Quality concerns spur scrutiny of Caribbean medical schools

State medical boards worry about the caliber of graduates' training as they seek U.S. medical licenses.

By — Posted Jan. 16, 2006

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With a recent explosion in the number of for-profit Caribbean medical schools catering to U.S. students, state medical board officials want to make sure students attending these schools get the skills they need to practice medicine in the United States.

The increase has prompted the Federation of State Medical Boards to review the existing systems used to evaluate American and international medical license applicants. Also, some state medical boards have created lists of schools from which they will not license graduates.

Licensing board officials are concerned that some medical school graduates might pass the U.S. Medical Licensing Exam, complete the clinical physical exam test and get into a residency program, but do so without a medical education that truly qualifies them to practice unsupervised, which is what a license ensures.

"This is becoming a huge issue on a national level and in California," said Joyce Hadnot, chief of licensing at the Medical Board of California. "You may find someone ... sharp enough to pass a test but not have the skills to practice medicine independently."

There's been no flood of disciplinary actions. Instead, it is the deluge of new schools that has raised concerns. Since 2000, California's board has documented 40 new medical schools outside the United States, with more than half of them in the Caribbean. At the other end of the pipeline, the Educational Commission for Foreign Medical Graduates reports that the number of U.S. citizens with foreign medical degrees seeking certificates to participate in the National Resident Matching Program jumped 39% in the past decade, from 527 in 1995 to 1,360 in 2004.

Dale Austin, the FSMB's senior vice president, said the changing statistics give medical board officials pause. One statistic that has caught their attention: In 2004, 53% of American citizens who graduated from international medical schools passed the USMLE Step 1 on their first try, a full 17 percentage points lower than the 70% of citizens of other countries who attended medical school outside the United States who passed the test on the first try that year.

In response to this and similar data, an FSMB committee's draft report recommends several things to evaluate the quality of medical schools outside of the United States, including creating a database to track international medical schools' records. The database could contain information such as the date a school opened, the percentage of Internet distance learning in the curriculum, the number of weeks of study required to earn a degree, graduates' job placement rates and USMLE scores.

"Boards are increasingly concerned about IMGs from these schools, their caliber and the rigor of their basic medical education," Austin said. "We have no good means of assessing that."

Increasing worries from FSMB member boards led to the special committee that produced the draft report. A final version is expected this spring. The proposed database is the most concrete report recommendation, but it's unclear if FSMB members will chose to pursue it, Austin said.

Call for a unified standard

International medical graduates make up a quarter of practicing physicians in the United States. The majority come from established schools, which state boards consider to be credible because they've existed for years and are geared to produce physicians to practice in their home countries.

The new Caribbean schools, however, have little history and are geared toward training U.S. citizens. While the schools often send students to the United States for clinical experience, the clerkship may or may not be as good as the ones U.S. students do through accredited programs.

In the United States and Canada, the Liaison Committee on Medical Education and the American Osteopathic Assn.'s Commission on Osteopathic College Accreditation maintain medical school standards. There is no comparable international accreditation group, the FSMB said.

California is the only state that visits foreign schools to determine whether they provide an education on par with U.S. schools. At least five other states keep lists of approved and non-approved schools but don't visit the campuses. The Kansas State Board of Healing Arts, for instance, has schools seeking acceptance to its approved list submit information on their curriculum and training to a review committee. Schools get automatic approval in Kansas if they've existed for 15 years or more. New York board officials visit campuses, but only for schools seeking U.S. clerkships, not for licensing.

Richard D. Fantozzi, MD, president of the Division of Licensing for the Medical Board of California, has conducted site visits. He'd like to see states adopt uniform standards so offshore schools have a clear idea of the measures they must meet.

"Let's embrace these schools and work with them," Dr. Fantozzi said. "But let's put a group together to say, 'This is what our standards are.' "

He said the USMLE is just one element of the licensing process and that students' medical education also needs to be evaluated. "Are you going to certify process or applicants?" Dr. Fantozzi asked.

California sees medical school admissions and curricula as a critical element to consider before issuing medical licenses. For example, the board wants to know how a school selects its students. Dr. Fantozzi said that if there is no admissions committee, it's likely that little screening occurs. If the school has a committee, he said he would want to know its criteria.

Bernd Wollschlaeger, MD, chair of the American Medical Association's IMG Section, agreed that uniform U.S. medical licensing standards were the way to go.

"When individual states create their own standards, this creates a patchwork that discriminates against candidates who are highly qualified," Dr. Wollschlaeger said.

Without uniform standards, Dr. Wollschlaeger said, medical residents might train in a state and discover they can't get a license there because they attended a school on the state's disapproved list. He was contacted by a medical resident in Indiana who faced this situation and after finishing training had to move in order to practice.

The IMG Section's stance on this issue is not the same as the AMA's. The IMG Section, while under the AMA's umbrella, may hold views that are not AMA policy. An IMG-sponsored resolution to support uniform licensing standards was rejected by the AMA House of Delegates in recent years, Dr. Wollschlaeger said.

The AMA does support the FSMB's efforts to look at designing a way to evaluate international medical schools and determine whether their programs are stringent enough for graduates ultimately to receive licensure from a state medical board.

Caribbean schools respond

Jerry W. Thornton, PhD, vice president of St. Matthew's University School of Medicine on Grand Cayman Island, said that although rogue schools are popping up in the Caribbean, the numbers being discussed were unreasonably high. He estimated that there were 30 medical schools in the Caribbean, as opposed to other sources who pegged the total near 65.

Dr. Thornton believes his institution and four others among the 30 schools provide an education equivalent to that of American schools. But he questioned state boards' ability to provide qualified inspectors to evaluate them. When the California board reviewed his school, he said, the site team consisted of a pediatrician, a social worker and an attorney. His school failed a review by the board in February 2005. It paid $65,000 for the evaluation.

He thought his school had every piece of the puzzle in place. Its students are allowed to do clerkships in Florida and New York, and its alumni are among board-certified physicians practicing in the United States outside of California.

"It was very disappointing," Dr. Thornton said. "We went through a two-year examination period that culminated in a site visit and exit interviews. We had no sense that there were problems."

Meanwhile, some international schools are taking matters into their own hands. The newly formed International Assn. of Medical Colleges' provisional members include five schools from the Caribbean, two from Poland and one from the Philippines. The group aims to adopt standards similar to those of the LCME by early 2006, gather a team of experts for site visits, begin evaluating schools and make the results public.

Medical licensing and education experts in the United States said the IAOMC's efforts were commendable, but they said an inherent conflict of interest could limit creditability.

Austin with the FSMB said a simple solution was unlikely. "In the final analysis, the grantor of a medical license is protecting the public," Austin said. "Are you licensing the wrong individual? That's what keeps you up at night."

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One state's list

California appears to have the only formalized review process in place that includes visiting international schools. Here are schools the Medical Board of California says do not meet medical training and education requirements for licensure in the state.

School, location Date listed
CETEC University,
Santo Domingo (closed)
CIFAS University,
Santo Domingo (closed)
UTESA University,
Santo Domingo
(reaffirmed 1997)
World University,
Santo Domingo (closed)
Spartan Health Sciences
University, St. Lucia
University of Health
Sciences Antigua, St. John's
Universidad Eugenio
Maria de Hostos,
Dominican Republic (closed)
Universidad Federico
Henriquez y Carvajal,
Dominican Republic
St. Matthew's University,
Grand Cayman

Source: Medical Board of California, Federation of State Medical Boards

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Offshore growth

Estimates of the number of Caribbean medical schools vary from 30 to 65. But there is agreement that growth is rapid. Here is the Medical Board of California's estimate of how many schools have opened each decade.

1970s 5
1980s 10
1990s 8
2000s 29

Source: Medical Board of California

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