Caribbean medical schools: A look inside

Did you know that several Caribbean medical schools provide postgraduate premed courses so students can complete their science requirements? At least one school’s nearly year-long premed curriculum includes 8 hours per day of classroom work, rudimentary general chemistry and organic labs, and a physics lab with 40-year-old equipment. The fee is more than $30,000 cash, no loans. That's a lot to pay for courses that are not accredited and credits transferable only to other Caribbean schools.

The goal of these premed programs is to prepare students to take the Medical College Admission Test (MCAT). However, some schools require only that applicants take the MCAT but do not reject anyone on the basis of their scores. 

A former student said, “Little did I know that a [Caribbean school] acceptance was the equivalent of a lottery ticket. They actually attempted to weed us out of the small (and unaccredited) pre-med class! It took me a month to figure it out.” One of his professors told him the administration said not to pass everyone in the premed course into the first year of medical school.

He struggled through the premed requirements and wound up at a different school. The dean at that school spoke to the students about USMLE testing and what to expect in the clinical years. Many times during the talk, that dean referred to the school’s “top students” in a way which implied that only the best students were likely to match to a residency position.

Another school administrator told him that some residency programs would not even look at his application if there was an F on his transcript. While most program directors would probably verify that statement, it was not widely known among the students at his medical school. Some had even failed a course but were still planning to become surgeons.

Regarding his struggles in the second year of medical school, the student said the volume of material was overwhelming, everyone in his class was stressed, and approximately one-third had dropped out. He observed that students who were doing well were “type A personalities who had some measure of prior academic success…and could make it through any US or Canadian program with ease.”

He barely made it through the first year with mostly C grades. During his second year he dropped two courses and had to repeat them.

After eventually withdrawing from that school, he applied to another and was turned down.

He warned that those who are thinking about going to school in the Caribbean don’t understand how many don’t make it through.

Dropouts and accurate figures on what percentage of each graduating class passes all USMLE steps and matches to a residency program are unknown.

Meanwhile tuition debt keeps accruing and doesn't go away. The student has over $200,000 to pay off and will be doing so without the benefit of a physician's income. He is now trying to get a job related to his undergraduate major—business.

Regarding the offshore medical school experience, the student had the following observations:

The schools accept many students who they know will not make it through to fill up the class and make a lot of money in the process.

I didn’t find the material in medical school to be all that difficult; it’s the volume of the material and the time constraints that are the problem.

I could not figure out why my studying was only yielding C's when some people were getting the A's and B's. I'm starting to believe people are born smart.

I am not a good test-taker. I make the process harder than it is. The right answer might stare me in the face but I'll always second guess it.

I was informed that residency programs look at more than STEP scores. I was actually under the impression that no matter what red flags I had on my transcript, my STEP scores would decide my future, but I was told by other students that residency programs will look at pre-clinical grades and I even heard from one student that an IM program asked for college transcripts! If that is the case, I would never stand a chance.

I wanted to be a primary care physician. Was all this stress worth it to go into primary care?

I keep reading that the match will continue to get harder and harder.

I have blogged about the decreasing number of residency positions available for international medical graduates.

Despite the recent ban on immigrants from certain countries, I do not expect the situation to change much for US citizen IMGs.

If it comes to a decision about whether to attend an offshore school or not, do your homework. Talk to people who have been there. It's not all palm tress and sunsets. 

Shortage of doctors in the future? Maybe

Shortage of residency positions for international medical school graduates in the future? Yes.

Google “shortage of doctors” and you’ll find that almost everyone believes what the Association of American Medical Colleges (AAMC) says—that we will need 90,000 to 130,000 more doctors by the year 2025.

There are a few naysayers such as Gail Wilensky, a health economist and co-chair of the Institute of Medicine panel that found no evidence to support those estimates and Princeton health economist Uwe Reinhardt, who says it’s in the best interests of the AAMC to predict a shortage.

A 2012 survey found that one-third of US physicians planned to retire by 2022. According to a study by the Kaiser Family Foundation, there are just over 900,000 active physicians in the US, meaning that if the survey is correct, about 300,000 doctors will have stopped practicing by 2022.

The AAMC says that about 18,000 medical students graduated from US schools in 2015. Will that be enough to replace those who say they are quitting? The number of residency positions available for med school graduates was 27,860 in the 2016 match.

If you multiply 27,860 residency slots x 10 years (between the years 2012 and 2022) you get 278,600, which approaches the projected number of 300,000 retirees lost.

No matter which side of the debate is correct, international medical graduates (IMGs) will be adversely affected. Here is why.

FAQs from IMGs about applying for surgery training

Here are some of my responses to common questions from international medical graduates (IMGs) looking to match in categorical general surgery residency programs.

1. Which programs should I apply to?

You should apply to a number of second and third tier programs, especially if you USMLE Step 1 scores are not outstanding.

2. What would you consider second and third tier academic programs?

There is no short answer to this question. I suggest you go to Doximity’s residency navigator and look at their list of surgery programs. You should start at the bottom and work your way up. Doximity’s list is not perfect, but it is better than any other one I have looked at.

3. How much of a level playing field is the interview process?

I’m not sure what you mean by this question. The object is to get some interviews. Most programs will not waste their time interviewing people they have no interest in. If you are offered an interview, you should obviously make the best impression you can.

4. What about observerships?

Another Caribbean med school graduate needs advice

I did not attend St. George's, Ross, or Saba. I chose my school because it has a premed program which leads to an MD program. My USMLE Scores on Step 1 and Step 2 CK are above 230.

I did not apply for the 2015 match because I did not have my step 2 CK results until November. It would have been too late. I could have rushed my step 2 but I wanted to get a good score and be a solid applicant. Also I would not have been able to complete my surgical electives in time to get letters of recommendation. At some point, I will be doing research at [a very well-known medical school]. I felt that for these reasons this would make me a better applicant the next year.

Since graduating I have been trying to find a medical related job (scribe) but have had no success. I have reached out to many institutions regarding research opportunities but have come up dry. I may be able to secure a volunteer research position by next month. Do you have any suggestions for me? I knew I would hate being out of the medical field for this long but this was my best bet. Does this gap hurt my chances?

I am concerned that despite your excellent USMLE scores, taking a year off from clinical medicine may cause your application to be rejected immediately. I do not know if a 9 week research elective, even at a premier med school, would be enough to offset your lack of clinical experience over the entire year. Acting as a scribe would not be considered clinical experience.

Another issue is what is the record of your school regarding matching graduates into surgical programs? Since you didn’t tell me your school’s name, I cannot give you any insight into that situation. Even if I did know the school’s name, it may not have published its match results.

To answer your specific questions:

How many gen surg programs should I apply to? I was thinking ~100. That seems reasonable. You should be able to gauge your chances better after you see if you receive any offers for interviews from the 100 programs.

During a gen surg interview, should I be open about my backup specialty? I would advise you to say that you would take a preliminary spot in general surgery if you didn’t match in a categorical position. Admitting that you would do internal medicine is often seen as a lack of commitment to surgery.

Most hospitals I am looking to apply are IMG friendly. Which means the surgery and medicine programs are both IMG friendly. Would it be a bad idea to apply to different specialties at the same hospital? I think it would be a bad idea. I suggest you wait and see if you get interviews from the general surgery programs. If you don’t, then there would be no problem applying to internal medicine at the same place. I doubt very much that the two services would talk about any specific applicants. Most surgery programs get hundreds of applications and those applicants who are not offered interviews are not remembered.

Some readers may have other opinions. I hope they will comment.

Externships or observerships: Can they help an IMG get a surgical residency slot?

A woman writes [some non-essential details have been changed to preserve anonymity. Permission to post this was obtained.]:

I am a non-US citizen medical graduate from The University of The West Indies in Trinidad and am currently an intern in a Caribbean nation. Although UWI has produced great students, you may not be familiar with it.

I would like to become a surgical resident in the US. I have no US clinical experience, but my USMLE Step 1 score was >235.

What do you think about my doing a post-intern year externship (hands on clinical) as opposed to an observership (just observing) in the US? I know that an externship carries more weight as far as applications go, and the only reason I would want to do either of these would be to get recommendation letters from surgeons in the US.

However, since I have already graduated from medical school, getting into an externship will be more difficult because this will no longer be a medical school rotation. I believe that observerships will be easier to get into but are they worth it?

Do you know of any IMG-friendly programs that facilitate this? Do you think that this is a good idea? Do you feel that I will be able to get an externship?

Other than this idea for externship/observership, I am blank for ways to improve my chances of matching to a US program in surgery. Do you have any suggestions?

What are the chances of international medical grads matching in surgery?

Anyone considering attending a Caribbean or any foreign medical school should do due diligence. An Internet search is step one. If the school does not list residency match statistics, that could be a red flag. It would not be easy to accomplish, but try to speak with some current students or recent graduates of any schools you are thinking about.

If the school won't give you any names, use caution, and remember, they are not likely to give you the names of dissatisfied students or alumni.

If a school does not require Medical College Admission Test (MCAT) scores, I would advise extreme caution. That suggests they probably take all comers.

2015 Match Review

Continuing grim news for international med school grads and some US grads too

There were a lot of happy faces on March 20th as depicted in this brief video of the excitement on the campus of the University of Rochester School of Medicine. Similar scenes took place at every US medical school because 93.9% of the 18,025 graduates of US allopathic medical schools matched in a specialty.

But for the 1093 (6.1%) US graduates who didn't match things were not so bright. These applicants had to go through the Supplemental Offer and Acceptance Program (SOAP) which connects unfilled programs with unmatched students.

Because there were over 8600 unmatched graduates from schools all over the world vying for about 1200 unfilled first-year residency positions, even some US med school grads did not secure a position. One of these unfortunate souls tells her story in this blog.

The 7400 or so new MDs left out in the cold will not be able to pursue their careers. They will not progress into any specialty, nor will they be able to obtain licenses to practice medicine anywhere in this country. Those with substantial tuition debt will have no way to pay off their loans.

The percentage of unmatched US graduates has been relatively stable over the last five years, ranging from 4.9% to 6.3% while the number of first-year residency positions offered has steadily increased by nearly 4000 from 23,420 in 2011 to 27,293 this year.

Graduates of osteopathic medical schools didn't fare quite as well. Of the 2949 osteopathic school applicants, 610 (20.7%) went unmatched, but this percentage has steadily declined from a high of 28.3% in 2011.

International med school grads were much worse off; 2354 (46.9%) US citizens and 3725 (50.6%) non-US citizen graduates of international medical schools did not match. Both of these groups also had declining percentages of unmatched applicants. In addition, about 1900 US citizen graduates of offshore schools either withdrew or did not submit a rank list compared to almost 2700 non-US citizen international graduates who did likewise.

Reentering the match next year is an option, but spending a year outside of clinical medicine greatly reduces one's chances of finding an accredited position.

If you factor in the number of applicants who either withdrew from the match for did not submit a rank list. graduates of international medical schools have well below a 50% chance of matching.

In previous posts here and here, I have warned about the risks involved with attending an offshore medical school. If you are considering attending such a school, I urge you to look at the numbers and think long and hard about your decision.

Source: Advance Data Tables 2015 Residency Match