The Accreditation Process of Caribbean Medical Schools

I received an email from a friend asking about accreditation of Caribbean medical schools, so I thought it might be helpful if I posted my answer here for anyone who has similar questions.

“I was reading online and it’d say how not all of the schools are accredited, which scares me. Ideally, going to a Caribbean school for 2 years and doing clinical rotations in the U.S. would be great and I wasn’t sure if all the Caribbean schools would allow that. do you know which of the Caribbean schools are top rated? I guess my fear is whether it could stop me from practicing in the states…” — J

Disclaimer: In this post, I am only addressing off-shore American medical schools in the Caribbean. Regional medical schools located in the Caribbean and U.S. domestic medical schools in Puerto Rico are not included in this article.

Dear J,
It is good to hear from you! How is the application process coming along? I’d love to answer some of your questions. It is true that not all international medical schools are fully accredited for its graduates to practice in the United States. Being “accredited” is a very broad term, and schools can be “accredited” on many levels. Therefore, try to be critical when you read that a school is “accredited.” It is not a black-or-white issue. The accrediting process is complex, but here I’ll take you step by step in the process in which foreign medical schools must go through to become fully accredited:

1. GOVERNMENT CHARTER
First and foremost, the prospective school must obtain a charter from the government of the country in which they plan to establish their med school.

2. WHO/IMED
The school then must apply for WHO recognition and be listed in the FAIMER-IMED to be recognized internationally as an “official” medical school. However, being listed in WHO and FAIMER-IMED is not significant as it says nothing about the quality of the medical school. According to the U.S. Educational Commission for Foreign Medical Graduates (ECFMG), only students who obtain degrees from schools listed in the WHO and FAIMER-IMED directories are eligible to take the USMLE exams and participate in matching. Therefore, it is not too significant for a school to be eligible to take the USMLE and matching.

3.  ACCREDITING BODY
The school must then be accredited by an accrediting body. For American medical schools it is the Liaison Committee on Medical Education (LCME), which only accredits schools in the United States and Canada. Foreign medical schools use other accrediting bodies, such as those of their own government or a multinational accrediting agency like the ACCM.

4. NCFMEA
Not all international accrediting bodies accredit schools in the same way. For this reason, the US has a National Committee on Foreign Medical Education and Accreditation (NCFMEA) that reviews the accrediting bodies that accredit foreign schools to determine whether or not they have standards comparable to the LCME used in the US and Canada.

As of 2011, there are only four accrediting bodies in the Caribbean that are recognized by the NCFMEA. The Accreditation Commission on Colleges of Medicine (ACCM), a non-profit international organization based in Ireland that accredits medical schools on behalf of several governments in the Caribbean, is recognized by NCFMEA and accredits AUC and Saba University. The Dominica Medical Board (which accredits Ross) and the Grenada Ministry of Health, Social Security, The Environment, and Ecclesiastical Relations (which accredits SGU), as well as the National Council of Higher Education, Science, and Technology (which accredits medical schools in the Dominican Republic) are also on NCFMEA’s list.

The NCFMEA does not determine whether or not graduates can practice in certain states. The main purpose of the NCFMEA for reviewing accreditation standards is to determine whether or not American students attending a particular international school can participate in the US federal financial aid program. Being recognized by the NCFMEA is only one of several strict criteria for being approved for the US federal financial aid program, which I will describe towards the end of this article.

5. STATE APPROVALS
In addition, there are many states that also require foreign medical schools to be reviewed by their own state board of medical education. States like California, New York, and Florida require state-approval in order for students to do clinical clerkships in those states during their third or fourth years in medical school (notice I emphasize clerkship, not internship, residency, or licensure). Schools like Ross, SGU, AUC, and Saba are approved by these states and conduct clerkships in these states. New Jersey used to allow international medical schools to conduct clinical clerkships in the state, but have since closed their clerkship sites to international schools. Schools that already had clerkships in New Jersey before the change in policy (like Ross and SGU) were grandfathered in and allowed to keep their sites in these states. Regardless of what states different international medical schools can do clerkships in, these approvals for clerkship sites do not necessarily effect whether or not graduates can get a residency or license in these states, which is what really matters in the end. Therefore in terms of accreditation, what matters most is California approval for licensure.

CALIFORNIA
California approval is important because it is not only a requirement for international medical graduates to obtain the license to practice in California but also in other states as well that follow California’s Approved List of International Medical Schools: Alaska, Arkansas, Colorado, Kansas, Idaho, Indiana, New Mexico, Oregon, Tennessee and Vermont. In addition to these states, some states follow California’s Disapproved List in which graduates of officially California-disapproved schools cannot obtain licensure in those states (but graduates of schools that are neither disapproved or approved may get licensed). These states are Alabama and North Dakota.

Only five off-shore Caribbean med schools are on California’s Approved List: American University of the Caribbean (AUC), St. George’s University (SGU), Ross University, Saba University, and American University of Antigua (AUA). Graduates from these schools can practice in all 50 states.

Off-shore Caribbean med schools on California’s Disapproved List include: Spartan Health Sciences University, University of Health Sciences Antigua, and St. Matthew’s University (SMU). Graduates from these schools cannot practice in any of the states that follow California’s Approved List and Disapproved List as stated above.

NEW YORK
For students who are interested in getting a residency in New York, New York state approval is also required for graduates to obtain residencies in New York, but not required for the graduate to be licensed as a practicing physician afterwards in the state.

TEXAS
For those students interested in practicing in Texas, the Texas Medical Board require state-approval of a school for graduates of the school to obtain licensure without the need to demonstrate substantial proof of equivalency through documents and questionnaires, as would be the case for graduates of international medical schools not approved yet by Texas. Of the off-shore Caribbean med schools, only AUC, SGU, and Ross are on the Texas’ Approved List. Graduates of all other schools not on the list can get licensed to practice in Texas but it will be more difficult.

6. US FEDERAL STUDENT AID
Finally, in order for a foreign medical school to be eligible to receive U.S. Federal Student Aid (Title IV of the Higher Education Act of 1965), they must satisfy an additional number of criteria: First and foremost, the school must be NCFMEA-recognized (as I have described above) and must possess the administrative capability to manage Federal Student Aid. The school must also have at least a 75% pass rate for all the step exams administered by the ECFMG (i.e. USMLE Step 1, Step 2 CK, Step 2 CS). Then here’s the tricky part: the school must either have had a state-approved clinical training program since 1/1/1992 and remain approved to this day, or must have at least a 60% non-US student body.Of the off-shore American medical schools, only AUC, SGU, and Ross (known as the “Big Three”) pass the former criteria and are therefore eligible for U.S. Federal student loans (FFELP loans before July 2010 and Direct Loans effective June 2010). As Saba only inaugurated its first class in 1993 (although the school was officially founded in 1986) and has a majority American student body, it passes neither the former or latter criteria, and therefore is not approved to receive U.S. Federal student loans, despite meeting (and exceeding) the 75% USMLE pass rate requirement. In this case, Saba’s lack of Federal financial aid has little, if anything, to do with Saba’s educational standards, which the NCFMEA and California have already considered to be on par with the “Big Three” schools that have US Federal Student Aid. As for AUA, although AUA has been approved by California in 2011 (and therefore graduates can practice in all 50 states), its accreditation standards have not been approved by the NCFMEA yet and therefore is not eligible for Federal financial aid. Nevertheless, the tuitions at Saba and AUA are substantially cheaper than AUC, SGU, and Ross, a benefit that compensates for the lack of Title IV funds.

SUMMARY
So to summarize, Out of the 20+ offshore American medical schools in the Caribbean, there are only five schools that have California approval and therefore have graduates that can get licensed to practice in all 50 states. They are St. George’s University (SGU), Ross University, American University of the Caribbean (AUC), Saba University, and American University of Antigua (as of 2011). Of these five schools, four are NCFMEA-recognized: SGU, Ross, AUC, and Saba. Three are approved by Texas (making it easier for graduates to get licensed here): AUC, SGU, and Ross. These three schools are also the only schools that are eligible for US Federal Financial Aid and are the oldest off-shore medical schools in the Caribbean, with a history of placing graduates in all types of residencies and teaching hospitals, and a consistent USMLE first-time pass rate comparable to that of the United States. These three schools are what is often called the “Big Three,” and they are the first schools I would consider when applying to the Caribbean for medical school.

CONCLUSION
In conclusion, of the 30+ med schools in the Caribbean, there are some that do not make it past step 2, yet call themselves “accredited.” Technically, they are accredited to a certain extent, but as I clarified above, there is nothing too special about being WHO or FAIMER-IMED-recognized. There are others that do not make it past step 3, like St. Matthew’s University, and these are considered second-tier Caribbean med schools. But thanks to the many steps and the stringent criteria that a school needs to go through to reach step 5, anyone who seeks medical education at any of the top Caribbean medical schools (i.e. AUC, SGU, Ross, Saba, AUA) should not worry about the educational quality or not being able to practice in all 50 States.

Good luck in the application process! It was definitely a stressful yet exciting time for me.
Benji