Medical school admission is a highly competitive process that only evaluates and admits the most qualified candidates for entrance, and more students apply than spaces available in schools across the United States. The criteria that U.S. medical schools exercise in making their admission decisions are highly rigorous, including grade point average, future potential in the medical profession, communication skills, bedside manner, leadership skills, and extracurricular activities. As a result, many worthy students are not accepted to the schools of their choice and their dreams are often shattered by this reality. Specifically, in the United States, earning a medical degree is a status symbol that garners much respect and attention from the general public, and the profession is highly regarded as a symbol of position and admiration. Therefore, the competition is fierce and medical training is a very difficult and often exhausting process with significant financial and personal rewards for those who complete and excel in training programs. However, many students that cannot gain acceptance to American medical school programs are not necessarily removed from contention and the opportunity to earn a medical degree. Other options are available in nontraditional settings outside of the United States. An increasing number of medical schools are opening in smaller geographic regions outside the United States, including such areas as the Caribbean Islands, Mexico, and Europe. Because training and accreditation standards vary widely between these areas and the United States, if medical school graduates return to the U.S. To practice, they may encounter some difficulties in attempting to gain entrance to residency programs as well as permanent employment, directly resulting from their medical training. Furthermore, since it is assumed that offshore medical schools typically do not possess the most advanced technology, faculty, training methods, and medical facilities, students that graduate from these schools are ill prepared for the rigorous processes found in U.S. healthcare facilities, nor do they possess the specialized training to work in today's specialty practices. However, in recent years, offshore medical school programs have gained attention and notoriety because they compete with American medical schools for students and revenue, regardless of their perceived value. The following discussion will identify the differences between offshore medical schools and traditional programs and will demonstrate that the training offered in nontraditional environments does not allow students to practice in their desired specialty because the specialized instruction is not available. Furthermore, it will be demonstrated that the standards applied in offshore medical programs does not compare to the outstanding training received in many United States medical schools. As a result, physician potential is limited in scope, net worth, and overall value. Offshore Medical School Programs

Rigorous criteria and limited opportunities for enrollment in U.S. medical schools have resulted in an increase of offshore medical schools in nontraditional locations. Many of these programs are specifically designed for American students because they can accommodate the enrollment that traditional schools cannot manage because of their strict admission criteria and limited enrollment capabilities. Canadian students have also demonstrated an interest in these schools, and they have been warned that their chances of practicing medicine with a degree from an offshore school are very limited (Korcok 865). Despite these warnings, two of the most popular Caribbean medical schools, St. George's University in Grenada and Ross University on the island of Dominica, have graduated a number of Canadian students since their inception. In total, approximately 20 medical schools exist in this area that typically admit American and Canadian students into intensive medical training programs.

St. George's Medical School was founded in 1970 by Charles Modica, and Ross University was founded by entrepreneur Robert Ross, both under primitive conditions in comparison to U.S. facilities (867). American educators did not believe that these schools could provide a quality education to students and laughed them off as scams: "It was widely believed that 'for-profit' proprietary schools would never measure up to the quality of U.S. Or Canadian schools accredited by the Liaison Committee on Medical Education. Given the lack of up-to-date clinical clerkship facilities and postgraduate training positions, their graduates were never expected to make it back into mainstream North American medicine. The conventional wisdom was that the intricate web of examinations required of foreign medical graduates would be an insurmountable barrier, and state licensing boards would never approve their applications" (867). These schools experienced hardships in their beginning years, but eventually, distinguished faculty from the U.S., Canada, and other countries traveled to these areas to establish curriculum, standards, and setup dorms...

Admission to these schools was driven by the high standards exercised throughout U.S. medical programs.
In 1994, the U.S. General Accounting Office evaluated the impact of these programs on American medical education and training: "Up to 6,600 American students were attending medical schools outside the U.S. And Canada, primarily in the Caribbean and Mexico...in 1992, about 39,000 doctors, or 6% of American physicians, were American citizens who had received medical degrees abroad" (867). For offshore schools that participate in the U.S. Guaranteed Student Loan Program, accreditation standards have been established by the National Committee on Foreign Medical Education and Accreditation to ensure that students graduating from these schools are sufficiently prepared for the requirements presented in U.S. healthcare facilities. As a result, many graduates from these programs are adequately trained and ready to engage in practice in healthcare facilities across the U.S., regardless of the perceptions engaged by those in the U.S. medical community.

In 1999, the desire of two foreign medical schools to open branches in the United States resulted in a state of alarm from the U.S. medical establishment. These particular schools are unaccredited and threatened the integrity of the quality of health care in the U.S. Ross University in the Dominica, discussed earlier, also planned to open a branch campus in Casper, Wyoming despite the opposition (Mangan A39). According to founder Robert Ross, "This is a first. We're now on their turf, and they don't like it. I've never been afraid of a good fight, and I'm not about to turn back now" (A39). One primary reason that many U.S. medical professionals objected to these new campuses was that the potential for an abundance of physicians exists and has raised red flags. However, statistics indicate that 95% of all Ross University graduates in 1997 obtained medical residencies within two years, primarily in the United States (A40). That same year, "The U.S. Department of Education found that the standards used to accredit medical schools in Dominica are comparable to those used in the United States" (A40). This caused a great controversy in the medical community and has continued to make waves across the nation.

A survey conducted in the State of Ohio indicates that although many physicians are currently practicing medicine within the state, there is a consensus that physicians are maldistributed across specific areas of the region. For example, physicians are heavily distributed in metropolitan areas and sparse in rural areas (www.odh.state.oh.us).Furthermore, the State of Ohio is one of the few states in recent years which are reporting a shortage of specialties, where income potential is constantly increasing. These statistics are easily applicable to most U.S. states. In addition, the following statistics have been presented regarding medical school admissions policies (www.odh.state.oh.us):

Two-thirds of all applicants to medical school are rejected

More American students are attending offshore medical schools to obtain their education and training physician shortage is projected in the next ten years

Fewer medical students are entering generalist residency programs, with a rate of 49% in 2000

These statistics demonstrate that although the admissions policies of U.S. medical schools are generally stringent and only the most qualified candidates are accepted, physicians are in high demand, particularly in the specialty professions, where the potential for income is very high. As a result, it is in the best interest of students that offshore medical schools such as St. George's and Ross University offer a wide variety of specialty programs in order to fulfill the demand of these areas in U.S. facilities. Although these specialty offerings are becoming increasingly common in these schools, the effectiveness of these programs is still under intense scrutiny from experts in the U.S. medical community.

The Economics of Medical Specialties

It is widely known that physicians that practice under a medical specialty are often more respected and preferred over those that work in general practice programs as a result of research and development practices across the nation. These developments have increased the prevalence of a wide variety of diseases and conditions that require expert analysis and treatment, requiring a need for specialized experts in a wide variety of areas. As student residents are becoming increasingly aware of this disparity, they are entering into programs that will ensure their future success in a variety of medical specialties.

Most metropolitan areas as well as some rural areas possess medical practices in a wide variety of specialties, from pediatrics and oncology to obstetrics-gynecology and cardiology. According to Thornton and Esposto (71), "Medical residents are most attracted to specialties that offer the prospect of longer and more certain annual vacations, higher earnings,…