To apply or not to apply? That is the question.
There are many strong opinions held about Caribbean medical schools. Some believe these schools provide great opportunities for students who have had set-backs, or foreign status keeping them from getting into a US medical school. Others oppose this option with no exception. There is no doubt that Caribbean medical schools can and do produce some very well-trained physicians, but in some cases, this comes at a cost. It should be noted however that International medical graduates (IMGs) contribute heavily in addressing the US doctor shortage by making up roughly 25% of the physician workforce.
I have met many IMGs who begrudgingly admit that they did not thoroughly investigate the offshore route before accepting their admission. I also know some who took this route and wouldn’t change a thing. After researching and discussing with a number of my colleagues, I offer advice in their own words and propose areas to research and consider prior to accepting admission to a Caribbean medical school. The simple truth is that for some, this option is viable, and for many, it’s not. You have to do your research and be well informed ahead of time.
You need to understand that not all 60+ Caribbean medical schools prepare you to practice medicine in the United States and some will not allow you the opportunity to get federal loans. Regional programs train students to practice medicine in that particular island or nearby areas while offshore programs train students to practice medicine in the US and Canada. Offshore programs will typically mandate students to do their 3rd and 4th year clerkships in the US. Accreditation ensures that schools are providing quality training to their students. The National Committee on Foreign Medical Education and Accreditation (NCFMEA) is responsible for reviewing the different accrediting bodies to make sure their standards match those of the US and Canada. This will determine if students attending that international medical school can receive US federal loans. Furthermore, schools must have state-approval to allow clerkships and approval is also required for IMGs to legally practice in the 50 states. Be very diligent since some wording like “recognized” or “approved” may be misleading when investigating accreditation. Understand if they are referring to regional standards or US/Canada standards. Also know whether or not your program of interest is on probation or any other disciplinary condition.
Larger and better recognized Caribbean medical schools are for-profit and can be quite pricey. IMG’s who have attended these schools are often left with loans in the $250,000 – $320,000 range while US medical schools tend to be on the order of $50-100K cheaper. Interest rates tend to run higher than 5 percent for medical students. As mentioned earlier, only schools that are NCFMEA-recognized will allow students to receive US federal loans. Tuition at larger Caribbean medical schools can be very expensive but you must also be aware of the many other fees. These include the cost of living expenses one would pay at a US school but one must also factor in travel as well as costs for examinations and prep courses which can be very pricey. With this type of price tag, you want to make sure you complete your training.
3. ATTRITION RATE
“We started out with 1,000+ students in my class, but at the end I felt like a quarter or more of my class was no longer with us at graduation.” -Yvonne (IMG)
The medical training journey is a tough road that only the disciplined can traverse successfully. Caribbean medical schools are no exception to this but they come with their own unique set of challenges. While US medical schools may sometimes “hold their student’s hands” through the training process, this may not be the case in some international medical schools. Many IMGs have informed me that they felt like they were “just a number” and it was difficult at times to get the proper resources. Therefore, one has to be extremely self-disciplined and resourceful. With such large class sizes, there is a diverse student body. The weeding-out process will start very early and eliminate those who probably should never have been in medical school in the first place. Some have poor or inadequate work ethics, lack of motivation, or inability to properly balance their tasks. Others are forced to withdraw due to unforeseen hardships. Different programs have their own unique requirements (such as attendance) which must be met in order not to be booted out. Scoring systems vary among programs and material learned varies. In order to sit for the Step 1 exam, schools require their students to take additional tests including the National Board of Medical Examiners (NBME) and the Comprehensive Basic Science Examination (CBSE). Failing these exams may disqualify you from taking the Step 1 exam and may lead to dismissal from the school. According to the 2016 United States Medical Licensing Exam (USMLE) performance data, 72% of non-US/Canadian schools passed the Step 1 exam compared to 94% of US/Canadian students passed.
4. RESIDENCY MATCH
“As an IMG, I felt very discriminated against during the residency matching process. It was important that I was realistic in the programs I applied to and in the end, I applied to 100 programs.” -Paul (IMG)
As an IMG, it is nearly impossible to match into a US residency program without outscoring US trained grads on their USMLE. According to the National Resident Matching Program (NRMP), 53.9% of US IMGs and 50% of all IMGs (including non-US IMGs) matched into a US residency program in 2016. Compare this to the 98% match rate for US trained seniors. This can be very painful for those who fail to match especially if they have loans to pay back. This is more reason why IMGs must outshine others on their board exams and clerkships. Furthermore, good networking skills is a must. It would be ideal if the school offers clerkships at programs that also train residents. This is a question you should definitely ask and if you are a non-US IMG you will also want to know if there is Visa sponsorship at that residency program. The Educational Commission for Foreign Medical Graduates (ECFMG) is the standard used in evaluating IMGs who intend on practicing in the US. Students must also take the same examinations that US med school students take (USMLE Step 1, Step 2 CK and Step 2 CS) but must first gain a diploma from an institution registered in the International Medical Education Directory (IMED) in order to be granted an ECFMG certificate and enter a US residency program. Despite all the hard work and effort, some residency programs still simply do not consider IMG applicants. According to the NRMP 2016 Program Director Survey, only 64% of the programs responded that they typically interview and rank US IMGs while only 49% would consider non-US IMGs.
5. LIFESTYLE & SUPPORT SYSTEM
“The international experience enables you to build cultural competence and self-confidence while adapting to a new environment.” -Tony (MS4)
“As a non-US student, I don’t believe I was as shocked living in a third world environment than many who came from the US.” -Yvonne (IMG)
The breathtaking beaches, beautiful wildlife, and exotic foods. It certainly appears to be 2-4 years of training in paradise and away from many distractions. Depending on where the school is located, you may be exposed to a new language and different culture. While this can be an amazing experience you must also realize that there certainly will be challenges. Being so far away from family and friends may make for some very lonely months. The local stores, sporting events, and foods you are accustomed to experiencing likely will not be readily available. Prices will also likely be different than what you are used to. If there are special diets, hygiene products, medications or devices you require it would be wise to see if they are available in that area. A friend of mine was flown back to the US after developing an illness and this took a huge toll on her training. Sometimes you long for a hug from that friend or a good home cooked meal from mom. Be sure to inquire about internet access and how best students communicate with loved ones (video chat, calling cards, etc.).
Some IMGs experience discrimination and bias during their clinical training. These individuals feel that they have to prove themselves during clerkships and during residency despite sometimes having higher scores on their exams. Rest assured, much of this dissipates as they begin to practice medicine as medical doctors. Those who are able to stay the course and make it through as IMGs have definitely earned my respect. In the end, patient’s want a well-trained physician with good bedside manners no matter the medical school they attended.
In summary, I have addressed some key areas that every premed should investigate for themselves prior to accepting an offer for an offshore medical school. The question of whether one should attend a Caribbean medical school really must be answered by one’s own self. If an offshore school is not a student’s first choice, I recommend that they always consider other options (retaking classes, post-bacc, research) which may strengthen their candidacy first but if this has been done already or other limitations exist I would make sure they are able to check these boxes prior to proceeding:
o I am 100% certain that being a medical doctor is really what I want to do
o I am financially secure and/or will be okay paying off a debt even if I don’t complete my degree
o I am a very good test taker or am certain I will be
o I am very self-motivated and disciplined
o I can adapt well to new environments
o I am willing to study harder and focus more than ever in my life
o I am willing to do my own research about the different schools
“Although you are a premed now, think ahead and really do your homework to ensure that this is right for you. I had my rough days, but would I do it all over again? Yes.” -Yvonne (IMG)
Written by Dr. Daniel
Resources and References:
USMLE Performance Data: http://www.usmle.org/performance-data/default.aspx#2016_step-1
NRMP 2016 Match Results: http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf
NRMP 2016 Match Program Director Survey: http://www.nrmp.org/wp-content/uploads/2016/09/NRMP-2016-Program-Director-Survey.pdf
van Zanten M, Parkins LM, Karle H, et al. Accreditation of undergraduate medical education in the Caribbean: report on the Caribbean accreditation authority for education in medicine and other health professions. Acad Med. 2009 June;84(6): 771-775.
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