AAMC Reporter: March 2006

A Word from the President: "Offshore But Incoming"

Suppose for a moment you were made "czar" of medical education in the United States at a time when the country faced the following scenario: a significant shortage of future doctors; thousands of well-qualified U.S. college graduates eager to become physicians but too few slots in LCME-accredited medical schools to accommodate them; and increasing numbers of these students choosing to go offshore to a Caribbean medical school in the hopes one day of working their way back to the United States through the ECFMG process so they could train and eventually practice alongside our graduates.

Would you be inclined to stand by and observe this situation? Or would you try to change it?

The answer might well depend on your judgment about the quality of medical education those students were likely to receive. If you concluded that "offshore" schools offered comparable preparation for entering an ACGME-accredited residency program, you might say, so what's the worry? Even if the facts convinced you otherwise, you might still conclude that the hurdles required by the ECFMG—especially passage of USMLE Steps I and II (including the clinical skills exam)—were sufficient to ensure that ECFMG-certified graduates of offshore schools were as well prepared as any medical student to enter residency training.

I wish I could give you hard facts to help you—and all of us—reach a firm conclusion about these matters. Unfortunately, we just don't know as much as we'd like about medical education in offshore schools or about the relative performance of their graduates during their careers as practitioners. Here's what we do know and some of what concerns me.

• Most, if not all, offshore Caribbean medical schools that cater to U.S. citizens are for-profit enterprises. Their dual loyalty to maintaining educational standards and to turning a profit invites a question about which priority takes precedence.

• Some offshore schools are on small islands that rely on revenue from their medical school for a significant portion of the island's economy. One can't help but wonder whether they can adequately assess and assure high-quality medical education under these circumstances.

• Although five offshore schools have existed for a number of years, some 15 have been established within the past decade. Ross (centered on Dominica) and St. George's (centered on Grenada) are two of the oldest and largest offshore schools. Ross recently increased the number of students it aims to admit each year to 900; that's right, 900 per year!

• On paper, the basic science curriculum at Ross and St. George's, while compressed in time, looks similar to that of a traditional U.S. medical school. Virtually no information is publicly available about the nature of the clinical instruction, other than that it is very widely distributed among a large number of "affiliated hospitals." Only one of Ross's 49 affiliates is local; the other 48 (of which 10 are COTH members) are spread across the United States in 13 states and the District of Columbia. St. George's 33 "major affiliated hospitals" (of which 15 are COTH members) are located in seven U.S. states; eight more are in the United Kingdom. The comparability of student experiences and the adequacy of faculty supervision seem likely to be problematic with these arrangements.

• Ross and St. George's each had more graduates (1,424 and 1,530, respectively) enrolled at all levels in GME programs in 2004 than any single U.S. school.

We know even less about the students who matriculate at offshore schools. We do know that:

• A sizable percentage of students admitted to offshore schools never make it to graduation.

• The number who do graduate and apply for ECFMG certification is rising smartly; recent data indicate that about 85 percent of such applicants eventually pass USMLE Steps I and II (compared to some 99 percent for our graduates).

• About 1,100 graduates of Caribbean schools entered ACGME-accredited residency programs in 2004, and that number is increasing.

• More than two-thirds of these residents had, at some previous time, applied to one or more U.S. medical schools. Consequently, we have data from their original AMCAS applications. Although their MCAT scores, as a group, are considerably lower than those of our graduates, the degree of overlap is also considerable. This group is likely to be the best prepared academically among those who began their medical education abroad, given that they completed the off-shore school's requirements for graduation, successfully cleared the ECFMG hurdles, and were accepted for residency training.

• Given the inconvenience, expense, and uncertainty of success associated with attending an offshore medical school, students who choose this path to become a physician are likely to be deeply motivated.

If I were czar of medical education in the United States, I would draw several conclusions from these facts.

First, the U.S. physician workforce will continue to rely on graduates of offshore (and other foreign) schools for the foreseeable future, no matter how quickly or how much LCME- and AOA-accredited schools expand their capacity.

Second, we need to begin a collegial dialogue with the offshore schools to learn more about the education they provide. Although it is hard to escape the conclusion that some, if not all, offshore schools were established to escape scrutiny by the rigorous educational standards of the LCME, the absence of good information breeds misconceptions, suspicions, and stereotypic thinking.

Third, we need to explore whether some credible process can be devised to evaluate the educational programs of offshore schools and to help them improve if they are not meeting acceptable standards.

Fourth, we need to ensure that the ECFMG continues to maintain its high standards for certification. However, we need to recognize that no summative examination, no matter how rigorous, can adequately evaluate many crucial objectives of contemporary medical education. Accredited programs in the United States are not faced with this limitation. They evaluate students over a lengthy period of immersion in a robust educational environment designed to inculcate the non-cognitive, professional attributes, the cultural sensitivities, and the ethical foundations that students are expected to demonstrate before being awarded the M.D. degree.

Finally, given the looming doctor shortage and the large number of well-qualified U.S. students who aspire to be physicians, our civic responsibility argues strongly that we increase substantially the number of graduates from accredited medical schools in the United States.

Jordan J. Cohen, M.D.
AAMC President

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