Thirty years ago, the Graduate Medical Education National Advisory Committee predicted a surplus of 145,000 physicians, including cardiologists, by the year 2000, and recommended a limitation of the number of entering positions in U.S. medical schools and the number of international graduates coming to the United States.
Although there was no restriction placed on international graduates coming to the United States, the number of positions available for students to enter U.S. medical schools has remained static until the last 2 years. This obstruction to medical school entry led many students to seek education at offshore medical schools (OMS), particularly in the Caribbean.
The flawed predictions of a surplus of doctors were made in anticipation of an expanded role of health maintenance organizations as gatekeepers for access to both family and specialty doctors. GMENAC also failed to foresee the expansion of the elderly population as a result of the baby boomer generation and the increased availability of new diagnostic and therapeutic technologies.
It is now estimated that by 2020 or 2025 there will be a shortage of almost 200,000 doctors in the United States (J. Gen. Intern. Med. 2007;22:264–8). U.S. medical schools are now projected to graduate 16,000 doctors annually, and that number is expected to increase by 30% in 2015, unless the proposed restrictions to education budgets by Congress come into place. However, this increase will continue to fall short of national requirements if physician retirement is factored into the estimates.
I recently had an opportunity to visit one of the Caribbean medical schools and to observe the students in the classroom. I also learned a great deal about the role that the OMS play in mitigating the doctor shortage in the United States. The students in these schools are clearly different from those who attend American medical schools. They are distinguished, not exclusively by their MCAT scores, as though that really matters, but also by being very motivated to become doctors. Many had been out of undergraduate programs for sometime – some as long 15 years – and had tested other careers and come to the realization that medicine is what they really wanted.
Most of these students will spend 2 years in the Caribbean and then move to clinical training in hospitals throughout the United States, ultimately entering residency programs and practice in mainland America.
One of the first hurdles that the OMS students will face is passing the United States Medical Licensing Examination taken by both U.S. and International Medical Graduates (IMGs). Measured against U.S. medical school graduates, who have a first-time passing rate of about 95%, they unfortunately fall short: The rate for non-U.S. IMGs is 73%, and that for American IMGs is lower still, at 60% (Health Aff. 2009;28:1226–33).
Upon the completion of their training, although they may go into subspecialties as do U.S. students, more of the Caribbean students enter family practice, a fact that has not been lost on health planners.
There have been some recent attempts to limit the number of training slots available for OMS students in New York City hospitals because of the presumed lack of total residency positions.
However, the state legislators, aware of current needs, have been reluctant to erect any barriers for physicians interested in family practice.
Currently there are 40 OMS in the Caribbean basin including Mexico, 24 of which were started in the last 10 years, which graduate more than 4,000 students annually in three classes, which vary in size between 60 and 600 students. Tuition is similar to that of U.S. schools and ranges from $47,500 to $186,085 for the 4 years. U.S. medical schools must be accredited by the Liaison Committee on Medical Education, but there is no accreditation process for OMS.
The LCME is now partnering with the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions to establish similar accreditation processes. Federally supported scholarships are available to U.S. citizens in the OMS just as they are for students enrolled in U.S. schools. As a result of the high tuition and relatively low overhead, some of these schools have been targets for venture capitalists.
Of the 800,000 actively practicing doctors in the United States, 23.7% are IMGs, a percentage that is sure to increase. Approximately 60% of the IMGs are from the offshore medical schools.
It is clear that the United States has become increasingly dependent on OMS to meet our doctor supply. It is also clear that a vigorous attempt to improve the certification process for OMS would go a long way to ensure the quality of our future doctors.