Caribbean Medical Schools: A Good Option?

Because the competition for admission to medical schools in the United States is extremely strong, many applicants consider attending medical school in the Caribbean. In fact, a great many bright and talented applicants are now opting to obtain their medical education in the Caribbean.
How can you decide what is the best choice for you? What must you consider in evaluating these schools? And will you be able to obtain a residency in the United States after you graduate? To help you decide if attending a Caribbean medical school is a good choice, this article provides a framework for evaluating these schools and the success of their graduates.

A Little Background

In the last four decades, the Caribbean has seen a steady increase in the number of medical schools on the islands as well as the size of their student bodies.  In the late 1970’s three Caribbean medical schools were established: American University of the Caribbean, originally located on the Island of Montserrat, Ross University on the Commonwealth of Dominica, and St. George’s University in Grenada.   Since their inception, these schools have educated many US citizens seeking a medical education outside the US,  and now about 60 medical schools in the Caribbean are listed in the Foundation for Advancement of International Medical Education and Research (FAIMERs) International Medical Education Directory (IMED).
The physicians who graduate from Caribbean medical schools play an increasingly important role in the US health care system by supplying residency programs with qualified applicants and helping to meet a well documented physician shortage, particularly in primary care medicine.  While accreditation, didactic studies (first and second years of medical school), and clinical rotations (third and fourth years of medical school) differ among institutions, requirements for graduate certification in the United States, as outlined by the Philadelphia based Educational Committee on Foreign Medical Graduates, are the same for all students graduating from all international schools, including the Caribbean.

Caribbean Medical School Accreditation

An article by van Zanten et al published in the June 2009 edition of Academic Medicine reviews some of the processes by which Caribbean medical schools undergo external quality assurance.  Accreditation for Caribbean medical schools is on several levels, including local Ministry of Health accreditation by some  individual Caribbean country’s government, regional accreditation by organizations such as The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP). The World Health Organization (WHO) does not accredit medical schools but maintains a list of schools that are recognized by local governments. In the United States,  The National Committee on Foreign Medical Education and Accreditation of the US Department of Education (NCFMEA) of the United States Department of Education determines whether the process conducted by an accrediting organization is comparable to the Liaison Committee on Medical Education (LCME) process of accreditation. This is a voluntary process so not all schools undergo this evaluation. If a school’s accreditation is deemed comparable to the LCME process, then that country can apply for US federal loans for those students. Currently, only 3 schools in the Caribbean are eligible for these loans.
California, Florida, New Jersey, and New York require individual school review and approval for Caribbean students to do rotations in that state.   In California, not only must the individual school be approved for clinical clerkships but the student’s clerkship and course work must be approved by the state medical board to obtain residency and subsequent physician licensure.  Any deficiencies in clinical training, as determined by the state, may need to be remediated to practice in California.  Many other states defer to California’s approval for the purpose of licensure because most do not have their own approval process. Also of note, New York has the largest number of international medical graduates in residency training and about one third of residency programs in the US are located in the state of New York.
It is important to know which organizations have accredited any school you consider attending.  Knowing if the state in which you intend to practice recognizes your school is also important.  Caribbean medical schools proudly display these accreditations on their websites so if an accreditation is missing, be wary.

Quality of Medical Education in the Caribbean

Another recent study by van Zanten and Boulet published in Academic Medicine examines the quality of medical education in the Caribbean. The report finds tremendous variability in both the quality of undergraduate medical education and in students’ performance. The only way to evaluate the education Caribbean medical students received was to examine students’ scores on the United States Licensing Exam (USMLE) Step 1, which is taken after the second year of medical school. Investigators calculated the average USMLE Step 1 first time pass rate for each country in the Caribbean. In evaluating this data they also took into account that some islands have more than one medical school.  The countries with the highest percentage of students passing the (USMLE) Step 1 on the first attempt were Grenada (84.4 %) and Dominica (69.7%). Countries with the lowest pass rates were Saint Lucia (19.4%) and Antigua/Barbuda (22.9%).

Preclinical Years

Students typically spend the first four to five semesters of medical school in the Caribbean completing basic science courses before taking USMLE Step I.  Basic science curriculums in the Caribbean are similar to US curriculums.  Some schools offer a fifth semester, either in the Caribbean or in the US, to help students prepare for the USMLE Step 1 and transition to their clinical semesters.
Living in the Caribbean can present many challenges for those who have never lived outside the United States. For many students, it will be their first time away from the United States for a prolonged period of time. Many of the luxuries found in large US cities, such as restaurants, movie theaters, shopping malls, and commercial gyms, are not available on the islands, and friends, family, and religious support groups are thousands of miles away. On the plus side, many students form strong relationships with classmates and also enjoy learning about the history and culture of the local West Indian population. Former students also have fond memories of celebrating yearly holidays such as Carnival, the colorful, festive, and historical event celebrated annually throughout the Caribbean.
After successfully passing the USMLE Step 1, students proceed to their clinical rotations, which usually are outside of the Caribbean.  When evaluating schools, it is important to ask what percentage of students who initially enroll in each class actually take and pass the USMLE Step 1 and successfully proceed to clinical rotations.

Clinical Years

Core clinical rotations and third and fourth year curriculum in Caribbean schools resemble those of US medical schools. Caribbean schools that offer clinical training in the US have strict guidelines about the location and quality of students’ clinical training.  All core rotations and subinternships must be completed in hospitals with which the Caribbean medical school has an active, written affiliation agreement and which have appropriate clinical faculty members. Rotations must be approved by the Accreditation Council for Graduate Medical Education  (ACGME). In addition, it is preferable that hospitals have approved residency training programs (or their British equivalents) in the specialties through which students rotate.  Students also take both parts of USMLE Step 2 (clinical knowledge and clinical skills) after the third year.
Hospitals in which electives are taken should also have approved postgraduate programs in those specialties.  For example, it is best to do an anesthesia elective at a hospital that has an anesthesiology residency. Regardless of school affiliation, however, individual hospitals still reserve the right to screen individual students for elective clerkship acceptance. Some individual hospitals and departments do not accept international rotating students, which can limit the away electives in which students can participate. From a competitive perspective, it is always preferable to participate in clinical rotations located in hospitals that not only have ACGME accredited residency programs but are academic teaching hospitals rather than community hospitals.

If I Go To a Caribbean Medical School, Can I Get a Residency?

Graduates of Caribbean medical schools have tremendous success in obtaining residency positions, even in competitive specialties. It helps to attend a well-established Caribbean school, perform well on the USMLE Steps 1 and 2, and obtain strong letters of recommendations. (See my previous articles: Getting Into Residency Part 1 and Part 2 for more information.) Before applying for the residency match and early in medical school, students should strategically plan their clinical clerkships in the US, ideally arranging rotations in the settings where they prefer to match.  In recent years, Caribbean students with strong academic and clinical performances have been able to obtain competitive residency positions at an increasing rate.  However, the largest number of students pursue less competitive specialties, such as internal medicine or family practice.  Some students are also able to ”prematch” into residency positions outside of the National Resident Matching Program (NRMP).
When evaluating the success of a Caribbean medical school’s graduates, it is important to find out specifically where and in what specialties students match. Also determine what percentage of fourth year students match into categorical programs. This information may not be easy to obtain. While schools typically publish their match results, it is unclear if these lists are truly comprehensive.
After residency, Caribbean medical students, along with their domestic colleagues, will obtain board certification and must meet specific requirements for state licensure. The quality of one’s residency training usually carries more weight than the medical school attended, so obtaining the best possible residency and even fellowship can help Caribbean students overcome some of the bias foreign students face when competing for competitive attending positions.

Educational Commission for Foreign Medical Graduate (ECFMG) Certification and Graduate Medical Education Programs

To be eligible for ACGME accredited residency programs in the United States, and for licensure in many states, students who graduate from a Caribbean medical school must obtain an ECFMG certificate. Eligibility for this certificate includes graduating from a medical school listed in FAIMERs online International Medical Education Directory (IMED) and passing the USMLE Steps 1 and 2 (both clinical knowledge and clinical skills).  For more details, see the ECFMG website at www.ecfmg.org.

Questions to Ask

School History

• When was the school established?
• What percentage of students are US citizens?
• By whom is the school run and what are the credentials of the academic faculty?
• Has the school had any recent changes in leadership? Are any leadership changes expected?

Caribbean Medical School Accreditation

• By whom is the school accredited and is the school accredited by the states of California, Florida, New Jersey, and New York?  Is the school listed in FAIMER’s IMED?

Admissions, Medical Education and Curriculum

• The quality of your medical education begins with the advice you receive prior to attending a Caribbean medical school. Is your premed advisor well versed in the pros and cons of attending medical school in the Caribbean?
• If interviews are required, by whom are they conducted – alumni, administrative staff, faculty and/or current students?
• What are the mean overall and BCPM (biology, chemistry, physics and math) GPAs and MCATS of accepted students? Are MCATs required to submit an application?
• Does the school have more than one matriculating class annually and are admissions rolling? Unlike most US schools, Caribbean medical schools typically have two to three first year classes that begin at different times during the academic year.
• What is the average size of each entering class? Does the size vary depending on the start date?
• How many students enroll in each first year class? What percentage of students who enter as first year students start third year rotations as scheduled?  What percentage of first year students match into categorical residencies in the United States during their fourth year? What percentage of first year students graduate? (Understand that graduating does not necessarily mean matching, so both of these questions must be answered.)

Financial Concerns and Living Conditions

• Do most students fund their education using outside loans or scholarships? Are these loans backed by the US government or are they private loans? Does the school offer financial guidance to help students choose the best loans and make responsible financial decisions?
• Where do students live and what are the housing conditions? Does the school provide housing?

Clinical Studies

• Where do students do their clinical training? Can students choose where they do core rotations? Are the rotations ACGME accredited? Do students work alongside US medical students?
• Are students allowed to do elective rotations? How many? Can students do away electives at nonaffiliated hospitals? Does the administration or faculty help students obtain away electives?

Residency Match and Professional Guidance

• Does the school provide guidance to help with the match process? Do students have an assigned advisor to help them?
• Where and in what specialties did students in the most recent graduating classes match for residency, and what percentage of fourth year students matched into categorical residencies?
• What percentage of students do not match annually? What percentage of students must enter the “scramble”? For students who enter the scramble, does the school provide assistance to find an unfilled residency spot?

Alumni and Student Support

• Where do alumni practice geographically, in what specialty and in what type of practice (community or academic)?
• Will the school provide contact information for alumni and current students with whom to speak?

Medical School in the Caribbean

Going to medical school in the Caribbean can be a good option as long as you do your research and make an educated choice. The medical education you will receive in the Caribbean varies tremendously, and the success you will have after graduation depends on many factors. Attending a top Caribbean medical school is a great option for some students but, just as for US medical students, once in school you must “do the right thing” to secure an excellent residency, (See my article Getting Into Residency Part 1 and Part 2.) I have had several Caribbean medical student clients earn residencies in competitive specialties, including anesthesia, emergency medicine, and internal medicine so, yes, it can be done!
Jessica Freedman, MD, a former medical admissions officer, is president of MedEdits (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. She is also the author of the MedEdits blog, a useful resource for applicants: (www.MedEdits.blogspot.com).
The author would like to thank Marta van Zanten for clarifying parts of this article.

References

1) van Zanten M, Boulet J R. Medical education in the Caribbean: variability in medical school programs and performance of students. Academic Medicine. 2008;83: s33-s36.
2) van Zanen 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. Academic Medicine. 2009;84: 771-775.