After rejection in Canada, more Canadians pursuing career dreams at offshore medical schools
Milan Korcok
CMAJ 1997;156:865-7,870
[en bref]
Milan Korcok is a freelance writer living in Lauderdale by the Sea, Fla.
© 1997 Milan Korcok
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In brief
Being denied admission to medical schools here isn't necessarily the end of the line for would-be Canadian doctors. The number of Canadians applying to medical schools in the Caribbean and Mexico is increasing, and graduates of some of them are winning respectable postgraduate training spots in the US, United Kingdom and even Canada. Milan Korcok looks at the calibre of these offshore medical schools and the impact they are having on training and accreditation in North America.
En bref
Être refusé à une faculté de médecine au Canada n'est pas nécessairement la fin du monde pour d'éventuels médecins du Canada. Le nombre des Canadiens qui demandent à être admis à des facultés de médecine des Antilles et du Mexique est à la hausse et des diplômés de certaines de ces facultés de médecine obtiennent de respectables places de formation postdoctorale aux États-Unis, au Royaume-Uni et même au Canada. Milan Korcok analyse le calibre de ces facultés de médecine étrangères et l'impact qu'elles ont sur la formation et l'accréditation en Amérique du Nord.
Glenn Morrison, 26, was denied admission by 3 Canadian medical schools, but he's still pursuing his dream of becoming a doctor. Currently enrolled in a doctoral program in anatomy and cell biology at the University of Toronto, Morrison is waiting to hear if his dream will be realized at the Ross University School of Medicine on the small Caribbean island of Dominica. If accepted, he will begin classes in January 1998 -- an opportunity he was denied by McMaster University and the universities of Western Ontario and Ottawa.
Like other young Canadian students confronted by cuts in enrolment at home, Morrison has been forced to look elsewhere for educational opportunities. Thanks to the phenomenal growth of offshore medical schools developed primarily for American students, his hopes for a career in medicine have stayed alive.
Although only a modest number of Canadians have attended Caribbean, Mexican and European medical schools thus far, the contingent appears to growing quickly, according to data from some offshore schools and from inquiries handled by the Association of Canadian Medical Colleges (ACMC). This has been occurring in spite of warnings that Canadians who graduate from offshore schools have little chance of entering mainstream medical practice in Canada.
Two of the more popular Caribbean medical schools for Canadians are St. George's University in Grenada and Ross University on the island of Dominica. In its 20-year history St. George's has graduated 54 Canadian citizens. It currently has 34 Canadians registered and boasts an active Canadian Students' Association. Ross University has graduated 7 Canadian citizens in the past 18 years, but currently 20 Canadian students are enrolled there.
These are 2 of the largest of about 20 offshore medical schools or campuses found throughout the Caribbean and Mexico; some are on tiny islands like Saba (pop. 1000), one of the smaller Netherlands Antilles islands. (Not included is the University of the West Indies, headquartered in Jamaica. It cannot be considered an offshore school since it was designed to educate and train West Indians, not North Americans.)
Eva Ryten, director of the ACMC's Office of Research and Information Services (ORIS), commented about the growing interest in these schools in a recent annual report: "Offshore, for-profit medical schools operate on a number of islands in the Caribbean. . . . They cater largely to rejected US applicants, but also draw on applicants rejected by Canadian faculties of medicine. Advertisements are beginning to crop up for a number of new offshore medical schools as well as the ones that have been in continuous operation since the late '70s. Also joining in the recruitment of rejected applicants are some universities in Poland, Hungary and elsewhere, which offer programs in English for fee-paying students.
"This is another phenomenon that needs to be studied for its potential impact on Canadian physician resource problems. ORIS has had a growing number of telephone calls from Canadians considering enrolling in these programs."
Can perseverance pay off?
Is enrolling in an offshore medical school a fool's errand? Not necessarily.
Dr. Ronald Dalton, a Canadian rejected by all 5 Ontario medical schools, not only has enormous perseverance but also a commitment from the Ontario Ministry of Health that it will provide him a 2-year assignment in the underserviced area of Hornepayne, Ont., after he completes his third year of residency (internal medicine, pediatrics) at West Virginia University Hospitals in Morgantown, and an additional year in Ontario. With that will come full licensure to practise in Ontario.
The government can't provide him the residency but it has offered him the job. The College of Physicians and Surgeons of Ontario requires a graduate of a foreign medical school (including Canadian citizens or even graduates of US schools) to have either 1 year of postgraduate training in Ontario or 1 year of active medical practice elsewhere in Canada for licensure.
Dalton will have to find the residency himself, but after all he has been through don't count him out. Even in Canada's tight training environment, it's not impossible: a Ross University graduate currently is doing a residency in medicine at a Toronto hospital.
Owen Adams, the CMA's acting director of research, admits that "it's a scramble every year to make sure that every graduate [of a Canadian school] gets matched with a post-MD training position." In Canada, says Adams, it's basically "a very snug fit," more so than in the US. "And I suspect there are a greater number of post-MD positions [in terms of relative access] in the US than in Canada.
"But it's not hermetically sealed," he insists. With some provinces still searching for international graduates to serve in "difficult-to-recruit" areas, that seal becomes more penetrable.
Before going to St. George's, Dalton, now 39, had worked as a flight paramedic for the Ontario Ministry of Health and also managed an ambulance service in Huntsville, Ont. He went back to Queen's University in Kingston for a degree in biology, graduating in 1990.
"I worked very hard to get my degree," he said. "I worked as a paramedic during the day and studied all night. There were no more hours in the day for me to study, and admittedly I had only a B average. But I went to the dean at Queen's, told him what I had done, that I really would like to be a physician, and asked what I could do to make myself a better candidate.
"He just looked at me and said, 'You don't have what it takes to be a doctor.' I knew then there was no possibility I was going to get accepted to a Canadian school."
That's when he made inquiries abroad and visited St. George's in Grenada, where he subsequently applied and was accepted. Aided by a government-guaranteed Canada Student Loan, he graduated and then did clinical rotations in New Jersey, Michigan, New York and an optional elective in radiology at McMaster. He passed the new United States Medical Licensing Examinations, as did the great majority of his classmates (USMLE is the new test for foreign medical graduates devised by the Educational Council for Foreign Medical Graduates [ECFMG]). Ultimately, he was accepted in the 3-year residency program in West Virginia. Next stop, he says, is Ontario.
"I had a great experience in Grenada," he told CMAJ. "As far as the quality of medical education, I don't think I lost anything by going to St. George's compared with any medical school in Canada. I don't have anything negative to say about Grenada. They gave me the chance that no Canadian school would. They allowed me to fulfil my dream."
That's a common sentiment among the school's alumni, many of whom are now firmly entrenched in American hospitals and training programs.
Do offshore schools measure up?
In the 1970s, when young New York lawyer Charles Modica -- he had been rejected by some American medical schools -- founded St. George's and entrepreneur Robert Ross established Ross University, facilities and training conditions were primitive by Canadian and US standards. American medical educators shrugged off these attempts at alternative educational pathways, considering them vain and fruitless, even scams.
It was widely believed that "for-profit" proprietary schools would never measure up to the quality of US or Canadian schools accredited by the Liaison Committee on Medical Education. Given the lack of up-to-date clinical clerkship facilities and postgraduate training positions, their graduates were never expected to make it back into mainstream North American medicine. The conventional wisdom was that the intricate web of examinations required of foreign medical graduates would be an insurmountable barrier, and state licensing boards would never approve their applications.
It was touch and go for the new schools, but only for a short time. Modica, Ross and some of the others who followed hired medical educators of considerable repute from the US, Canada, the United Kingdom and other countries -- some retired, some part time, some visiting lecturers and professors -- to set curricula and establish standards. They acquired libraries, equipment, built state-of-the art campuses and dormitories, and continued to recruit students from the growing pool left behind by North America's increasingly stringent medical school admission practices. "If American [medical] schools had opened their doors," said Robert Ross, "Ross University wouldn't be around."
In 1994, the US General Accounting Office (GAO) showed the impact some of the offshore institutions are having on American medical education and training. Its report, Millions loaned inappropriately to US nationals at foreign medical schools, noted that 19 state medical licensing boards were approving foreign medical schools or regulating the clinical training of foreign medical students at hospitals in their states, that there were at least 20 medical schools in the Caribbean and Mexico, and that 74 hospitals or other medical facilities were training medical students from foreign medical schools.
Since that 1994 report, these numbers have increased substantially, thanks to populous states such as New York and California. The number of offshore medical graduates in the United Kingdom is also growing.
The GAO reported that at the time up to 6600 American students were attending medical schools outside the US and Canada, primarily in the Caribbean and Mexico. It also noted that in 1992 about 39 000 doctors, or 6% of American physicians, were American citizens who had received medical degrees abroad.
A nagging concern of the GAO was that between 1986 and 1991, more than $100 million in government loans had gone to students at these schools even though the quality of their undergraduate or postgraduate training had not been evaluated. With few site visits and no formal accreditation programs, there was no way to equate the institutions to mainstream schools.
Supporters say the schools have plenty of evidence of equivalency. Modica, now St. George's chancellor, has gleefully publicized his students' pass-rate statistics on the various ECFMG examinations required of foreign graduates.
The GAO showed that Americans who attend foreign medical schools average below 50% on ECFMG-administered medical-knowledge examinations and have a significantly lower pass rate than their US or Canadian-trained counterparts.
But St. George's and Ross University boast a much higher percentage. "The average American school has a pass rate of 89% on these examinations," says Modica, "but St. George's has 89.2%. We're right at the average of the US school mark." By the end of 1996, St. George's has graduated 2378 students, and 1267 undergraduates have been able to transfer to US schools.
Adds Neal Simon, president of Ross University, which has graduated more than 2000 MDs: "Almost 90% of our students are passing the USMLE and obtaining residencies in the US. We're equal."
But caveat emptor -- not all schools in the Caribbean can claim such results. The GAO's revelations followed horror stories about some schools being nothing more than diploma mills, and caution has stood Ronald Dalton in good stead. He first applied at another Caribbean school but asked to speak to Canadian students and graduates about their clinical-rotation experiences and satisfaction levels. "They were vague when I asked to speak to other Canadians," he said. "They didn't give me anybody to speak to. But at St. George's they were more than helpful. They put me in touch. I looked around. I said 'I can do this.' "
The GAO also found some unsavoury practices. It reported that Universidad Federico Henriquez Y Carvajal School of Medicine in the Dominican Republic (not to be confused with the eastern Caribbean country of Dominica), was operated by someone who had pleaded guilty to practising without a license in North Carolina and Florida. Another school run by the same administrators, British West Indies Medical College, was granting medical degrees after as little as 10 or 11 months of "education." Disgruntled students complained of receiving credits for courses they had not taken or for tests not administered; 1 student said his training consisted of "scrub-nurse" activities at clinics and hospitals in and around Santo Domingo.
Since being criticized by the GAO, the federal Department of Education has established a National Committee on Foreign Medical Education and Accreditation, which recently issued accreditation standards -- of sorts -- for countries whose medical schools wish to participate in the US Guaranteed Student Loan Program.
Although foreign-education student loans is a political issue in the US, in Canada it is relatively benign since so few students have enrolled at offshore schools. The joint federal-provincial Canada Student Loans Program provides 60% of assessed need for each full-time student up to a weekly loan limit of $165.
An officer of the Ontario student-loan plan said that in addition to the requirements that must be met by all institutions, an offshore school must have been open for 10 years, must offer at least a full-time, 8-semester program and has to be "approved" by the World Health Organization (although WHO neither recognizes nor evaluates schools in its directory, but lists any school the host country wishes it to list). Site visits or other evaluation procedures are not required; designation is made on the basis of whatever information the school publishes in its calendar.
As Ronald Dalton found out, it pays to study the terrain: "You have to know that at the end of medical school, there will be something there."
It also helps to have a high tolerance for rejection. In all of his clinical clerkship and residency experience, Dalton was treated like any other student from any other mainland medical school -- by Americans. "They made no distinction between us," he said. "Yet when I spoke to a Canadian program director about a position, he told me, 'We don't care how good you might be, we would never take you over a Canadian graduate.' "
"It's unfortunate," he says, "but we were treated better by US authorities than Canadians. [In Canada] nobody seemed to care."
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