Friday, September 13, 2013

Quality vs Costs of US Corporate Owned but Offshore Medical Schools

Background: Off-Shore Medical Schools for US Students Owned by US Corporations

While US health care appears to be more corporate than health care in any other developed country, one part of health care that has remained a bit less corporate is medical education.  In particular, no US medical school is a for-profit venture, to my knowledge.  (This just makes US medical education a bit less corporate than the rest of health care because, as we have discussed endlessly, academic medical institutions in the country have frequent institutional conflicts of interest, and their boards of trustees, administration, and faculty have frequent individual conflicts of interest.

Nonetheless, there are many Americans attending for-profit medical schools owned and run by US based corporations.  It is just that these schools are not physically located in the US.  Since the number of US citizens who want to go to medical school has been greatly exceeding the capacity of US medical schools, many who want to become physicians have sought medical training in other countries.  Some go to medical schools outside of the US which are primarily operated to provide doctors to the countries in which they operate. However, the limited availability of places available in such schools for foreign students, and the difficulties of training in unfamiliar medical systems and often in unfamiliar languages limit the attractiveness of this option.

Enter American entrepreneurs into the picture, who realized they could set up schools in willing locations (often in small countries in the Caribbean) meant to educate Americans in English.  While there are plenty of reasons to be concerned about the role US based medical schools play in the dysfunction of US health care, there may even be more reasons to be concerned about for-profit, US owned, but off-shore medical schools that cater to US students.  Yet although such schools now train a large number of students, they tend to fly under the radar.

Reasons for Concern about US Corporate Owned but Off-Shore Medical Schools

In 2010, we posted about an investigative report in the St Petersburg (FL) Times that provided reasons for concern.  These included suggestions of quality problems, such as high attrition rates, high rates of failure to complete residency training and lack of quality controls over clinical education, high costs imposed on students, and the role of extremely well compensated executives with no apparent knowledge of medical education.

Now Bloomberg has published another report on for-profit, US owned Caribbean medical schools that underscores these concerns.  The report focused on schools owned by the US based, publicly traded DeVry Inc.  These include American University of the Caribbean School of Medicine, located in St Maarten, and Ross University School of Medicine, located in Dominica... 

Quality Concerns

- Attrition

 Many DeVry students quit, particularly in the first two semesters, taking their debt with them. While the average attrition rate at U.S. med schools was 3 percent for the class that began in the fall of 2008, according to the AAMC, DeVry says its rate ranges from 20 to 27 percent. 

One reason for this is that for-profit schools may take students who are less academically qualified,

 Many of those students, ..., failed to gain admission to U.S. schools, where the mean score on the Medical College Admission Test, or MCAT, was 31.2 out of a possible 45 last year. At DeVry’s schools, the average score was 25.

- Time to Completion of Training

 Of those who remained, 66 percent of AUC students and 52 percent of students at DeVry’s other Caribbean medical school, Ross University School of Medicine, finished their program -- typically two years of sciences followed by two years of clinical rotations -- on time in the academic year ended on June 30, 2012. 

- Difficulty Obtaining Residencies

The National Resident Matching Program says 94 percent of fourth-year students schooled in the U.S. landed a first-year match in 2013, while 53 percent of U.S. citizens trained internationally did.

DeVry students fare better than the average foreign-trained student. Of the 914 Ross students who applied for residency in 2013, 76 percent, or 699, earned places. Another 41 had preliminary one-year spots, which would require the students to win a second residency in order to be eligible for a medical license in 48 states.

Of the 268 AUC students who applied for residency, 212, or 79 percent, got matches, and seven more had one-year slots. The remainder of the students failed to win a residency.

- Lack of Standards

The Bloomberg article also emphasized the fact that the US owned corporate off-shore schools do not have to meet the same accreditation standards as do US based schools:

  The Accreditation Commission on Colleges of Medicine, an Ireland-based body, accredits four Caribbean medical schools, including AUC, according to its website.

High Costs

While the quality of education provided by US owned corporate off-shore medical schools may be questioned, there is no doubt about their high costs.

 First-year tuition on Dominica costs $56,475, based on the three terms Ross divides the year into. That compares with a median of $50,309 for tuition and fees at private U.S. medical schools in the 2012-to-2013 school year.

These costs are of particular concern because many students of off-shore schools amass impressive amounts of debt. 
DeVry, which has two for-profit medical schools in the Caribbean, is accepting hundreds of students who were rejected by U.S. medical colleges. These students amass more debt than their U.S. counterparts -- a median of $253,072 in June 2012 at AUC versus $170,000 for 2012 graduates of U.S. medical schools.

And that gap is even greater because the U.S. figure, compiled by the Association of American Medical Colleges, includes student debt incurred for undergraduate or other degrees, while the DeVry number is only federal medical school loans. 

 These high debt loads are enabled by US government loans, even though the schools are not located or accredited in the US.

And though neither AUC nor Ross, in the island nation of Dominica, is accredited by the body that approves medical programs in the U.S., students at both schools are eligible for loans issued by the U.S. Education Department.

In addition,

 Students at the four schools -- the two DeVry schools, along with St. George’s University School of Medicine and, since July, Saba University School of Medicine -- are also eligible for tuition benefits from the U.S. Department of Veterans Affairs.


The Bloomberg article briefly questioned the motivations of DeVry leadership, quoting David Bergeron, previously of the US Department of Education

If they have to make a choice between students and profit, they choose profit

They may do so because the off-shore medical schools bring in a lot of money

DeVry got 34 percent of its revenue in the year ended on June 30 from medical and health-care education, including a chain of U.S. nursing schools. The unit contributed $673 million of DeVry’s $1.96 billion in revenue, up more than sevenfold from $91 million in fiscal 2005.

'The diversification strategy is working,' Chief Executive Officer Daniel Hamburger said at an investor conference in Chicago in June. 'About a third now of our enrollment is in the growing field of health-care education.'

It seems clear that this revenue stream is greatly dependent on US government money
DeVry acquired AUC in 2011 for $235 million, attracted partly by the school’s eligibility for federal loans, says Harold Shapiro, DeVry’s chairman and a former president of Princeton University.
'Access to federal student loans is very important for a lot of DeVry programs, including that one,' says Shapiro, 78, an economist by training, who plans to retire from DeVry in November after 12 years on the board and five years as chairman. 'Obviously, it’s part of what makes it work.'

A Quick and Dirty Look at Costs vs Value

As I noted earlier, little seems to be written about the commercial nature of the US owned, but off-shore medical schools that purportedly educate a growing number of US citizens.  I thought I would try to add a little to the Bloomberg article by trying to see if I could find any other obvious way to contrast the quality of the Caribbean based schools with their high costs.

As noted above, the tuition at one DeVry medical school was more than 10 percent higher than the median for US schools.

For comparison, I thought I would make some sort of quick assessment of the faculty of one DeVry school, Ross University School of Medicine.  That turned out to be easier than I thought it would be.

My first stop was the web-page that conveniently lists all of the school's faculty and administration.  I assumed that this would be cumbersome to use.  After all, a typical US medical school has a huge faculty, divided among pre-clinical departments (anatomy, physiology, biochemistry, etc), and clinical departments (usually one for each important specialty and or sub-specialty).  I thought I would start with the Ross department of internal medicine (since my background is in internal medicine).  Imagine my surprise when I discovered that Ross does not have individual departments for clinical disciplines, but simply one Department of Clinical Medicine.

Imagine my further surprise when I reviewed its membership.  The web-page lists all of 31 people in this department.  The list, with a summary of the individuals' positions at the school, and previous training appears below in the appendix.

The qualifications of this small number of clinical faculty were mixed at best.

- Note that of the 31, 8 are not actually faculty, but staff (color coded pink)

- Of the 23 actual faculty, only 5 seem to have received their medical degree and residency training in the US (color coded blue).  In addition, one received US residency training after medical school in South Africa.  (This is relevant because this school caters to US students, emphatically not students from Dominica.)

- Of the remaining 18 faculty, for 10 no background information was supplied (color coded green).

While the number of clinical faculty was small, keep in mind that Ross University School of Medicine is very large:

Ross typically enrolls 900 to 950 students per academic year, who start in either January, May or September.

 That’s about seven times the average of 139 for the 2013 graduating class of U.S. med schools, according to figures from the AAMC. 

Yet a typical American school has orders of magnitude more faculty for almost one order of magnitude less students.  For example, my own medical school, Alpert Medical School of Brown University, has 457 students in four classes, and has 180 campus-based and 652 hospital-based faculty.  Its Department of Internal Medicine, just one of many clinical departments, is much larger than Ross University's single Department of Clinical Medicine.

While the argument could be made that Ross only provides the first two years of medical education at its Dominica campus, and farms out the rest to a variety of hospitals in the US, keep in mind that the second year of a typical medical school curriculum is clinical topics and taught by faculty in clinical departments, often hospital based.  

So what in the world is the rationale for charging a higher tuition rate than a typical US based medical school, when the school only has to support a tiny faculty whose qualifications do not seem sufficient to demand a high price?


Based on admittedly limited information mainly from media sources, we find that US corporate owned but off-shore based medical schools make large amounts of revenue, charge their large student bodies big amounts for tuition, yet provide proportionately minuscule numbers of not clearly all well-qualified faculty, producing high attrition and residency completion rates.  Yet these schools' revenue streams are derived mainly from US government loans, made even if many students will not eventually obtain medical qualification and work as physicians. 

This seems like a great deal for the corporate executives and perhaps stockholders, but a poor deal for the students and the US tax-payers who support them.

We see another aspect of the US health care system in which money seems to trump mission, facilitated by an unseemly alliance between wealthy corporate executives and bad US government policy.  We need to reexamine our fascination for "market based" approaches to health care, when almost nothing about any part of health care resembles, or could resemble a free market (see this post).  We need to make health care more transparent, and shine more sunshine on the nooks and crannies, like off-shore but US corporate owned medical schools.  We need to facilitate health care leadership and governance that puts patients' and the public's health first, way ahead of the personal enrichment of the participants.  


 "Faculty" Listing for Ross University School of Medicine Department of Clinical Medicine

 Jane Bateson - "Data Analyst & Research Associate"

Anne M Beaudoin - "Operations Specialist"

Liris Benjamin - "Associate Professor," "Doctorate in Physiology from the University of West Indies"

Lisa Buckley - "Simulaton Cordinator"

Yasmin Burnett -"Associate Professor" [no further details listed]

Diana Callender - "Professor and Chair" "graduate of the University of the West Indies where she completed her MBBS and

Residency in Clinical Hematology."

Terri Carlson- "Associate Professor," "Creighton University Medical School in Omaha, Nebraska and completed residency

training in Family Practice at University of California, San Francisco in 2001."

John Charyk - "Assistant Professor," "medical school at Georgetown University in Washington DC. In 1981 he completed his

family medicine residency program at the University of Colorado in Denver."

Phillip E. Cooles - "Professor," "BSc at King's College, London, then a medical degree at St George's Hospital medical

school, and then a residency in internal medicine in Aberdeen, completing the MRCP"

Lauri Costello - "Assistant Professor," "UC Davis for medical school then further north to Spokane Washington for her

residency at Family Medicine Spokane,"

Hedda Dyer - "Associate Professor," "University of Edinburgh Medical School with a bachelor of Medicine and Surgery (MB

CHB). She is a Member of the Royal College of Surgeons of Edinburgh, Scotland (MRCS Ed)"

Sean Fitzgerald - "Assistant Professor" [no further details]

Lyudmyla Golub - "Associate Professor," "Doctor of Medicine degree in 1983 from Vinnitsa National Medical University,

Ukraine. She completed an Internship in Surgery at Vinnitsa Teaching Hospital #3, Ukraine"

Lata Gowda - "Harvey Facilitator"

Aimee Hougaboom - "Simulation Coordinator"

David Johnson * - "IME Facilitator"

Sybille Koenig - "Coordinator, Standardized Patients Program"

Jaya Kolli - "Professor," "undergraduate degree at the Guntur Medical College, Andhra University, India. He went on to the

Government General Hospital/Guntur Medical College, Nagarjuna University, in Guntur, India and completed a residency in

Internal Medicine"

Kamalendu Malaker * - "Visiting Faculty" [no further details]

Ganendra Mallik - "Associate Professor" [no further details]

Sanghita Mallik - "Assistant Professor" [no further details]

Robert Nasiiro - "Professor" [no further details]

Worrel Sanford * - "adjunct Assistant Professor" [no further details]

Robert Sasso - "Professor" [no further details]

Harold Schiff - "Associate Professor," "board certified neurologist, trained at Boston City Hospital, Boston University and

has a fellowship in Behavioral Neurology, Higher Cognitive Function and Geriatric Neurology. He graduated from the

University of the Witwatersrand, Johannesburg South Africa"

Nancy Selfridge - "Associate Professor" "medical training and MD degree from Southern Illinois University School of


Rose-Claire St. Hilaire * - "IME Instructor" [no further details]

Lynn Sweeney - "Assistant Professor,"graduated from the University Of Tennessee School Of Medicine in 1987. She completed

residency in emergency medicine at the University of Arkansas for Medical Sciences"

Valarie Thomas - "Assistant Professor," "D.V.M. degree from the Universidad Agraria de La Habana in Havana Cuba"

Nash Uebelhart - "Assistant Professor," [no further details]

Miscilda Vital-Harrigan - "Assistant Professor," [no further details]


Bernard Carroll said...

One of the strengths of US medical schools is that preclinical and clinical training take place in an environment where research also is paramount. My guess would be that faculty directed research is not a high priority in these off-shore schools. And what about infrastructure like well stocked medical libraries, on-line journal access for students, etc?

Judy B said...

Well said! My parents have/had a doctor who graduated from George Medical School in the Caribbean. He is on staff at a nursing facility. He does not correct people when they hear Georgetown....

Afraid said...

What part of this post surprises anyone? Of course its that way.

The Truth said...

I would have liked your post except for a few details...
First... the source you are quoting is a Bloomberg article... Hardly an unbiased source considering "A benefactor of JHSPH is Michael Bloomberg"...

Second, the only research you seem to have done is look at a "Faculty" Listing for Ross University School of Medicine Department of Clinical Medicine.
If you had done the same research on a school such as Brown University, and also used "no background information was supplied (color coded green)" you results would be similar.
There are many points in your post that I would agree with, but I think you do your subject matter an injustice by aligning yourself with dubious sources...

Roy M. Poses MD said...

Re the comment by "The Truth," whoever this may be,

Umm, thanks for noting the relationship between Michael Bloomberg and the Johns Hopkins School of Public Health. I would note that this appears to be a pretty indirect conflict of interest, since it was Bloomberg who gave the money to the school, not the other way around; it was the school of public health, not of medicine; and Bloomberg is the owner, not the editor of the publication.

I did not claim to have done exhaustive research. My resources are very limited, and so what I did was, as I said, a quick assessment.

My main point was that Ross seems to have an orders of magnitude smaller faculty/ student ratio than does a typical US medical school. The fact that a major proportion of its tiny clinical/ medical faculty did not list their qualifications merely iced the cake. Even if Brown has the same proportion of faculty with unlisted qualifications, the comparison of the ratio is not really affected.

Further, regarding conflicts of interest, I do not hide that I am currently on the voluntary faculty of Brown. On the other hand, I have hardly been a an unequivocal supporter of the Brown administration's actions in the past.

However, "The Truth" chose to be anonymous, so who knows what his or her conflicts of interest might be, or not?

Ross Student said...

Lack of standards section is erroneous. Your choice of quotations is excellent for misrepresenting the situation. Ross is not accredited by the LCME, but it is accredited by the ECFMG (Educational Commission for Foreign Medical Graduates), whose members are: American Board of Medical Specialties; American Medical Association; Association of American Medical Colleges; Association for Hospital Medical Education; Federation of State Medical Boards of the United States, Inc.; and National Medical Association. Basically, it certifies that the quality of education and training at an international medical school meets the same standards as an equivalent US medical school. You also left out the section about Ross University having essentially the same first time Step 1 pass rate as the US medical school national average (Ross:95% in 2011, US: 96%), and that's higher than your US DO school (92%).
Now about the faculty, your research was so terrible that I don't know how you're not ashamed to write the letters MD behind your name. Couldn't you have written an e-mail or something? What kind of slander is this? Ross doesn't list all of it's faculty there, but you can have a list if you ask for one. The actual number of faculty is much much higher. Regardless, it's not anywhere near "180 campus based or 652 hospital-based" faculty. Sir, be honest with yourself and these people. How many of those "faculty" don't have office hours because their sole purpose is student education. Probably not a single one. One of the flaws at Ross (lack of research programs) is actually one of our greatest strengths. Professors aren't tied up with other responsibilities. Their responsibility is the students. How's that for quality? I've spoken to professors for hours at a time, because that's how many professors are available to the students.
How much did you get paid for this bullshit article?

Roy M. Poses MD said...

"Ross Student," or whoever you may be,

My post was based on the Bloomberg article to which it links. If you have a quarrel with any facts in the article, or in the post but derived from the article, please provide specifics.

My understanding is that the ECFMG certifies students who graduate from medical schools in the US for US practice, not medical schools. Looking at the ECFMG website I see nothing about accrediting medical schools, and nothing about Ross University. (Look here: So your statement about Ross being "accredited by the ECFMG" appears wrong. If you have any justification for it, please let us know.

Maybe your statement about the Step 1 pass rate is correct (although a citation would have helped.). However, Step 1 is obviously only the first step. If you have any reason to question the facts in the Bloomberg article about other aspects of the results of education at Ross, please explain.

You are actually asserting that Ross has a secret faculty list, that one can have "if you ask for one," but without explaining from whom one should ask? Really? Again, note that I did not provide a list of all Ross faculty, just those who seemed to be involved in teaching more clinical rather than basic science topics and were in the Department of Clinical Medicine. The comparison was with faculty in clinical departments in US medical schools (which are usually divided by specialty, e.g., medicine, surgery, psychiatry, etc)

I concede that most full-time faculty at US medical schools have responsibilities other than teaching students, and we have posted about the problems created by faculty who are not given enough support and incentives for teaching. Nonetheless, it is still hard to see the very small number of Ross faculty per student in Ross' one clinical department as comparable to the orders of magnitude larger number of faculty in clinical departments per students in US schools, even if the Ross faculty were 100% devoted to teaching, and the US faculty were not.

Finally, note that I did not post anonymously. It is ironic that you questioned my degree, and used inflammatory language from behind a shield of anonymity. Were you you truly a Ross student who wants to support your school, you would look more credible if you were to identify yourself.

As I have noted many times before, all our bloggers, including yours truly, are volunteers and get paid nothing to write.

Of course, since we do not know who you, "Ross Student," really are, it is reasonable to ask whether you got paid to write this comment?

Norma said...

I think if you attend one of top caribbean medical schools, you will be just as well prepared. I attend UMHS St. Kitts and they have a great program there. The professors really care and the classes aren't huge. It has been a good option.

Roy M. Poses MD said...

Note that I allowed the comment by "Norma" to be posted on the off chance that the person who wrote it might really be a student. However, the post is anonymous (and links to a blog apparently written anonymously that seems to be unabashedly positive about Caribbean medical schools that cater to US students.) So if the post and the blog are both disguised marketing exercises, it is ironic that they appear on this blog.

At this point, I should note that my post above has attracted three anonymous comments that seemed to be awfully positive about offshore schools that cater to US students, and that none of the anonymous people who wrote them chose to reply to my responses, suggesting that they these comments were all stealth, deceptive marketing/ public relations exercises.

I submit that if the for-profit offshore schools want to get people to trust them more, they should not attempt to disguise their marketing and public relations efforts.