Eckhert, N. Lynn MD, MPH, DrPH
American allopathic medical education is in the midst of a transformation, as the number of annual graduates rises from the steady state of 15,000 to 16,000 during the years 1980 to 20051 to a predicted total of more than 21,000 by 2015, a 30% increase.2 The expansion strategies—increases in class size and in the numbers of branch campuses, as well as the establishment of new medical schools—are carefully monitored by the Liaison Committee on Medical Education (LCME). Occurring simultaneously, but more rapidly, is the growth in offshore medical schools (OMSs), which are identified by the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) as for-profit institutions whose purpose is to train U.S. and Canadian students who intend to return home to practice medicine (personal communication, Lorna M. Parkins, executive director, CAAM-HP, June 14, 2009). Since the 1970s, as the New York State Education Department3 recently pointed out, these schools have commonly been referred to as “‘split-campus’ schools” whose enrollees study the basic sciences at one location, outside of the United States, and the clinical sciences at other locations in the United States.
Since 2000, 24 new OMSs have opened (4 of which have subsequently shut down). Located in various national jurisdictions, OMSs do not fall under a single accreditation body; rather, schools seek accreditation, or mere recognition, by local and international organizations, which may or may not apply rigorous assessment standards. In 2004, a nascent effort by the International Association of Medical Colleges,4 a consortium of medical schools enrolling North American students, promoted an accreditation built on composite standards derived from internationally recognized standards such as those set forth by the World Federation for Medical Education, the LCME, and the New York State Education Department. Data on a few of the reviewed medical schools were available online at one time, but those data were later withdrawn.
In the meantime, work was ongoing in the Caribbean in response to the 2001 decision by the General Medical Council (GMC) of the United Kingdom to discontinue the accreditation of overseas medical education programs—a decision that left the University of the West Indies (UWI) without recognition by an internationally recognized body. UWI, established as the University College of the West Indies in 1948 to educate students from the Caribbean region, is a multicampus university that is a former constituent of the University of London (having become an independent entity named UWI in 1962). Absent the GMC accreditation process, UWI's collaboration with the Caribbean community to establish an accreditation body, CAAM-HP,5 opened up a potential avenue for the international accreditation of offshore schools. CAAM-HP built on standards from the United Kingdom, the United States, and other countries to establish the Standards for the Accreditation of Medical Schools in the Caribbean Community6 and a system of self-assessment and external review. To date, seven medical schools, two non-OMSs and five OMSs, have been reviewed by CAAM-HP. Only one, UWI (a non-OMS), has received a full six-year accreditation without conditions. The CAAM-HP accreditation statuses of OMSs that have been assessed are shown in Table 1.7 Unlisted in the International Medical Education Directory (IMED), the British International University in Montserrat was reviewed by CAAM-HP, and its status of provisional accreditation was withdrawn because of a failure of response.
One hundred years ago, the Flexner Report,8 whose creation was prompted by concern about the uneven quality of education offered in the rapidly expanding number of medical schools (many of them proprietary) in the United States, stimulated major changes in standards, curriculum, and the number of schools. In 2000, Kassebaum and Cohen,9 acknowledging that students from OMSs were returning to the United States for clinical clerkships, recommended “measures to strengthen the oversight of U.S.-based educational programs serving the interests of foreign medical schools.” More recently, the Special Committee to Evaluate Undergraduate Medical Education, a part of the Federation of State Medical Boards, called for the establishment of a national clearinghouse for data and information on international medical schools with an emphasis on quality indicators.10
International Medical Graduates
Our need to know more about international medical education is underscored by the growing migration to the United States of physicians from other countries and the increasing number of U.S. citizens who are attending medical schools outside of the United States.11 Industrialized nations rely on a continuous stream of international medical graduates (IMGs) to shore up their health care systems; IMGs make up 25% of the U.S. physician workforce, 27% of medical residents,12 and 17% of medical school faculty.13 IMGs are more likely than are U.S. medical graduates to practice as generalists (39.3% and 34.2%, respectively), but they are less likely to practice in rural areas.14 However, IMGs are more likely than are their U.S. counterparts to practice general surgery in isolated rural areas (25.2% and 20.1%, respectively).15 Although IMGs are required to obtain certification from the Educational Commission of Foreign Medical Graduates (ECFMG) as a condition of licensure (and, thus, their medical school graduation must be verified), little is known about medical education in the more than 2,000 medical schools located outside of the United States and Canada. An analysis of these schools would be a daunting task, but evaluating those schools close to the United States is a good beginning, because 27% of the IMGs are U.S. students,16 most of whom graduated from OMSs. An example of the significance of OMSs is the fact that, in 2007, two of them—St. George's University and Ross University—each had more graduates (1,644 and 1,591, respectively) enrolled in Accreditation Council for Graduate Medical Education (ACGME) programs than did any single U.S. medical school.17
Issues Surrounding Accreditation
Unlike the world's hospitals, which have the option of achieving international recognition from the Joint Commission International, a global accreditation spinoff of the Joint Commission, the world's medical schools have no international accreditation process in place. Several efforts in the United States obliquely approach the accreditation of foreign medical schools. At the national level, the Higher Education Act of 1992 (Public Law 102–325, sections [a][B]) established the National Committee on Foreign Medical Education and Accreditation (NCFMEA),18 whose role is to review the medical school accreditation standards of foreign countries. The NCFMEA does not review individual schools, but if another country has accreditation standards deemed comparable to U.S. standards, U.S. students enrolled in a medical school in that country may be eligible for the Federal Family Education Loan (FFEL) Program. In a 2009 report to Congress, NCFMEA recommended institutional criteria for participation by certain foreign medical schools in the FFEL Program. Five medical schools, three of which are located in the Caribbean Basin (American University of the Caribbean School of Medicine, on St. Maarten; Ross University School of Medicine, on Dominica; and St. George's University School of Medicine, on Grenada), have been “grandfathered in” under the 1992 Higher Education Act amendments and thus are exempt from certain institutional eligibility requirements.19
At the state level, the New York State Education Department, in response to the proliferation of both OMSs and requests for clinical clerkships in New York, developed a system for evaluating OMSs.20 Similarly, the New Jersey Board of Medical Examiners21 and the Florida Commission on Independent Education (part of the Florida Department of Education)22 have each developed systems to determine whether OMSs should be approved to conduct clinical training programs in their respective states.
The lack of uniform global accreditation standards is problematic for the Federation of State Medical Boards and its 70 state and territorial jurisdictions that are responsible for granting medical licenses to trainee physicians and practitioners. There are two parts to the common gateway for all physicians seeking U.S. entrance: verification of medical school graduation and a passing score on the United States Medical Licensing Examination (USMLE). Because the inclusion of the clinical skills examination as Step 2 CS of USMLE eliminated the separate assessment of clinical skills that was required by the ECFMG, the pathway for IMGs and U.S. medical school graduates became the same. Nonetheless, U.S. medical schools attended by U.S. students must meet LCME standards, whereas schools attended by IMGs (U.S. or non-U.S.) merely need to be listed in IMED, a compilation of recognized but not necessarily accredited schools. Some states, such as Arkansas,23 California,24 Indiana,25 Kansas,26 Michigan,27 Oregon,28 and Texas,29 do not consider USMLE performance sufficient evidence of the quality of a medical education and have identified international schools whose graduates are ineligible for licensure.
The Medical Schools
Although we may have confidence in LCME's oversight of the expansion of medical schools in the United States, the growth of OMSs is not monitored by a similar process. For students applying to U.S. medical schools, the Association of American Medical Colleges' Medical Schools Admission Requirements (www.aamc.org/students/applying/msar.htm) and the Web sites of individual medical schools are rich resources. In contrast, gaps in information on OMSs occur, whereby students are unable to gather key data such as admissions criteria, faculty qualifications, and information on curriculum design and clinical rotations. In this article, we describe a study of the 38 English-language medical schools listed in IMED that are located in the region of the Caribbean and Central America and that cater to U.S. citizens.30 This study drew on all available sources, including regulatory and evaluative body reports, Web sites, and news reports.
Figure 1 indicates the growth in the number of OMSs over the past four decades. Twenty-four (63%) of these 38 schools have opened since 1999. Figure 2 shows the distribution of the existing medical schools: 67% of the existing OMSs are sited in four countries: the Netherland Antilles (six schools), St. Kitts (seven), St. Lucia (five), and Belize (four).
Table 1 shows key characteristics of the OMSs. With the exception of the Universidad Autónoma de Guadalajara (UAG), a private, not-for-profit university whose medical school has an international program, OMSs are for-profit entities. Three schools—St. Matthew's University, Saba University School of Medicine, and the Medical University of the Americas—have been recapitalized by Equinox Capital within the past few years.31 In 2003, Ross University in Dominica was purchased for $310 million by DeVry Inc., a publicly traded company.32
Admissions occur three times a year—September, January, and May. Science prerequisites are similar to those in LCME schools, although only 7 of the 33 OMSs required applicants to submit Medical College Admissions Test scores. Dual-degree programs of two different types are offered by some OMSs—those offering a second advanced degree such as an MD–MBA or MD–MPH and those offering early admittance to undergraduate students from selected partner institutions. In the latter programs, students who meet a prescribed level of performance receive their BA or BS after successful completion of a portion of the medical school curriculum and then receive the MD at the end of the program. One school, the University of Science, Arts, and Technology in Montserrat, offers accelerated MD degree programs for enrollees who already are doctors of osteopathy, physician assistants, or dentists. Most schools accept transfer students; in some cases, these students can matriculate for as short a time as the final 36 weeks of the program and still can graduate from the institution. Many schools promote their small class sizes, but three OMSs report total enrollments of several thousand: Ross University School of Medicine, with more than 2,500 students; St. George's University Medical School, with more than 2,300; and UAG, with more than 4,000 (of whom 20% are U.S. citizens).33 Responding to its rapid growth, Ross University opened a branch campus on Grand Bahama Island in early 2009.
The educational program
The UAG stood out for its offering of four years of basic and clinical science in Mexico and a fifth year in the United States. This so-called “Fifth Pathway,” an American Medical Association (AMA)-endorsed program that began in 1971, was offered to U.S. citizens who were graduates of a U.S. undergraduate institution and who had completed four years of education in a foreign medical school. These students were required to complete a fifth year of clinical service in the United States as a condition of graduation. In lieu of the service-year obligation, students could complete a year of supervised service at a U.S. medical school. They did not graduate from either the foreign or the U.S. medical school but received a certificate of completion of the Fifth Pathway, which made them eligible for licensure and a U.S. residency. The AMA Council on Medical Education ceased accepting entrants into this program on June 30, 2009.34
All other OMSs teach basic science for four semesters (60 weeks) at their own locations and clinical science for five or six semesters (72–88 weeks) at U.S. clinical sites. The first clinical science semester (the fifth semester overall) commonly combines an introductory course on medicine in the United States with a commercial USMLE Step 1 preparatory course. Students may be required to pass the USMLE Step 1 before they begin their clinical rotations, which are offered throughout the United States but predominantly in Florida, Georgia, Illinois, Maryland, Michigan, New Jersey, and New York. Some hospitals provide clinical rotations for students from more than one OMS, and each OMS pays approximately $400 per student per week of clinical training. In a move that sent shudders through U.S. medical schools in 2008, New York City's Health and Hospitals Corporation signed an exclusive, 10-year, $100 million contract with St. George's University to provide 600 clinical rotations for its students at the city's 11 public hospitals.35 In a similar arrangement, the American University of the Caribbean agreed to pay $19 million to Nassau University Medical Center (Hempstead, NY) for exclusive rights to train 64 medical students on clinical rotations.36 Because of the paucity of available data on class size at OMSs, the number of medical students enrolled in clinical rotations in the United States is unknown, but estimates are several thousand per year.9
Variability exists in the availability of information on faculty; where data exist, it is noted that most of the permanent on-site basic science faculty members are internationally trained, many have no documented medical education experience in the United States, and it is not uncommon for them to be OMS alumni. Core on-site teaching faculty often are joined by current and retired U.S. medical school faculty who come to the OMS for several weeks or months to lecture in their areas of expertise. The clinical teaching is provided at U.S. facilities that are not likely to be first-choice hospitals for U.S. medical students and that are mostly staffed by IMG physicians and residents. Notably minimized and in most cases absent at OMSs is a research enterprise.
Tuition and loans
Information on four-year tuition was available for 28 of the OMSs; it ranged from $47,500 to $186,085 (median: $84,500). Students at four schools were eligible for the U.S. FFEL Program.37 The U.S. Government Accounting Office data from 1992 to 2002 indicated that 75% of students (n = 9,000) who received FFEL Program support to study at foreign universities were attending a medical school.38 The 2009 report to the U.S. Congress by the U.S. Department of Education's NCFMEA indicated that three foreign medical schools—the American University of the Caribbean School of Medicine, on St. Maarten; Ross University School of Medicine, on Dominica; and St. George's University School of Medicine, on Grenada—certified $293 million or 93.1% of FFEL Program funds dispersed to students enrolled in foreign medical schools.19
The Need to Know More
Although Caribbean medical schools are considered “OMSs,” perhaps they would best be classified as “hybrid medical schools,” whose students begin their medical training offshore but return to the United States for clinical clerkships. The OMSs are not accredited by LCME, and so the public, the profession, and the next generation of U.S. medical students need assurance from U.S. experts that OMS students receive a quality education and that they are prepared to become colleagues and caregivers as they rotate through U.S. hospitals and physicians' offices, join ACGME residency programs where they will care for patients, and become frontline teachers of U.S. medical students. Furthermore, there is an a priori value in assisting U.S. students who, for diverse reasons, such as a failure to attain admission to an LCME-accredited medical school, personal circumstances, or preference for training at an OMS, make a decision to enroll in an OMS with the intention of practicing medicine in the United States.39
An examination of OMSs raises questions about medical education at those schools and reveals challenges for U.S. medical education. Foremost among these challenges is the paucity of available data on OMSs and on the outcomes of their educational programs and the follow-up on their graduates. A broad array of data on the institutions is needed, including information on institutional recognition, accreditation, governance, ownership, leadership (qualifications and experience), students (admissions, mentoring, and advising), faculty (qualifications, supervision, and mentoring of medical students), and curriculum (basic science and clinical rotations). Also greatly needed are data on outcomes: student performance on USMLE exams, success in obtaining an ACGME-approved residency position, and success in obtaining a license to practice medicine. Whereas the proposed national clearinghouse on international medical education programs that emphasizes quality indicators may be a step forward, several economic and societal policies of the OMSs mean that a more detailed look at this educational alternative for U.S. students is merited. Given the proprietary status of these schools and the effect of that status on their responsibility to their students and faculty (besides that on the owners and/or shareholders), a closer analysis of the tensions that arise and how they are managed is warranted. The leverage for clinical rotations that OMSs have with U.S. hospitals also deserves further attention. As U.S. academic health centers struggle with the rising cost of educating medical students, the increasing level of medical student debt, and expansions in class size, the potential competition with OMSs for federal loan monies and clinical clerkship sites may lead to conflict—or to innovative, collaborative solutions. The possibility that performance on the USMLE has become the proxy measure for quality medical education, regardless of the school attended, raises troubling issues. If the USMLE alone is a sufficient measure, how does that reflect on the LCME accreditation process in the United States? Another challenge is the need to define and measure the effect on medical education of the robust research enterprise to which medical students are exposed at U.S. schools and to compare that effect with the minimal or absent research element of the programs at OMSs.
OMSs also may provide lessons of management and efficiency, because these “for-profit” schools, with relatively small faculty rosters, train three groups of students each year. As what Christensen40 termed “disruptive competitors,” OMSs may have innovative methods of instruction, creative financing proposals, or distance learning modalities that could prove useful for U.S. medical schools.
In all likelihood, further study will reveal a wide variation in the quality of educational programs being offered at OMSs, but recognition that OMS graduates will likely practice in the United States obligates U.S. medicine to take a closer look at these educational programs. Just as the Flexner Report strengthened medical education by raising standards, recommending quality improvements, and suggesting closure of weaker schools,8 a present-day review of the schools whose purpose is to train physicians for the United States could lead to recommendations for improvement and/or accreditation, educational innovations, or sanctions against poorly performing medical schools.
In the best of circumstances, when the common goal is expanding the U.S. physician workforce, opportunities may arise for cooperation and collaboration. In the long run, a better understanding of OMSs as a subset of foreign medical schools may lead to insights into medical education around the globe, which is a necessity as more and more physicians migrate from country to country. If we begin by acknowledging our need to know more about the medical education of the IMGs who will be central to health care delivery in the United States, we can debate within the “house of medicine” how best to improve the medical education in foreign medical schools of students who intend to practice medicine in the United States.
In this perspective, I have identified gaps in our knowledge of the medical education of a subset of IMGs—primarily, U.S. citizens who will practice in the United States—and have supported the recommendation by the Federation of State Medical Boards for a national clearinghouse for international medical schools. Nearly a decade after they published it, Kassebaum and Cohen's9 recommendation to strengthen the oversight of these educational programs is even more critical now, when such a brisk growth in the number and size of OMSs is under way. Moreover, a coordinated review of OMSs by U.S. academics and regulators would benefit state medical boards, residency selection committees, and hospitals as they wrestle with the evaluation of applicants.
Now is the time for the United States to boldly step forward to improve the quality of medical education. As the recognized world leader, we can look beyond our borders to ensure that physicians around the world obtain the best possible education. To begin this effort close to home—in the Caribbean Basin—makes good sense, because the growing number of graduates from the OMSs there will be part of the next generation of physicians caring for the U.S. public and practicing alongside U.S.-trained physicians.
The author wishes to thank Rachel D'Ambrosio, associate director, Global Programs, Partners Harvard Medical International, for her review of this manuscript.
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