Thousands of students from offshore medical schools flock to teaching hospitals in the United States each year to complete the clinical portion of their education. In New York, the number of students performing third- and fourth-year hospital rotations from these offshore programs now almost equals the number of students from the state's own medical schools.
That is making a number of medical educators in the state angry. They say their students are being crowded out of opportunities, in part because the offshore medical schools are paying hospitals to secure the spots—something they say their budgets prohibit them from doing. Some also say many offshore students have been poorly supervised and are inadequately prepared to practice medicine.
The offshore schools counter that their students are not only qualified but badly needed at a time when the United States faces a looming shortage of doctors.
The New York State Board of Regents is weighing those arguments as it decides whether to tighten requirements for offshore medical-school students to participate in clinical rotations, commonly referred to as clerkships, at the state's teaching hospitals.
Students enrolled in offshore, or "dual campus," medical schools spend the first two years of basic-science study in offshore institutions, mostly for-profit medical schools in the Caribbean. The next two years are spent in clinical training, shadowing doctors in teaching hospitals or clinics in the United States.
Medical training in the United States generally follows a similar model. After graduating from college, students enter medical school, typically spending two years of basic-science study followed by two years of clinical rotations in hospitals or clinics.
Once they graduate from medical school as doctors, they begin several years of residency training, practicing medicine under a doctor's supervision.
The discussions in New York focus primarily on the third- and fourth-year clinical rotations that are part of the training students receive before they become doctors.
Charles R. Modica, chancellor of St. George's University School of Medicine, in Grenada, contends that there are plenty such slots in New York, and that medical deans are using the training issue as an excuse to limit class sizes and deny New Yorkers access to medical education. Many of those students end up on his campus, which he helped found in 1977.
St. George's has nearly 1,000 students in training in New York hospitals, he says. "They could have attended New York medical schools, but the deans rejected them."
Pay to Play
New York hospitals have a financial incentive to accept as many students as possible from offshore schools, which typically pay hospitals $400 to $450 per student per week for clinical training. Since most American medical schools pay little or nothing for clinical placements, "it's practically impossible for the U.S. schools to compete," says Jo Wiederhorn, president of the Associated Medical Schools of New York, an advocacy group representing the state's 10 private and five public medical schools.
In order to match the fees paid by offshore programs, "our schools would have to significantly raise tuitions, which would make them noncompetitive with schools in other parts of the country," she says. "The hospitals in New York are operating on very small margins, and in some respects you can't blame them for wanting to accept the money."
Two years ago, the New York City Health and Hospitals Corporation angered New York medical-school officials by signing a 10-year contract, reportedly worth up to $100-million, to provide clinical training at its 11 public hospitals for students from St. George's.
International medical-school graduates already make up 36 percent of New York state's physician work force, compared with 25 percent nationwide. Many came from one of the 14 dual-campus medical schools approved for training by the state, half of which are in the Caribbean.
While the academic caliber of some offshore schools worries New York educators, so does the sheer number of students streaming in from the Caribbean.
Last year, St. George's graduated 640, and Ross University School of Medicine, in Dominica, graduated 754. That compares with an average class size in New York medical schools of about 120.
New York State, which has one of the nation's largest concentrations of teaching hospitals, is a popular destination for offshore students.
In the 1980s, when medical educators were warning of a glut of doctors, New York medical schools severely restricted class sizes, and parents whose children weren't getting into the highly competitive schools complained to state lawmakers, Ms. Wiederhorn says. Over the next few decades, the state's education department expanded the number of offshore schools from which it accepted third- and fourth-year students, making it easier for students who didn't get into U.S. schools to attend medical school elsewhere and end up back in New York.
Last year the state education department approved an estimated 2,000 third-year students from offshore schools to train in New York hospitals (although some may have ended up spending some of their time in other states). That compares with about 2,220 from New York medical schools in 2008, the most recent year tracked.
"Offshore schools have increased exponentially the number of students they're accepting, and we're beginning to see a wave of students coming in," says Michael J. Reichgott, a professor of medicine at the Albert Einstein College of Medicine. Dr. Reichgott, who is also chair of the education committee of the Associated Medical Schools of New York, says he is unaware of any students being unable to land a clerkship but adds that New York schools have had to reach out to hospitals they hadn't considered before.
"Einstein had to take students out of a couple of sites because of the number of offshore students there," he says.
Two years ago, New York Methodist Hospital told officials at the State University of New York's Downstate College of Medicine that the hospital could no longer accept students into its small internal-medicine rotation because of the number of offshore students training there, says Ian L. Taylor, the New York medical school's dean.
"Our university hospital only has about 325 beds, so we're very dependent on affiliates taking our students," he says. "Given the massive expansion of Caribbean schools, our worry is that when the big wave hits—maybe next year and the year following—the problem may be more significant."
Critics argue that offshore students, many of whom hope to practice in New York, are poorly supervised during their clinical training. The few doctors appointed to oversee them are thousands of miles from the schools' Caribbean base, and many have had only a cursory training in how to structure and oversee clinical assignments, they say.
Accreditation requirements for U.S. medical schools dictate that clerkships expose students to a sufficient number of patients with diverse conditions, maintain a certain faculty-to-student ratio, and meet set educational objectives. Offshore schools generally don't dictate the same standards.
"We're just seeing the tip of the iceberg of what's going to be a huge quality-of-care issue," Dr. Taylor contends.
Nancy Perri, chief academic officer at Ross University, says such concerns don't apply to the Dominican institution, which hires clinical-faculty members to teach and supervise its students in New York.
She adds that more than 98 percent of Ross's students are American citizens, many of them New Yorkers who want to practice in the state. "We recognize that both U.S. and international schools like Ross are needed to fill the shortage of physicians needed in the U.S.," she wrote in an e-mail message.
A Successful Business Model
Touro College of Osteopathic Medicine, which opened in Harlem in 2007, seeks to increase the pool of minority physicians and those committed to working in underserved areas. Largely because of competition from offshore medical schools, which pay to place their students, it has been shut out of nearby hospitals, including Harlem Hospital Center, just 10 blocks away, says Joseph R. Maldonado Jr., assistant clinical dean. Instead, its 225 or so third- and fourth-year students train in New Jersey or Queens.
"We recruit students from underserved neighborhood schools, but when it comes time for training, we have to send them away. It's ironic," he says.
Meanwhile, the State University of New York at Stony Brook's medical school has kept its class size constant for the past three years, in part because of the difficulty of placing some students in clerkships at hospitals that have contracts with offshore schools, SUNY administrators say. Among those schools, the American University of the Caribbean School of Medicine signed a contract in 2008 with Nassau University Medical Center, a Stony Brook teaching affiliate.
The Association of American Medical Colleges has called on medical schools in the United States to raise their first-year enrollments by 30 percent over 2002 levels by 2015 to help prevent a projected physician shortage.
But state budget cuts and competition for clinical placements are making it hard for New York medical schools to expand, Ms. Wiederhorn says.
A New York-based lobbyist for American University of the Caribbean, in St. Martin, which has about 250 students training in New York hospitals, says domestic schools feel threatened by the success offshore schools have had in placing students, in part by paying for clerkship positions.
"The Caribbean schools have developed a business model that works for them and works for the hospitals, and domestic schools historically haven't had to do that," says the lobbyist, Lisa H. Reid.
Rather than squeeze domestic students out of clerkships, offshore schools have created new clinical positions and filled slots that many American trainees would not be interested in, she says.
Mr. Modica, the St. George's chancellor, says that so far this year, his medical school has paid New York hospitals more than $23-million for clerkships. Those costs are covered by tuition, which is comparable to that at many private schools.
As for the argument that offshore students are crowding out onshore students, "these are ridiculous assertions of a group of hysterical medical-school deans who should be ashamed that they didn't accept these students years ago," he says.
"These same deans have for years kept the enrollment of their own institutions down to a bare minimum using the excuse of quality."
Todd J. Mekles, a fourth-year student at St. George's, was rejected by all 15 medical schools he applied to in the United States. He says he had a grade-point average of 3.93 from Emory University and a 30 on his Medical College Admission Test—just below the 31 average for entering medical-school students in the United States this year.
"I was upset that I had to leave my country, but Charles Modica is my hero for giving people like me, who deserve to be doctors, a chance," Mr. Mekles says. Having worked with students from Weill-Cornell Medical College at New York Methodist, he believes his clinical experience is as closely supervised as any American program's.
"Students from St. George's can run with the kids from Cornell or Einstein," he says. "They have the utmost respect for us and don't treat us any differently."
While many educators are less critical of established schools like St. George's and Ross, critics often paint all offshore schools in an unflattering light. They point out that students from offshore schools tend to have lower grade-point averages and MCAT scores, if those scores are required at all.
The proliferation of medical schools in the Caribbean in recent years—now up to 55—has created headaches for schools like St. George's. "They want to lump us all together, and I'm not going to let them do it," Mr. Modica says. He welcomes the recent push to require a uniform accreditation process for foreign medical schools that train students in the United States.
Among the recommendations the New York State Board of Regents is considering is that it hold offshore schools to standards comparable to those set by the Liaison Committee on Medical Education, the main accreditor of American medical schools.
Schools that wanted to place their students in New York hospitals would have to be able to prove that they met clearly articulated standards.