van Zanten, Marta MEd; Parkins, Lorna M. MA; Karle, Hans MD; Hallock, James A. MD
The Caribbean is a heterogeneous region composed of 24 countries and territories in which approximately 38 million inhabitants speak English, Spanish, French, Dutch, and a variety of indigenous languages. Approximately 60 medical schools in the Caribbean currently are listed in the International Medical Education Directory (IMED).* This region has a higher density of medical schools per capita, with 1.42 medical schools per 1 million inhabitants,1 than any other region of the world. In contrast, Western Europe has 0.60 and North America has 0.50 medical schools per 1 million inhabitants. Despite this high concentration of medical schools in the Caribbean, the density of practicing physicians in the region is comparable with that in the United States and Canada, which indicates that many physicians are training in the Caribbean and practicing elsewhere. Because of the globalization of medicine and the increasing numbers of students who go abroad for their medical education,2 Caribbean medical education issues of quality, scale, student populations, oversight mechanisms, and so forth are of great interest in the United States3 and around the world, as well as in the Caribbean.4–6
This growth in the number of medical schools in the Caribbean is a relatively recent phenomenon. Fifty years ago, there were only a few medical schools in the region, including the University of the West Indies (UWI), which was established in 1948 in Mona, Jamaica, as a College of the University of London and which had students from a number of Caribbean Commonwealth countries, and a small number of schools in Cuba, the Dominican Republic, and Haiti. The student populations at these early schools were composed primarily of nationals from the schools’ respective countries, who, on completion of their training, remained in their countries to practice. The second half of the 20th century saw a slow but steady increase in the creation of medical education institutions in the region. St. George’s University, located in Grenada; the American University of the Caribbean School of Medicine, originally in Montserrat and now in the Netherlands Antilles; and Ross University in Dominica all opened their doors in the late 1970s. The most prolific growth has occurred most recently: The number of operating medical schools has increased by more than 40% since the year 2000.1 Unlike the domestic student body at some of the more established educational institutions, the student body at these newly created schools consists, almost exclusively, of an international population of students, including a large number of U.S. and Canadian citizens.
Governments in the Caribbean have often encouraged the establishment of medical schools aimed primarily at international student populations, because of the potential contributions of such institutions to the islands’ economic development. These schools have created fiscal benefits with their need for infrastructure building, the use of local housing for student accommodation, and employment opportunities for local workers. In addition, many of these schools grant scholarships to local students, some of whom are likely to remain in their countries to practice.
Because of differences among the schools in the region—including differences in the length of time in operation, mission, resources, admission requirements, student population, and clinical experience—there is significant variability in the structure of the educational programs and the performance of the students. In a study of almost 30,000 students who took at least one United States Medical Licensing Examination (the examination series leading to Education Commission for Foreign Medical Graduates [ECFMG] certification) for the first time between 1993 and 2007, pass rates ranged, by country of medical school, from 19.4% to 84.4% for Step 1 Basic Science, from 26.3% to 79.7% for Step 2 Clinical Knowledge, and from 60.6% to 97.2% for Step 2 Clinical Skills. Variations also exist in the degree awarded (MD or MBBS), the language of instruction (English, Spanish, or French), and the length of the curriculum (three to six years).7
Accreditation in the Caribbean Region
In the past, review of the educational quality of medical programs was conducted sporadically by various organizations, depending on the country and the affiliations of the schools in question. Some countries, such as Cuba and the Dominican Republic, have in place a governmental agency that oversees medical education quality as part of a mandatory review of higher-education institutions as a whole. In Jamaica, until recently, accreditation from the General Medical Council (GMC) of the United Kingdom allowed graduates of UWI medical education programs to register and practice in the United Kingdom and most other Commonwealth nations without further examinations. In countries without a national system of accreditation, some schools have chosen to become accredited by entities located outside of the region. For example, an independent organization, the Accreditation Commission on Colleges of Medicine, located in Ireland, has accredited medical schools in various Caribbean countries, including the Cayman Islands and the Netherlands Antilles.8–10 Because of the overlap in jurisdictions of some accrediting entities or the desire to promote quality claims, a small number of educational institutions have chosen to be reviewed by more than one accrediting body. Conversely, some schools in the region have never undergone a formal accreditation process by an external review body because of the noncompulsory nature of the process, the absence of a national system in some countries, or the perceived lack of value of the system.
The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions
The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) was established in 2004 under the auspices of the Caribbean Community (CARICOM). CARICOM is a political and economic affiliation of 15 member states, and it includes most of the English-speaking islands and some Central and South American nations. Member countries are Antigua and Barbuda, the Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago. Associate members of CARICOM include Anguilla, Bermuda, the British Virgin Islands, the Cayman Islands, and the Turks and Caicos Islands.
The establishment of CAAM-HP by CARICOM is an integral component of the regional emphasis on ensuring quality education and training in the context of the Caribbean Single Market and Economy (CSME). The CSME entails the creation of a single economic space without restrictions on the cross-border movement of skilled persons and without discriminatory access to the region’s resources for CARICOM nationals. When physicians can move freely among countries within the region, it is imperative that the quality of their education and training has been ensured, and that obligation underscores the importance of an accreditation authority such as CAAM-HP. In addition, as of 2003, a new interpretation of European Union requirements dictates that the United Kingdom comply with new regulations regarding academic and professional training programs. In fulfillment of these policies, the GMC sent notice of its intentions to abolish the concept of recognized overseas institutions. This change meant that the GMC would no longer have a role in accreditation of medical education programs located outside of the United Kingdom, including those of the UWI, which would leave a void as far as organizations that are qualified to evaluate medical training programs in the region. Therefore, CAAM-HP was established as a way to fulfill regional and local needs for a governmentally recognized quality assurance body.
The objectives of CAAM-HP are to achieve and maintain standards of excellence, to establish an efficient system of regulation in relation to the standards and quality, to secure international recognition, and to maintain confidence in the quality of the education for medicine and other health professions that is offered in the region. In addition, CAAM-HP is charged with ensuring that the education programs for medicine and other health professions that are offered in CARICOM member countries comply with nationally and internationally accepted standards of educational quality. The CAAM-HP accreditation system is based on the model of the Liaison Committee for Medical Education, and it functions with a clear, authoritative mandate, independent of governments and institutions.
The CAAM-HP standards and procedures for evaluating an existing medical school program are available on the organization’s Web site (http://www.caam-hp.org/documents/0-Standards_Accreditation_Med_Schools.pdf). Separate guidelines for minimal requirements are also available for new and developing schools. Established medical education programs are evaluated in the following areas: (1) the institutional setting, (2) the students, (3) educational programs, (4) the faculty, (5) educational resources, and (6) internships.
In the accreditation process, institutional data are analyzed in relation to the accreditation standards. A self-evaluation, which includes completion of the CAAM-HP medical education database and compilation of supporting documents, is conducted by school officials. Next, the database and other information sources are analyzed by an institutional self-study task force and its committees, and the reports are studied and synthesized into an institutional summary report.
The CAAM-HP secretariat appoints a survey team (typically, five persons) from among its database of experienced professionals from Europe, North America, and the Caribbean to visit the school. The team includes a representative cross-section of basic science and clinical educators and medical practitioners and also one member of CAAM-HP or its secretariat. All members have participated in training sessions focused on interpretation of the standards and assessment of compliance. The site visit usually lasts approximately 3.5 days. The team is charged with assessing, on the basis of the institutional summary report and data obtained on-site, how well the medical education program fulfills the accreditation standards.
After the visit, the team secretary prepares a draft report, which is reviewed by the secretariat, the team members, and the dean of the surveyed school. Pending any necessary amendments, the final report is disseminated to the members and staff of CAAM-HP for consideration at the next scheduled meeting. Membership of CAAM-HP comprises representatives from the training institutions in the region, medical students, civil society, professional associations, and specialists from outside the region, including the United States, Canada, and Europe, who have expertise in and knowledge of medical education and accreditation. Finally, CAAM-HP meets to determine the accreditation status of the program or, if necessary, to defer action pending receipt of further information.
Full accreditation is granted for six years, and when accreditation is granted for shorter periods, it is expected that deficiencies will be corrected within a specified period, usually two years. In the event of probation, denial, or withdrawal of accreditation, the medical school must notify all enrolled students, newly accepted students, and those seeking enrollment of this accreditation decision within three months of the receipt of CAAM-HP’s determination. The CAAM-HP procedures document includes details on policies on conflict of interest, confidentiality, appeals, and complaints (http://www.caam-hp.org/documents/1_Procedures_CAAM.pdf).
Transparency of the system is maintained by the public availability (on the organization’s Web site) of the standards, procedures, levels of accreditation, names of panel members, dates and locations of upcoming site visits, accreditation decisions, policies, fees, and so forth. Whereas the decisions are made available on the CAAM-HP Web site, the final report is submitted to the school but not disseminated publicly. The report may be disclosed by the school at its discretion.
Data describing CARICOM members or other countries in the Caribbean that have open medical schools listed in IMED are given in Table 1. Currently listed in IMED are 57 medical schools located in 16 Caribbean countries. Of these 16 countries with medical schools, 12 are part of CARICOM and are therefore under the jurisdiction of CAAM-HP (Antigua and Barbuda, Barbados, the Cayman Islands, Dominica, Grenada, Haiti, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, and Trinidad and Tobago). CARICOM also includes three countries that are not geographically part of the Caribbean (Belize, Guyana, and Suriname) that have medical schools. Eight IMED-listed schools are located in these three countries. Therefore, the total number of medical schools listed in IMED and under direct CAAM-HP jurisdiction currently is 33. In addition, another 32 IMED-listed and open schools are located in four countries in the Caribbean that are not part of CARICOM. CAAM-HP does not normally accredit educational programs in institutions located outside of CARICOM countries, but the organization will, if requested, provide information and consultation about medical education accreditation standards and processes.
To date, CAAM-HP has carried out seven site visits, four to established schools and three to proposed or newly developing schools. The established schools evaluated are the UWI at its four training sites located in Jamaica, Barbados, Trinidad and Tobago, and the Bahamas; the University of Guyana; St. George’s University located in Grenada; and Ross University located in Dominica. UWI’s MBBS programs have been accredited for the period of 2006 through 2010. St. George’s University has been accorded provisional accreditation for its MD program for the period of 2007 through 2009. The University of Guyana’s medical program has been accorded provisional accreditation for the period of 2008 and 2009. The survey team report on Ross University is currently pending consideration by the authority.
The proposed or newly developing schools visited by CAAM-HP included the St. James School of Medicine in Anguilla and the British International University in Montserrat, both of which received provisional accreditation for development, and the University of Science, Arts and Technology in Montserrat, which was not given provisional accreditation status.
Whereas accreditation by CAAM-HP currently is voluntary for schools in the CARICOM region, incentives are in place to encourage schools to undergo the review process. For example, in addition to CARICOM support, the United Kingdom has given formal recognition to CAAM-HP as the authority responsible for the accreditation of new and developing medical schools for British Overseas Territories located in the Caribbean. These territories include Anguilla, Bermuda, the British Virgin Islands, the Cayman Islands, Montserrat, and the Turks and Caicos Islands. The UK government has indicated that it would endorse a new medical school for listing in the World Health Organization (WHO) World Directory of Medical Schools or IMED (or both) only after CAAM-HP issues provisional accreditation. The latest information regarding CAAM-HP activities, including governmental recognitions, decisions, and additional planned site visits, can be found on the organization’s Web site (www.caam-hp.org).
World Federation for Medical Education
As part of CAAM-HP’s mission to enhance and strengthen the organization’s ability to provide a fair and meaningful system of medical education oversight, partnerships with other international authorities are being forged. The World Federation for Medical Education (WFME) is the global organization dedicated to enhancing the quality of education and training of medical doctors worldwide and, ultimately, to improving the health of all people. The WFME’s general goal is to strive for the highest scientific and ethical standards in medical education, taking initiatives with respect to new methods and new tools and management of medical education.11
In 2004, the WFME and the WHO entered into a strategic partnership to improve medical education worldwide. This collaboration includes assisting in the support and development of national and regional accreditation systems. The WFME has established close collaboration with CAAM-HP with the purpose of quality improvement of the Caribbean accreditation system.
Specifically, the WFME is involved in performing an assessment of the accrediting organization’s standards and procedures. WFME advisors plan to compare CAAM-HP standards with the WFME Global Standards for Quality Improvement of Basic Medical Education. These standards were endorsed at the World Conference on Medical Education in 2003 and are now widely used as a basis for accreditation of medical schools in all parts of the world. Furthermore, WFME advisors intend to compare the procedures for accreditation used by CAAM-HP with the accreditation guidelines jointly developed in 2005 by the WHO and the WFME. Concrete plans for conducting these evaluations are now being prepared.
In addition, WFME advisors participate in CAAM-HP’s activities as external reviewers, including making site visits to schools seeking accreditation. To date, the WFME has participated in the accreditation process for Ross University in Dominica. Plans for further external reviews are under preparation. Additional information regarding WFME activities can be found on the WFME Web site (www.wfme.org).
Invitational Conference on Accreditation of Medical Education Programs in the Caribbean
CAAM-HP and the WFME, with assistance from the ECFMG, successfully hosted the Invitational Conference on Accreditation of Medical Education Programs in the Caribbean in Rose Hall, Jamaica, on May 13–15, 2007. The conference brought together 80 leading regional and international experts from more than 20 organizations, institutions, and governments and from the Caribbean, South America, North America, and Europe. The purposes of the conference were to reflect on the process of accreditation as it is conducted regionally and worldwide and to examine efficient and effective options for maintaining and improving established accreditation systems such as CAAM-HP.
In addition to plenary presentations on topics such as an overview and status report of CAAM-HP and global perspectives and the value and importance of accreditation, conference participants were given the opportunity to attend two of the five small-group discussion sessions. The subjects of these break-out sessions were the role of the WFME in supporting regional accrediting activities; the needs of CAAM-HP and opportunities for support; how to maintain an objective and independent accreditation process; accreditation and professional regulation; and accreditation and assessment of medical students. Additional information regarding the conference, including transcripts of presentations and photos, can be found on the CAAM-HP Web site (http://www.caam-hp.org/conference/conference0507.html).
Overall, the conference was very well received, with delegates examining the value of accreditation processes and expressing support for the activities of CAAM-HP. An important intended outcome of the conference was the presentation and dissemination of information regarding CAAM-HP activities to a global audience. This forum presented a unique opportunity for participants from outside the Caribbean to enhance their understanding of the complexity of the issues in the region. The conference stimulated an increased recognition of the value of accreditation for schools in the Caribbean. The WFME partnership provides support, enhances credibility, and gives international exposure for developing organizations such as CAAM-HP. The conference also stimulated thought and discussion from delegates on how they could collaborate with or act as a resource to CAAM-HP in helping it meet its objectives. It was also noted that CAAM-HP can serve as a model for other regional initiatives.
Challenges and Plans for the Future
High-quality medical education is crucial to the delivery of high-quality medical care. The evaluation and monitoring of undergraduate medical education programs in the Caribbean by a regional accrediting system such as CAAM-HP can help ensure the quality of the education delivered. CAAM-HP does, however, face numerous challenges in carrying out its mission. To date, only a minority of medical schools under the jurisdiction of the organization have initiated the review process. Because of the voluntary nature of accreditation, some schools may delay seeking accreditation pending the outcomes of similar programs. For some smaller schools, the cost of the process may be prohibitive. At present, the extent to which the public views an accreditation status granted by CAAM-HP, or any other accrediting organization, as a marker of quality in medical education programs in the Caribbean is unclear.
CAAM-HP continues to seek international recognition and global dissemination of its mission and policies. The organization is a member of the International Network for Quality Assurance Agencies in Higher Education. In addition, CAAM-HP has initiated a review by the National Committee on Foreign Medical Education and Accreditation (NCFMEA), which is part of the U.S. Department of Education. The purposes of the NCFMEA are to review the standards used by foreign countries to accredit medical schools and to determine whether those standards are comparable with standards used to accredit medical schools in the United States (www.ed.gov/about/bdscomm/list/ncfmea.html). The recent acceptance of CAAM-HP by the UK government as the official accrediting authority for new and developing schools in the British Overseas Territories located in the Caribbean is evidence of external governmental support. In addition, CAAM-HP’s membership includes highly respected individuals from the Caribbean, the United States, Canada, and Europe who are experts in the fields of medical education and quality oversight mechanisms.
Stakeholders benefiting from improvement of medical education in the Caribbean through an organization such as CAAM-HP include the patient populations served by graduating physicians, national governments and other regulatory agencies in the region, and current and prospective students. In addition, because many of the graduates of schools located in CARICOM countries are U.S. citizens who intend to return to the United States to practice medicine, residency directors and medical licensing boards will also benefit greatly from improved training and oversight in the region.3
The development and implementation of an oversight organization such as CAAM-HP is a step forward in increasing the quality of medical education, especially in a region such as the Caribbean, which has a large number of training programs that vary substantially across numerous criteria, including admissions standards, size of program and facilities, available resources, medical science curriculum, and clinical training opportunities. In light of the challenges inherent in promoting and implementing an accreditation process, we look forward to further development in this area as CAAM-HP continues to implement a system of encouraging excellence in medical education in the CARICOM region.