fact, 30 of the 34 incoming and current residents had already secured positions elsewhere to complete their training, according to Sea Mar.
The clinic chain asked a judge to step in and issue an emergency injunction to block the council, saying its decision was unfair, lacked a timely appeal process, and created an “imminent risk of additional irreparable injury to Sea Mar, the Family Medicine Residency Program, and the diverse under-resourced communities they serve.”
In February, the program had been deemed in substantial compliance. But weeks later, according to the suit, “two ACGME field representatives conducted a perfunctory, remote ‘site visit’ of the Family Medicine Residency Program. Despite being directed to conduct an ‘in-person’ evaluation, the field representatives conducted a video visit, lasting less than a business day, with residents and Sea Mar personnel meeting either in groups for brief discussions or for five-minute individual sessions. At the end of the visit, Sea Mar’s administration was granted only a few minutes with the field representatives for discussion, with no opportunity to learn of, respond to, or disabuse them of any inaccuracies of their impressions and findings or otherwise address their concerns.”
“On April 21, 2024, Sea Mar received a notification from ACGME’s review committee that the Family Medicine Residency Program’s accreditation would be withdrawn in just two months’ time—effective June 30, 2024.”
ACGME told Sea Mar it wouldn’t provide the basis for the decision for another 60 days, prompting a protest and eventual appeal of the decision, according to Sea Mar's filings. They asserted that the site visit tapped into understandable dissension over recent program changes as opposed to any legitimate basis for concern.
The “rationale was provided thereafter, consisting of alist of forty-seven citations that purportedly chronicled shortcomings in Sea Mar’s program but was actually a hodgepodge of vague, manifestly erroneous, trivial or insubstantial claims that were plainly designed to discredit the Family Medicine Residency Program without justifying why the draconian remedy of accreditation withdrawal was chosen rather than one of the less-drastic, progressive remediation options available to ACGME..”
“ACGME informed Sea Mar that an appeal of the accreditation withdrawal was scheduled for July 17, 2024—after the withdrawal will have gone into effect—and that that date could not be accelerated. The hearing has since been postponed by ACGME to August 2, and the ACGME board, which has the ultimate authority to rule on the recommendation stemming from the appeal, will not do so until its meeting on September 28. Meanwhile, ACGME has refused all of Sea Mar’s requests to either delay the date of accreditation withdrawal or expedite the appeals process to allow it to finish before the withdrawal decision takes effect.”
Rebuttal cites ‘imminent dangers’ to patients
In court, however, the council’s lawyers filed a scathing rebuttal of the effort to block the accreditation denial, blaming Sea Mar for its situation. The council’s “decision was not made lightly, and was taken only after the ACGME had provided Sea Mar—over the course of years—with multiple notices of its deficiencies, encouraged specific improvements, and consistently followed its normal procedures for determining the adequacy (in in this case, gross inadequacy) of training programs for the next generation of doctors.”
The filing added that “multiple layers of medical professionals found and confirmed scores of deficiencies in Sea Mar’s program, which if allowed to continue past the current academic year would pose significant risks to patient safety and medical resident education. It is manifestly in the public interest for the ACGME’s institutional judgment of these imminent dangers not to be reversed by non-medical professionals.”
It cited a declaration by one of the two representatives who had conducted the virtual inspection by interviewing 21 residents. In it, the doctor wrote that she was “shocked and appalled by what we learned during our site visit,” adding that “[t]he seriousness and number of areas of non-compliance were the worst [she had] experienced,” and that Sea Mar’s family medicine residency program was “the worst program” she had seen in 34 years.
The residents interviewed “consistently reported that the program’s learning and working environment was hostile, placing responsibility for this deficiency on the program’s director.” The program director, according to the filing, was described as “inflexible, harsh, and detached from the program. They said they feared speaking up because the program director had fired the program’s previous coordinator after the coordinator repeatedly raised concerns that the program was out of compliance with ACGME requirements.”
Sea Mar representatives did not respond to requests for comment or information made by The Lund Report.
Judge calls council action ‘head-spinning’ but not clearly unfair
On July 3 U.S. District Judge Jamal Whitehead ruled that while the case will proceed, the effort to block the move to withdraw accreditation would not be blocked pending the case’s outcome
He wrote that the council’s switch from finding Sea Mar in substantial compliance in February of 2024 to suddenly moving to withdraw accreditation in April was a “head-spinning reversal” that “could be viewed as evidence of arbitrary action by the Council. But there are also facts in the record from which to conclude that the Council acted on substantial evidence like the survey results, site visit, and concerns about patient care. While it is possible that Sea Mar will ultimately prevail on its common-law due process claims, Sea Mar has not made a clear showing that success on the merits is likely.
He added that “Indeed, 20 of the program’s 22 current first- and second-year residents and 10 of its 12 incoming first-year residents have elected to leave. Injunctions are issued to forestall harm, and Sea Mar has not shown how issuing a preliminary injunction until the fall would prevent “irreparable harm” beyond the harm that has already occurred. Nor is there any evidence suggesting the program will be shut down forever.”