By Antonella Parolini and Cindy Platek, Credential Evaluators, World Education Services

What are offshore medical schools?

Offshore medical schools are medical institutions outside the United States that mainly cater to international medical students, most of them U.S. or Canadian citizens. These schools tend to attract students in large numbers who have failed to gain admission to accredited North American medical schools, whether because of low scores on the Medical College Admissions Test (MCAT), low undergraduate GPAs or a combination of both. Distinguishing offshore medical schools from other (public) academic institutions in the Caribbean is the fact that the former offer programs that are geared almost exclusively towards U.S. medical students while the latter mostly train domestic students.

The business of training North American medical students offshore began in the late 1970s with the establishment of campuses on the islands of Dominica, Grenada and St. Martin by American entrepreneurs and medical professionals who saw a demand for medical education that could not be met domestically. Entrepreneurs were able to begin meeting this demand by developing profit-generating institutions that were subject to much less stringent oversight from local authorities than was the case in the United States or Canada.

While in the past only a few Caribbean offshore medical schools existed, more recently they have mushroomed significantly both in number and location. Today, there at least 30 institutions catering almost exclusively to international students, and they are located on more than 15 islands and nations.

The reasons behind this explosive growth over the last decade are fairly straightforward. The primary factor is demand. Simply put, there are not enough places at North American medical schools to meet the demand of aspiring medical students; a demand that comes in part because of severe personnel shortages in the healthcare labor market in the United States. And of course, the basic laws of economic theory suggest that where there is demand for a product or service, supply will emerge to meet it. Also, from a Caribbean perspective, offshore medical schools bring in significant revenue to very small economies that are otherwise almost exclusively reliant on tourism dollars.

A secondary, but not insignificant factor, is the lower tuition costs and laxer admission standards of offshore medical school programs.

Concerns

With such tremendous growth in the number of offshore medical institutions in recent years, there is a considerable degree of concern surrounding the industry among stakeholders and lawmakers in the United States. Given that the primary motivation for the development of offshore medical schools appears to be related to profits (given that they are all for-profit enterprises), critics frequently point to the fact that the non-profit, public-service mission of the medical school as understood in the United States is lost.

Additionally, there are doubts about teaching methods and the availability of teaching materials. Anecdotally, it appears that much of the teaching at these schools is designed specifically to prepare students for the United States Medical Licensing Examination (USMLE) and the Educational Commission for Foreign Medical Graduates (ECFMG) certification process in order to become licensed in the Unites States. This ‘teaching to the test,’ it is argued, leaves students poorly prepared for the rigors of a professional career in medicine.

There is also significant concern that the teaching frequently occurs over the internet and through distance learning programs, which runs contrary to the American medical school model where strict attendance policies are enforced.

With regards to clinical rotations and the integration of offshore medical school students into medical school programs and clinical study programs in the United States, it is very hard for students to transfer to U.S. medical schools. Furthermore, a number of offshore schools fail to meet the necessary standards set by the Liaison Committee on Medical Education (LCME) standards for U.S. residency, and broadly speaking residency directors in the United States do not favor international medical graduates. Many states also require longer periods of residency for international students in order to become licensed.

Another important consideration is that (typically) only a business license is needed to open a medical school in the Caribbean, which is in stark contrast to the rigorous series of standards covering academics, finances, and governance that U.S. medical schools have to comply with to meet the standards of accreditation set by the LCME or the American Osteopathic Association. In most Caribbean nations, licenses are issued with little to no concern over academic standards, and it is these licenses that allow institutions to be listed as a medical school on the International Medical Education Directory (IMED), which qualifies their students to undergo the ECFMG certification process.

Developing Standards

Caribbean Accreditation Authority for Education in Medicine and other Health Professions

These concerns notwithstanding, the establishment of the Caribbean Accreditation Authority for Education in Medicine and other Health Professions(CAAM-HP) has been noted as an important step with regards to improving some of the oversight concerns noted above. Prior to 2003, the Caribbean did not have an entity responsible for the regional assessment and quality assurance of offshore medical school programs. In 2003, CAAM-HP was established, replacing the General Medical Council (GMC) of the United Kingdom, which accredited the medical education programs at the University of the West Indies, at its campuses in Jamaica, Barbados and Trinidad and Tobago.

According to its website, the CAAM-HP is a “legally constituted entity … empowered to determine and prescribe standards and to accredit programs of medical, dental, veterinary and other health professions education on behalf of the contracting parties in CARICOM, … the political and economic affiliation of 15 member states that includes most of the English-speaking islands and some Central and South American nations.”

Certification from the CAAM-HP helps in improving the international acceptance of qualifications awarded by offshore medical schools. For example, the British government has accepted the CAAM-HP as “the official accrediting authority for new and developing schools in the British Overseas Territories located in the Caribbean.” It is also worth mentioning that the CAAM-HP developed its accreditation system based on that of the LCME and the GMC of Great Britain.

However, the accreditation process is voluntary and it is therefore difficult to compare quality standards between different offshore medical schools. So far, the Caribbean Accreditation Authority for Education in Medicine and other Health Professions have only assessed programs from the following schools, only three of which would be considered ‘offshore medical schools’ in the sense that they enroll largely overseas students:

• The University of the West Indies, Jamaica, Barbados, Trinidad & Tobago
• University of Guyana, Guyana
• St. James School of Medicine, Anguilla
• St. George’s University School of Medicine, Grenada
• Ross University School of Medicine, Dominica
• The University of the West Indies School of Veterinary Medicine, Trinidad & Tobago

The CAAM-HP accredits institutions for a six-year period. The only medical education program that is fully accredited for six years is that of the University of the West Indies. For details on assessments and accreditation decisions made by CAAM-HP for the other schools listed above, please refer to assessment page of the CAAM-HP website.

The Foundation for Advancement of International Medical Education and Research

The Foundation for Advancement of International Medical Education and Research (FAIMER) was established in 2000 by the Education Commission for Foreign Medical Graduates (ECFMG). While FAIMER is not an accreditation agency, it is responsible for a process through which overseas-educated medical students can become licensed in the United States. The foundation oversees the International Medical Education Directory (IMED), which, according to its website, is “a free web-based resource” listing all “international medical schools that are recognized by the appropriate government agency in the countries in which they are located.” However, the listing of a medical school in IMED does not mean that the school is recognized or accredited by FAIMER, but simply that it has a license to operate and is listed in a directory of medical schools compiled by the World Health Organization.

In the United States, medical licensing is regulated by each individual state, with each licensing board establishing its own rules and regulations, which are listed on the Federation of State Medical Boards’ website. With regards to the acceptance of students who are educated overseas, California is one of the few states that evaluates offshore medical schools, or accrediting bodies, before licensing their graduates, and it is the only state that visits foreign schools to determine whether they provide an education equivalent to that offered at U.S. schools.

The California board recognizes just four offshore medical schools in the Caribbean as providing education that is equivalent to North American Medical schools:

• St. George’s Univ. School of Medicine, Grenada
• Ross University School of Medicine, Dominica
• American University of the Caribbean School of Medicine, St. Martin
• Saba University School of Medicine, Netherlands Antilles

California, Florida, New Jersey and New York “require individual school review and approval for Caribbean students to do rotations in that state.” ¹ The New York board only visits offshore medical schools for the purpose of U.S. clerkships, but not for licensing purposes. It might also be worth mentioning that “New York has the largest number of international medical graduates in residency training.”²

Differences between medical licensing for U.S. students and international students

The licensing process in the United States consists of three examinations; the so-called USMLE Step 1 to 3 (United States Medical Licensing Examination). To be eligible for licensure, most state boards require that U.S. medical schools be accredited by the Liaison Committee on Medical Education (LCME). Furthermore, residency programs for graduates of LCME-accredited schools must be accredited by the Accreditation Council for Graduate Medical Education (ACGME), which is the entity responsible for the accreditation of U.S. medical education programs.

International students have to undergo the same licensing process as U.S. students; however, additional steps are required in order for them to become state-licensed. First, to be eligible to take the USMLE examination, an international student’s medical school must be listed in the IMED. Second, to be eligible for ACGME-accredited residency programs in the United States, international students must obtain an ECFMG certificate.

There is more on the ECFMG certification process in the accompanying piece in this month’s WENR.

Structure of offshore medical school programs

Typically, the curricula at offshore medical schools parallel that of medical schools in the United States. Admission to medical school programs usually requires three years of undergraduate study, sometimes a bachelor’s degree, but rarely scores from the MCAT. The length of program varies between three to five years and generally, the academic year is organized on a tri-semester basis (spring, summer, and fall). Students typically need to complete both the basic sciences component and the clinical rotations of the medical school program. Usually, the basic sciences component is four to five semesters and the clinical rotations are completed during the third and fourth year. Clerkships need to be at either Caribbean hospitals, U.S. hospitals or U.S. schools which are affiliated with the offshore medical school.

U.S. Equivalency

At World Education Services (WES), study completed at offshore medical schools is considered professional study. WES does not deem offshore medical schools equivalent to accredited U.S. medical schools. Because of the growing number of offshore medical schools being recently established in the Caribbean and the newly founded CAAM-HP, it is difficult to determine the accreditation status of an institution. Since the CAAM-HP is still in its infancy stage and therefore not many schools have been reviewed, more time is needed to determine the quality of education being imparted at Caribbean offshore medical schools.

Conclusion

Considering the anticipated shortage of physicians in the United States, the number of newly established medical schools will most likely continue to grow. Thus, evaluating programs from offshore medical schools in the Caribbean will continue to be a difficult task to undertake. With time, the accreditation processes in place will assist us in deepening our understanding of offshore medical schools and their comparability to American medical school programs.

1. Jessica Freedman, MD. Caribbean Medical Schools; A good option? Student Doctor Network. 2009.

2. Ibid.