Friday, December 5, 2014

Caribbean medical schools: "second chance" or serving a real need?

chance med school
”, by Anemona Harticollis in the New York Times July 31, 2014,
is the most recent treatment of the topic of for-profit Caribbean medical
schools that train American students who, in most cases, were unable to gain admission
to traditional US-based schools. This is not the first time Ms. Harticollis has
covered the story; they are also the subject of her article in the Times from December 22, 2010, “Medical
schools in region fight Caribbean flow”
, which focused on the fear of US
schools that these Caribbean schools are willing to pay for the use of clinical
teaching spots in hospitals that these US-based schools have been using for
free. This most recent piece focuses on St. George’s University in Grenada, one
of the more established and better-regarded Caribbean schools. It was briefly
famous when protection of its students was one of the justifications for
President Ronald Reagan’s invasion of that country in 1983. The article also
mentions the other three schools that have been approved for US loans by the
Department of Education. However, beyond this, and despite Harticollis’
efforts, the discussion gets murky on two counts: which Caribbean schools are
under discussion, and what are the issues of concern.

 Harticollis notes
There are more than 70
medical schools across the Caribbean, about half of them catering to Americans.
A handful — including St. George’s, Saba University, Ross University in
Dominica and American University of the Caribbean in St. Maarten, all of which
are for-profit — have qualified for federal financial aid programs by
demonstrating that their standards are comparable to those in the United
States. And they report that high numbers of their test-takers — 95 percent or
more — pass the United States Medical Licensing Exam Step 1, a basic science
But quality is all over
the map in the Caribbean. A 2008 study in the journal Academic Medicine looked
at 14 schools and found that the first-time pass rate on the exam ranged from
19 percent to 84 percent. Countries whose schools performed lowest were the
Cayman Islands, Haiti, Cuba, Aruba, Dominican Republic, Antigua and Barbuda
and, the lowest, St. Lucia, which hosted four medical schools at the time. High
performers were in Jamaica, Barbados, Dominica and, the highest, Grenada.
It is irrelevant to the discussion of American medical
students going to the Caribbean to look at the national medical schools in
Caribbean (or any other) countries; it is only relevant to look at those which
were created to educate Americans, and for the purpose of this discussion to
limit it to the four that have Department of Education approval. The next thing
is to understand that what is “good” or “bad” about any of these schools, or whether
they should exist altogether, depends on who is looking and what their interests
are. From the point of view of the individuals or companies that own these
schools, the motivation is profit, but having a high-quality product increases
their enrollment. From the point of view of students enrolling, the motivation is
a chance to become physicians and practice in the US. From the point of view of
those who are responsible for the academics of the schools themselves, it is to
support students, provide a good education, and help them to be successful.
From the point of view of many American medical schools, it may be to limit
competition, whether that is for clinical teaching spots in hospitals such as
those of the New York City public hospitals or for good students.
Most US allopathic medical schools, and their trade
association, the Association of American Medical Colleges (AAMC), disparage the
Caribbean medical schools in terms of quality of the students that they accept,
since the majority of those attending such schools have failed to gain
admission to AAMC member schools. However, since most of these AAMC schools
have recently or are in the process of expanding their own classes, they must
believe that there are well-qualified students who are not currently being
admitted, and many of these have ended up in Caribbean schools. When AAMC
campaigns to disparage the Caribbean schools, they tend to lump them all
together, rather than looking at individual schools or only the 4 listed above.
Unquestionably, students even at these four schools have, on average, lower grade-point
averages (GPAs) and Medical College Admissions Test (MCAT) scores, and may, on
average, not do as well on the USMLE exams as those from US allopathic schools,
but there is great overlap. On the other hand, what is perhaps the most
concerning part of education at the Caribbean schools is their clinical
training – where they learn clinical medicine in the last two years of school.
Are the doctors teaching them and the institutions in which they practice of
high quality? Is there a well-defined curriculum? Is there standardization of
the curriculum so that they can be confident that students are learning what
they need to whether they are doing, say, a surgery clerkship in a NYC public
hospital or a community hospital in Michigan? However, when AAMC schools are
fighting with them about whether they should be able to have spots at the same
places US medical schools use – say, NYC public hospitals – this point is also
The most important perspective, of course, is not that of the students,
the owners or faculty of the Caribbean schools, or that of the US schools and
the AAMC. It is that of the American people and whether they will have access
to physicians who will provide excellent care for them. The measures that are
usually used for assessing the “quality” of applicants and students – MCAT and
GPA and USMLE Step 1 scores – are at best peripheral, since, as I have often
argued, they are scarcely relevant to being a good doctor. Does it matter that
a doctor didn’t focus when they were a freshman in college and so got C’s, and
so even after doing well for 3 years had a lower GPA than another? Should the chance
to become a doctor be a reward for having your nose to the academic grindstone
your whole life without surcease, or an opportunity for those with skill,
passion, and commitment? I have often argued that the way to judge a medical
school is by what its graduates do with their lives, and that the percent that
enter primary care and practice in underserved areas is a major criterion. It
is fine to have some of your graduates doing laboratory research or entering
narrow subspecialties, but a school should be judged on its overall output and
how well it provides for the needs of our nation.
There is some concern that because of recent agreements
between the Accreditation Council for Graduate Medical Education (ACGME), which
accredits allopathic (MD) residencies and the American Osteopathic Association
(AOA), which accredits DO residencies, that osteopathic graduates will be more
welcome in allopathic residencies, tending to crowd out Caribbean graduates. I
would doubt that this will be an issue in the Midwest, where osteopathy is
strong and most residencies already tend to prefer DOs to Caribbean grads, but
it might have an impact in the East, where osteopathy is less present, and
where I hear that information pre-med students get from peers (and perhaps
sometimes pre-med advisors) is that Caribbean schools are preferable to
US-based osteopathic schools.
Like osteopathic schools, Caribbean medical schools,
including the 4 DOE-certified schools, place a much higher percentage of their
graduates into primary care than do US-based allopathic schools. Is this just a
result of the fact that primary care residencies are less competitive than many
other specialties, so easier for students from Caribbean schools to get into?
Unquestionably, this is part of the explanation, but there is also more
encouragement for primary care in these schools, which do not boast a huge
research enterprise or maintain tertiary-care hospitals. It also doesn’t change
the fact that graduates of these schools, like many international graduates who
were not US citizens, are serving the needs of our country because the US
schools are not stepping up to the plate. US medical schools are very selective
about taking students with high grades, and putting most of them into
oversupplied specialties.
The education at Caribbean schools varies, and it would be a
mistake to say that they are doing a better job than US allopathic schools.
However, US schools are doing a poor job of training the doctors America needs,
of ensuring that all people have equal access to quality health care, and the
students graduating from Caribbean schools are often filling the holes that
they leave.

Those who live in glass houses…


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