Medical School Admission Is a Highly Competitive

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 and classrooms (867). 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, shorter residency programs, more certain weekly work schedules, and for primary-care specialties shorter work weeks, everything else the same." Medical schools are aware of these differences and typically offer programs that will promote specialty diversity and choice. Offshore medical schools, although they are relatively new in scope, recognize the importance of medical specialties since they are responsible for observing trends in U.S. healthcare, and most of their students will reenter the U.S. system upon graduation from their programs.

As a result, offshore medical school programs, with their responsibility to adhere to high accreditation standards, are required to provide students with maximum opportunities for learning and diversity. Perhaps the only deterrent that exists is the lack of funds, income from tuition, and student enrollment that exists in U.S. medical schools that prevents these organizations from providing students with the best possible technology and expert faculty in specialty areas. However, as these medical schools have emerged as feasible alternatives to American programs, their standards have risen and must be satisfied in order to promote growth and preparedness of their students, and this includes the option to declare study in a medical specialty.

The Emergence of International Medical Graduates (IMGs) study by Koehn, Fryer, Phillips, Miller, and Green evaluated the prevalence of International Medical Graduates in U.S. residency programs in recent years, specifically in the area of Family Practice. The study indicates that in 2000, 27% of U.S. citizen IMGs entered family practice residency programs, and these residents often relocate to poverty areas in a number of large cities upon graduation (433-434). Furthermore, "A study of general pediatricians found that while international graduates are less likely to practice in rural areas than U.S. graduates, IMGs were more likely to be located in shortage areas...the increased number of IMGs entering family practice may not represent a sustained commitment to the specialty or a stable source of applicants. The full implication of the rise in IMGs in family practice residency programs will only be ascertained by further studies to determine the practice patterns of U.S. citizens and non- U.S. citizen IMGs in family practice, particularly in physician shortage areas" (434). The existence of IMGs in family practice programs demonstrates that graduates from nontraditional medical school programs are gaining wider acceptance in traditional healthcare institutions than in previous years, although their acceptance is not yet proven to be universal across all areas of the United State, and their value and knowledge must still be demonstrated in many regions.

Physician Distribution study conducted in Ontario focused on the shortage of qualified physicians in the area and has responded by allowing International Medical Graduates to practice in Canada. Furthermore, "With the implementation of the new IMG program for fully trained foreign positions, many spots in the recently expanded IMG program will become available to new graduates of foreign medical schools. Historically, foreign physicians who have come to work in Canada have made vast contributions to the development and quality of the current health care system. While it is hoped that this new program will attract high-caliber medical graduates, it may instead be exploited by Canadian students who were not able to gain entry into a highly competitive Canadian medical school. Some of these students may subsequently obtain a medical degree from any of the numerous foreign programs designed specifically to attract such candidates...admissions criteria for these schools have lower academic requirements and are unlikely to include selection for those non-academic traits that are specifically desired of successful candidates at Ontario medical schools" (Drzymala 170). The same can be stated for medical schools in the United States. In areas of physician shortage, including rural and disadvantaged areas, the need may influence the likelihood that medical students from offshore programs may be accepted into these programs to fill the gaps in care. However, it is difficult to measure the standards of care provided by these residents and its relationship to the medical training provided in offshore medical programs.

Medical School Specialty Choices research study conducted by Reed, Jernstedt, and Reber revealed that primary care providers, including those that practice family medicine, general internal medicine, or general pediatrics make up fewer than 30% of all physicians that practice in the United States (117). The study also indicates that "As medical schools have planned and implemented changes designed to reverse the trend toward specialty rather than generalist choice, there has been a dramatic increase in the number of studies conducted to examine medical school specialty selection. Educators and researchers alike hope that understanding the forces affecting specialty choice will provide clues to the best ways to influence such choice in the future" (117-118). The choice of medical specialty is influenced by a number of factors, including student desire, program desire, and competition for available spaces (118). Furthermore, "Medical students who chose primary care were more likely to consider opportunities to provide direct patient care, continuity of care, care in an ambulatory setting, and care involving psychosocial aspects of medicine as important, whereas students who chose nonprimary care specialties were more likely to be influenced by opportunities for research, prestige, income, and more control over their time" (122).

The referenced study also demonstrates that "The more knowledge an individual has of the possible consequences of selections, the better able she or he should be to assign both a value and a probability to each possible outcome, thus reducing some of the uncertainty in decision making. Many of the studies that have examined specialty choice in medical education have focused on this aspect of decision-making. These studies have explored whether programs that provide increased information about a specialty, usually in the form of exposure to that specialty through a preceptorship or clerkship, can positively influence medical students' ultimate choice of that specialty" (119). The implementation of a required internship mechanism before the assigned residency has begun is an influential factor in medical decision-making. In offshore medical programs, internships are a positive factor that will enhance the educational outcomes of graduates from these programs. Since the areas in which these schools are located may include areas that are faced with poverty or other predicaments, student internships can provide a positive influence for both students and local communities. In areas where primary care physicians are in high demand, the existence of such internship programs may influence the decisions of new medical residents to enter into primary care programs, filling a need in certain areas of the U.S.: "90% of students stated that such an experience had increased their understanding in primary care medicine and that 41 of students indicated that the experience had influenced their specialty choice. 93% of students reported that the clerkship helped them learn about common problems in medical practice, whereas 87% agreed that it helped them to develop their ability to communicate with patients, and 81% reported that the role of the primary care preceptor was an important factor in their learning" (120).