Evaluating Educational Quality: The Challenge to Offshore Medical Schools

Twenty years ago, a fraudulent medical diploma scandal in the Caribbean initiated a series of proactive steps by the Division of Licensing of the Medical Board of California. What followed is still being refined and can best be described as a recognition (not accreditation) process to ensure physicians from so-called “off-shore medical schools” meet the minimum requirements in California’s Business and Professional Code which clearly lists the preclinical and clinical courses and hours of study which must be successfully completed before granting the M.D. degree.¹ 

Students from those schools seek clerkship opportunities in California hospitals. They also frequently vie for residency positions in accredited teaching hospitals and many desire to eventually qualify for a license to practice in the state.

During the past 15 years there has been a steady increase in the number of proprietary medical schools, mainly in the Caribbean but also in the Philippines, parts of Asia, Africa and Europe. It is clear the major motivation for the establishment of off-shore schools is the profit to be realized by levying high tuition costs while keeping their operational budgets as low as possible. At last count there were 35–40 schools in the Caribbean alone.²  It is almost impossible to know the number at any given time as they open and close.

A new phenomenon has been the establishment of English language pre-clinical programs in established medical schools in some eastern European countries such as Poland. After two or three years of basic science instruction in English, the students are expected to have gained enough of a knowledge of that nation’s language to enter clerkships in the hospitals affiliated with those schools. Many states, including California, recognize these European schools and have done so for many years. However, the creation of English language programs for Americans poses a new challenge to recognition.³ 

A formal application process has recently been modified to conform more closely to the format used by the Liaison Committee for Medical Education (LCME) of the American Medical Association and the Association of American Medical Colleges.⁴  The application probes all aspects of the medical educational experience including history and setting of the school, finances, admission procedures, number and qualifications of faculty and administrators, the facilities and the school’s governance and its relationship to the country in which it resides. The curriculum is also evaluated both in regard to the sciences basic to medicine and the various clinical clerkships both required and elective.⁵ 

Obtaining reliable information about the clinical phase of an off-shore student’s education is especially difficult because the majority of offshore schools contract with several hospitals scattered mainly in the United States, but also in the United Kingdom, that provide clinical clerkships of variable quality.

The Division of Licensing (DOL) in California then utilizes the services of a licensing consultant, someone with a background in medical education as well as patient care such as a current or former dean or associate dean of students and/or curriculum. After both staff and licensing consultant review the school’s application, the decision is then made as to whether an on-site inspection will be conducted. In this way, the DOL has a chance to evaluate and approve the school’s educational program before the school’s students and graduates are accepted into clinical clerkships and postgraduate training programs in California. Using this process, only four Caribbean schools currently are recognized by California with one additional school pending.

Additionally, the DOL has finalized a self-study to be performed by a school initially applying for recognition or for continuing recognition after a seven year period.⁶  The self study, similar to that used by the LCME, is to be conducted over a 12 to 18 month period by a school’s administrative leadership, its faculty and students and will be used as an additional and perhaps primary tool in deciding on the merits of a site visit.

The DOL has also recently defined the agenda of a site visit that will be conducted by a member of the board’s DOL, one or more staff members and a licensing consultant physician. Recommendations pertaining to recognition with provisions will then be forwarded for consideration by the board’s licensing division at one of its quarterly meetings. Visiting a school in its host country is not as much a challenge as how clinical clerkships are to be evaluated. A given school might have as many as 30 or more hospitals which accept their students. These hospitals are widely scattered in the United States, Canada and the United Kingdom and obviously cannot be evaluated in toto. The DOL has taken the recent step of selecting a sample of three or four hospitals, usually in one city, in order to gain some knowledge of the educational experience. The DOL currently is debating whether to only recognize programs that have Accreditation Council for Graduate Medical Education (ACGME) credentials. The final requirement is to only recognize students from offshore schools who have been successful in Step I of the United States Medical Licensing Examination (USMLE) for third and fourth year clerkships and requiring successful passage of both Steps I and II for students seeking postgraduate residency positions.

Everyone agrees the admission process for U.S. medical schools is not perfect. Some students who would make good doctors are rejected and some are admitted who do not succeed. Many graduates of the more reputable offshore medical schools who have successfully negotiated the arduous process of education, residency training and eventual licensure are competent physicians.⁷  Additionally, there is data from several sources which indicates U.S. citizens who are educated in foreign schools are more likely to obtain residency positions in primary care specialties and are also more like to gravitate to underserved areas either because they are motivated to do so or perhaps, viewing it more cynically, because they are less likely to be successful competing for specialty residencies and practices in “desirable” areas.⁸ 

For these reasons, it is probably safe to predict the demand for medical education in unregulated offshore schools will continue and even increase. There seems to be no lack of enterprising entrepreneurs who realize the potential profits of these institutions. However, these schools will succeed only if their graduates are successful in gaining admission to mainstream American medicine.

Such states as California and New York, which have instituted appropriate procedures for recognition, are responding to the challenge of ensuring that these schools are doing a responsible job of education. Those schools that fail to meet the challenge will undoubtedly wither and disappear as prospective students learn of their inability to gain recognition by the states in which their students and graduates wish to train and practice.