Secondary Logo

Journal Logo


The Shortage of Clinical Training Sites in an Era of Global Collaboration

Burdick, William P. MD, MSEd; van Zanten, Marta PhD; Boulet, John R. PhD

Author Information
doi: 10.1097/ACM.0000000000001129
  • Free


The growing number of health professions students and the shift toward ambulatory care and shorter hospital stays are combining to create a shortage of clinical training sites around the world. In this issue of Academic Medicine, Halperin and Goldberg1 have framed the struggle to identify clinical training sites in the United States as a competition between U.S. medical schools and unaccredited, low-quality, for-profit Caribbean medical schools that are “buying” clinical sites. While greater competition between U.S. and overseas medical schools has indeed had an impact on clinical training opportunities, moral arguments based on profit status do not stand up to scrutiny in the presence of a valid accreditation process. Halperin and Goldberg imply that adherence to the Hippocratic Oath means that medical schools should not offer payment for clinical education. On the contrary, we believe direct payment for clinical training slots can be seen as a transparent accounting of the true cost of clinical education. In this Commentary, we will address medical school accreditation in the Caribbean region, quality and cost concerns, and the potential for global exchange of clinical training opportunities as a solution for regional shortages.

Medical School Accreditation in the Caribbean Region

Several accreditation agencies operate in the Caribbean region: the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP), the Accreditation Commission on Colleges of Medicine, and the Netherlands-Flemish Accreditation Organization. In some Caribbean countries, the ministries of education and/or health also review domestic medical education programs.

In 2010, the World Federation for Medical Education (WFME) implemented a system to “recognize” agencies that accredit medical education programs in an effort to promote quality of medical education around the world.2 The WFME recognition process includes analysis of an accreditation agency’s standards and procedures and on-site verification of compliance with the recognition criteria. Recognition by the WFME confers the understanding that an accreditation agency has credible policies and procedures to ensure the quality of medical education in the programs and schools that it accredits. CAAM-HP obtained WFME recognition in 2012, and other accrediting agencies are now undergoing review. Beginning in 2023, to be eligible for the Educational Commission for Foreign Medical Graduates certification required for entry into a U.S. residency, an applicant must have graduated from an “appropriately accredited” medical school3—a designation satisfied by WFME recognition of the accrediting authority.

CAAM-HP operates under the aegis of the Caribbean Community nations, and its accreditation system is based on the Liaison Committee on Medical Education (LCME) process.4 As of September 2015, CAAM-HP had assessed 17 of the approximately 32 English-language medical schools in the Caribbean region. The agency granted provisional accreditation to 5 schools and accreditation with conditions to 4 schools, and it denied accreditation to 7 schools. One decision is pending.

Halperin and Goldberg refute the notion that the U.S. Department of Education’s National Committee on Foreign Medical Education and Accreditation (NCFMEA) provides oversight of medical schools in the Caribbean, and they are correct. In a process separate from accreditation, the NCFMEA determines the comparability of LCME standards with the standards used by the agencies that accredit medical schools in their region of the world. The purpose of NCFMEA determination of comparability is to decide whether U.S. citizen students at international medical schools are eligible to receive Federal Family Education Loan funds.5

Quality and Cost Concerns

Concerns about the quality and role of international graduates in the U.S. and Canadian medical systems have been addressed in a number of places.6,7 Most U.S. international medical graduates (USIMGs) return to provide patient care in the United States, and good clinical training is in our patients’ interest. Currently, there are 10,409 USIMG residents in the United States (8.2% of all residents), and 50,838 (5.3%) of all the active physicians in the United States are USIMGs. Fifty-five percent of USIMGs are in primary care specialties compared with 30% of U.S. graduates.8 Together, graduates from two Caribbean schools, Ross University School of Medicine and St. George’s University School of Medicine, represent over 2% of the U.S. physician workforce.

As Halperin and Goldberg point out, students at Caribbean schools have lower Medical College Admission Test (MCAT) scores than students at U.S. schools. Yet while MCAT scores are a modest predictor of medical school grades, correlation of grades with quality of care provided after graduation is lacking.9 Quality of medical school graduates is not only hard to judge but also varies widely within the United States. Indeed, using mortality rate data for myocardial infarction and congestive heart failure, a recent study found that patients of foreign medical graduates and U.S. graduates had similar outcomes.10

Halperin and Goldberg imply that student indebtedness, loan default rates, and for-profit status create a moral argument against sharing clinical training sites in the United States with Caribbean schools. While median medical education indebtedness for students at U.S. schools is $180,000,11 the range is wide ($13,902–$239,68012) and similar at the upper end to the debt levels of students at schools in the Caribbean. A few Caribbean schools are considerably less expensive than those in the United States.13 Furthermore, the loan default rate for Caribbean students ranges from 0.70% to 2.44%, which is consistent with the rate for U.S. graduates.14 Finally, the Commission on Osteopathic College Accreditation and the LCME have both accredited for-profit medical schools. In our view, rigorous accreditation standards are the key, not where the net revenues go.

Global Educational Exchange: A Possible Solution

The shortage of clinical training sites and clinical supervisors around the world, particularly in Europe and Australia, has not been rigorously documented, but is widely acknowledged and has been attributed to rising numbers of medical students, shorter hospital stays, more outpatient surgeries and prehospitalization workups, and increasing demands on clinicians’ time.15 Because fewer students can be accommodated at an outpatient site compared with an inpatient setting, more sites are needed. In the United States, the challenge of recruiting and maintaining clinical training sites was highlighted in a 2013 survey of nursing, physician assistant, osteopathic, and allopathic disciplines in which 80% to 90% of respondents indicated a shortage.16 In addition, while students may provide opportunities for enhancing care, on balance they are generally a drain on the system. This cost can be borne by the clinical site, the clinician, the patient, or the medical school, but it needs to be acknowledged. Payment has traditionally been provided by medical schools in the form of faculty appointments, library rights, and other benefits, but the demand has increased—and the price has increased with it.

In an era of global collaboration,17 the shortage raises the question of whether there should be a free market for clinical training sites, and whether the U.S. market should be open to students from accredited medical schools outside the United States. Global educational exchange of health professions students, such as that facilitated by the GEMx program at the Educational Commission for Foreign Medical Graduates,18 needs to emphasize equitable access to clinical training opportunities in high- and low-resource countries. Educational exchanges may be part of the solution to the site shortage, but only if such exchanges are bilateral.

In Sum

The shortage of clinical training sites is real. Recognizing the true cost of educating students in the clinical arena and embracing global educational exchange may be part of the solution. Acknowledging that students may participate in that exchange if they attend a school accredited in a WFME-recognized process is another critical element.


1. Halperin EC, Goldberg RB. Offshore medical schools are buying clinical clerkships in U.S. hospitals: The problem and potential solutions. Acad Med. 2016;91:639644.
2. World Federation for Medical Education. Recognition of accreditors. 2015. Accessed December 22, 2015.
3. Educational Commission for Foreign Medical Graduates. Medical school accreditation requirement for ECFMG certification. Accessed December 29, 2015.
4. van Zanten M, Parkins LM, Karle H, Hallock JA. Accreditation of undergraduate medical education in the Caribbean: Report on the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions. Acad Med. 2009;84:771775.
5. U.S. Department of Education. National Committee on Foreign Medical Education and Accreditation (NCFMEA). Accessed December 22, 2015.
6. Norcini JJ, Boulet JR, Opalek A, Dauphinee WD. The relationship between licensing examination performance and the outcomes of care by international medical school graduates. Acad Med. 2014;89:11571162.
7. Andrew RF. How do IMGs compare with Canadian medical school graduates in a family practice residency program? Can Fam Physician. 2010;56:e318e322.
8. American Medical Association. AMA Physician Masterfile. 2015.Chicago, Ill: American Medical Association.
9. Julian ER. Validity of the Medical College Admission Test for predicting medical school performance. Acad Med. 2005;80:910917.
10. Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Evaluating the quality of care provided by graduates of international medical schools. Health Aff (Millwood). 2010;29:14611468.
11. Association of American Medical Colleges. Medical student education: Debt, costs, and loan repayment fact card. October 2015. Accessed December 22, 2015.
12. U.S. News and World Report. Which medical school graduates have the most debt? Ranked in 2015, part of Best Medical Schools. Accessed December 22, 2015.
13. Eckert NL, van Zanten M. Overview of For-Profit Schools in the Caribbean. FAIMER Short Report. 2014. Philadelphia, Pa: Foundation for the Advancement of International Medical Education and Research; Accessed December 16, 2015.
14. U.S. Department of Education. Federal student aid. Default rates. Accessed December 22, 2015.
15. Sen Gupta T, Hays RB, Woolley TS, Seidl I, Johnson A. Challenges with maintaining clinical teaching capacity in regional hospitals. Med J Aust. 2011;195:584585.
16. American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, Physician Assistant Education Association, Association of American Medical Colleges. Recruiting and maintaining U.S. clinical training sites: Joint report of the 2013 multi-discipline clerkship/clinical training site survey. 2014. Accessed December 16, 2015.
17. Ke Y, Sun Q, Zhang L, Hou J, Du W. Wartman SA. Chapter 10: Advancing collaborative global education programs. The Transformation of Academic Health Centers: Meeting the Challenges of Healthcare’s Changing Landscape. 2015:London, UK: Academic Press; 9199.
18. Educational Commission for Foreign Medical Graduates. GEMx. Global education exchange in medicine and the health professions. Accessed December 16, 2015.
Copyright © 2016 by the Association of American Medical Colleges