When the United States sent some 6,000 troops to invade the Caribbean island of Grenada in 1983, ostensibly to rescue American medical students affected by a Marxist coup, it was the first time most people outside the region heard that Americans went to the Caribbean to study to become doctors.
Since then, St George's University School of Medicine, where the students were enrolled, has gone on to become one of the best known private medical schools in the Caribbean and one of the biggest employers in Grenada. It has a campus that includes professors and students from more than 140 countries and "a clinical training programme involving more than 60 hospitals in the US and the UK," according to the institution.
But that growth could be in jeopardy, and many of the more than 50 medical schools in the Caribbean who cater to students from the US are also worried about the future.
The reason is that universities in New York now want the state's Board of Regents to impose restrictions on offshore medical students doing their clinical training in the state's hospitals. The New York schools say offshore students compete with their own students who are struggling to obtain training slots, and such slots are a priority as the state faces a significant shortage of doctors that is predicted to worsen.
Other authorities are also taking measures to toughen the medical licensing procedure for off-shore-educated doctors, by ensuring that they come from accredited schools and also by heightening the standards of regional accreditation bodies.
The number of students from 'offshore' medical schools who do training in New York is about half the number of students from the state's own medical schools, and runs into the thousands. St George's sends around 1,000 students in their third and fourth year to do clinical training in these hospitals, while another 900 students come from other schools in the Caribbean, such as Dominica's Ross University.
Offshore schools often pay the state's hospitals for the training placement. They say they have little alternative because the small Caribbean islands lack the hospitals and large teaching facilities needed to provide the training required for a doctor to be licensed in the US.
"The most important thing for the students is the school's ability to give them training in the top hospitals in the United States," said Herman Hall, a New York-based, Grenada-born businessman and publisher of a Caribbean affairs magazine. "So if that goes, the schools will be in jeopardy."
Motivated by rivalry
Hall believes the moves by institutions in New York state are motivated by rivalry and jealousy. "It's all because of the competition," he said.
"St George's has expanded incredibly over the years, and they now have graduates in all the top hospitals in the northeastern United States. I believe that many of their students are much more qualified than some of the students from universities in the United States," Hall said.
Margaret A Lambert, St George's Dean of Enrolment Planning and Director of University Communications and Publications, said she did not think her institution would be affected.
"We support the Board of Regents in implementing tougher standards because some of the medical schools need it," she told University World News.
"The initial motivation [from the New York universities] might not have been the best and the reasons may not have come from a good place, but the result of what they're doing is actually quite good," she added.
The Jamaica-based Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP) agrees that a strengthening of standards is a good idea. CAAM-HP is the legal body that accredits medical, dental, veterinary and other heath education programmes in the region under the auspices of the Caribbean Community.
"We're not bothered by the new rules at all," executive director Lorna Parkins said.
"We've completed the first stages of the three-step process of getting international recognition. We had a team of observers shadow us on our visit to St George's and next month a team will be in attendance at our board meeting in Jamaica," she said.
The rapid growth of medical schools in the Caribbean is the reason for CAAM-HP's stance.
"The number varies from time to time, but the Caribbean now has the highest density of medical schools in the world," Parkins said.
"There are all kinds of issues surrounding these schools. Sometimes the school says it is up and running and there is really nothing happening on the ground. Sometimes we send requests for information, and we don't get it. And sometimes we get information from sources that these schools are not what they are claiming to be," she added.
To address some of these issues, the Education Commission for Foreign Medical Graduates (ECFMG) has decided to set new accreditation guidelines.
The group, which evaluates whether international medical graduates are ready to enter certain residency or fellowship programs in the United States, has announced that, effective in 2023, "physicians applying for ECFMG Certification will be required to graduate from a medical school that has been appropriately accredited".
Medical licensing authorities in the US require ECFMG certification among other requirements, for international medical graduates to obtain an unrestricted licence to practice medicine.
To satisfy this requirement, ECFMG states that "the physician's medical school must be accredited through a formal process that uses criteria comparable to those established for US medical schools by the Liaison Committee on Medical Education or that uses other globally accepted criteria, such as those put forth by the World Federation for Medical Education."
All of these measures boil down to the fact that the accreditation process will become more stringent, and accreditation bodies themselves will now need to meet certain standards, Parkins said.
"The rapid expansion in the number of medical schools globally represents a challenge to those who rely on the current diverse systems of recognition and accreditation to evaluate these schools and their students and graduates," she has stated.
When CAAM-HP was observed by the World Federation for Medical Education on its recent site visit to St George's University, this was the first step in "accrediting the accreditors".
Next month a team comprising ECFMG and other observers will also be in attendance at CAAM-HP's board meeting in Jamaica, Parkins said. The Caribbean authority has been invited to be the pilot project for the new accreditation guidelines, she explained.
Meanwhile, CAAM-HP is currently discussing the renewal of accreditation for St George's, and a decision is expected by the end of June.
"I think improved standards is a wonderful idea," said the university's Margaret Lambert. "The more the programmes are assessed the better. Countries have to get together and figure out acceptable standards. Some doctors should not be practising."
The few other schools that have received conditional or initial (provisional) accreditation by CAAM-HP include Jamaica's All American Institute of Medical Sciences, Dominica's Ross University School of Medicine, Anguilla's Saint James School of Medicine, The University of the West Indies School of Medicine and its School of Dentistry, and the University of Guyana.
The addition of more schools to this list could depend on the outcome of the campaign in New York as well as on the impact of the new accreditation regulations. To paraphrase one medical trade organisation: "Will doctor hopefuls around the world continue to pack up and travel to tropical climates in search of medical education?"
All articles in the Special Report: The Internationalisation of Medical Education
GLOBAL: Internationalisation and medical education
ASIA: World-class medicine pursuit drives collaboration
MIDDLE EAST: Medical cities seek foreign academics
INDIA: Medical education gets international flavour
CARIBBEAN: Medical schools battle to retain US access
SOUTH AFRICA: Cuba helps to train rural doctors
AUSTRALIA: Overseas doctors fill large gaps
FRANCE: Medical reform aims to fight 'human wastage'
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