http://www.naahp.org/resources_Forei...rticleflat.htm

International Medical Schools
for U.S. Citizens:

Considerations for
Advisors and Prospective Students

**** J. Crosby, M.A., and Robert E. Cannon, Ph.D

This is a modified version of an article that was originally published
in 2004 (The Advisor, Vol. 24, 1, pp. 36-41).

Introduction

Often we like to think that we have all or at least most of the
answers for questions asked by our students. We know about the medical
schools in our home state. If we have been members of the National
Association of Advisors for the Health Professions (NAAHP) and have
gone to national meetings, we have learned about medical schools in
other parts of the country. Also, at national and regional meetings,
we may have taken the opportunity to meet and speak with
representatives of international medical schools that help support the
NAAHP.

Still, when a student comes to us and says, "I'm considering going to
a medical school in another country," and that student is clearly
looking for our help in making a decision, we often are uncomfortable
about how to respond because we, ourselves, may not have much specific
knowledge about the pros, cons, intricacies, and strategies that would
help students learn about international medical education.

Maybe we are talking with an enthusiastic, but quite average student
whose potential for admission into U.S. medical schools is uncertain
at best. Or, it is a student who has applied to U.S. medical schools
and has been rejected by them, and she is seeking advice about
re-application. When a student mentions the possibility of applying to
an international medical school, what will you say to her as an
advisor? Probably most of us will begin by asking some questions.

We hope that the following article will help both you and your
students ask and seek answers to important questions. We will try to
give you some answers by briefly reviewing classic research in this
area, anticipating extra demands of completing a medical school
curriculum in another country, raising residency eligibility and
matching issues, suggesting personal qualities that might predict
student success, and offering a framework for gathering information
about international medical schools. International medical schools
offer a path for meeting student goals, but there are many unknowns.

Research Review

How many U.S. citizens go to international medical schools? The
Educational Commission for Foreign Medical Graduates (ECFMG) is the
body that certifies candidates who complete their medical education in
other countries as eligible to apply for Accreditation Council for
Graduate Medical Education (ACGME) accredited residency programs in
the United States. According to the ECFMG's 2002 Annual Report, the
exact number of U.S. citizens receiving their education abroad is "not
known," but in that year alone, the organization registered 4,186 U.S.
citizens for Step 1 of the U.S. Medical Licensing Exam (USMLE), and
2,520 for Step 2 of the USMLE. Interestingly, U.S. citizens who
registered with the ECFMG actually had lower USMLE pass rates, 42% for
Step1 and 68% for Step 2, than non-citizens, 59% for Step 1 and a 75%
for Step 2. In 2002, the ECFMG issued 1,427 certificates to candidates
who were U.S. citizens at the time they entered medical school in
another country.1

Earlier, in the 1980's, the ECFMG and the Association of American
Medical Colleges (AAMC) made a concerted effort to learn more about
the U.S. citizens who had attended international medical schools.
These organizations gathered information on all of the U.S. citizens
who took the ECFMG exam between 1969 and 1982, and matched this with
data on students who had applied to U.S. medical schools.
Surprisingly, Johnson, Swanson, Jolly, Teich, and Asper found that
only 45% of these students had ever applied to a U.S. medical school,
and only 65% had ever taken the MCAT.2 The data also suggested that
the mean GPA and MCAT scores of the students at international medical
school who had applied to U.S. medical schools were lower than those
of both accepted and unaccepted applicants to U.S. medical schools.
Another interesting discovery was that 55% of the U.S. citizens who
had taken the ECFMG exam were from the states of New York, New Jersey,
California, or Florida. Only 29% of students enrolled in U.S. medical
schools were from one of these four states. Looking at the ECFMG
1969-1982 data set, Dublin, Bloom, Knorr, and Casterline noted a
marked increase in the number of U.S. citizens who were earning their
medical credentials from the then relatively new medical schools in
the Caribbean.3

In the same era, Carlos Pestana, then Associate Dean for Student
Affairs and Professor of Surgery at University of Texas Medical School
at San Antonio, visited many of the international medical schools that
were accepting U.S. citizens, and gathered extensive qualitative
information about the schools and their students. He published the
first edition of his guidebook, Foreign Medical Schools for U.S.
Citizens,
in 1983.4

Together with the findings from the ECFMG & AAMC data, Pestana's work
laid the foundation for many of the best sources for information in
the late 1990's, like the excellent Foreign Medical Schools chapter in
Iserson's comprehensive book, Get Into Medical School!: A Guide for
the Perplexed.5 Another commonly used reference, Sen's Complete Guide
to Foreign Medical Schools in Plain English was also published in
1997.6 Much about the individual schools may have changed since these
works were published, but issues the authors raised, and the advice
they offered to prospective students, are still relevant.

Terminology

Medical schools outside the U.S. are referred to variously as
"foreign," "off-shore," or "international." Many of the agencies
involved in working with graduates of these schools are shifting
toward using the "international" designation. Although "international"
does not technically distinguish as clearly as "foreign," and lacks
the subtle connotation that these schools are somewhat outside of
normal experience and what can be known with certainty, this article
will conform by using the currently preferred "international" term.

Prepare for Medical School, and Consider All Options

Some students who go to international medical schools have exotic
reasons for their decision, such as wanting to escape their home state
or country, but most do so because they believe they cannot gain
admission to a U.S. medical school. Although the early ECFMG and AAMC
GPA and MCAT data supported the notion that most of the ECFMG
certification candidates would not have been competitive, the fact
that most went to international medical schools without ever applying
to U.S. medical schools is disconcerting. Before confronting all of
the extra problems posed by getting a medical education in another
country, candidates should give themselves every chance for admission
to allopathic and osteopathic medical schools in the United States. If
they believe they are not competitive, they should consider retaking
the courses in which they did not perform well, going further in their
science coursework, retaking the MCAT, and gaining more healthcare
experience, perhaps by participating in a formal post-baccalaureate
program. If they are residents of a state with an unfavorable ratio of
resident candidates for the number of openings at in-state, public
medical schools, they can explore the possibility of establishing
legal residency in another state. If they did apply to U.S. schools
and were not accepted, they should consider re-applying. Even if these
candidates eventually choose to attend an international medical
school, further academic preparation, additional practice taking
standardized tests, and more life experience and maturity, will
improve their chances of successfully completing a medical education.

It is possible to gain admission to some international medical schools
with less than a 3.0 undergraduate GPA, and without ever taking the
MCAT, but to complete the degree, and return to practice medicine in
the United States, students must master a very extensive basic and
applied science curriculum, and must pass licensing and certifying
exams. And, there are many additional difficulties along this path.

Extra Challenges

One of the biggest issues that students should consider is that many
of the U.S. citizens who go to international medical schools drop out
before completing their medical education. Given the extra pressures
on students at international medical schools, many of whom are
admitted with marginal academic abilities and test-taking skills, this
is not surprising. It is impossible to get accurate, independent
measures for attrition rates, and the rates surely differ from school
to school, but the possibility of failure is something prospective
students should seriously consider. Even if they pass their classes,
many are still not able to pass the USMLE. To provide some balance, it
is also important to note that many students do complete their
educations at international medical schools, meet the extra Fifth
Pathway or ECFMG certification conditions required for graduates of
international medical schools, successfully match with residency
programs, and eventually become practicing physicians.

Wherever a student goes, medical education will be expensive! Together
with travel, housing, food and other living expenses, and without the
tuition discount that a student at an in-state, public medical school
would receive, the costs of attending an international medical school,
even one with a modest tuition, quickly escalate. U.S. citizens at
many international medical schools are eligible for U.S. Government
Guaranteed Student Loans, which may be interest subsidized or
unsubsidized, and there are other possibilities for borrowing money.
If they are not independently or dependently wealthy, medical students
will, however, have to go deeply in debt.

All medical students are confronted by academic, and financial
pressures, but those who attend international medical schools must
contend with additional difficulties. Students will be isolated from
their social support network of friends and family. Even at
well-established international medical schools, students often find
more difficult living conditions, less extensive learning resources,
more limited teaching and clinical facilities, and fewer permanent
faculty members. At some schools, a substantial part of the curriculum
is taught in a language other than English. On rare occasions,
international medical students have felt threatened by political
unrest, hurricanes, earthquakes, and even a volcano.

As if the challenges of completing their medical education in another
country were not enough, the candidates who do successfully complete
their medical educations at international medical schools must take
extra steps to be eligible for accredited residency programs in the
U.S., board specialty certification, and state licensure.

Transferring

What about the possibility of heading off the extra difficulties
graduates face by transferring, and earning a degree from a medical
school in the United States? Many international medical students
apply, but few are accepted. The AAMC's Enrollment Services tracks
transfers into U.S. allopathic medical schools, and in recent years, a
nationwide total of only about 40-55 international students have
transferred in per year.7 Additional students may transfer to
osteopathic medical schools, but advisors should warn their advisees
that they should not count on being able to transfer into a U.S.
medical school. Policies regarding transfers vary from school to
school, so interested students should contact the admissions offices
of the individual medical schools to which they are planning to apply.
Because of differences in curriculum structure, some of the students
who do successfully transfer have to take a step backwards, and
re-take up to an additional year's worth of classes at the receiving
U.S. medical school.

Fifth Pathway

In much of the world, students who become physicians enter an
intensive science track in high school, and are then admitted directly
to a medical school. The medical schooling takes five- or six-years,
and sometimes includes an internship and/or social service program.
Students who complete all of their requirements for graduation except
the internship or social service obligation, and who meet all of the
other conditions for eligibility, most notably having completed their
undergraduate premedical education at a U.S. college or university,
can apply to Fifth Pathway programs in the United States. The Fifth
Pathway programs involve a year of clinical clerkships, similar to
those completed by third-year students at U.S. medical schools. The
only active Fifth Pathway programs are coordinated by medical schools
in the State of New York, and competition for admission is very
intense. Students who successfully complete a Fifth Pathway program,
and meet all of the other requirements, including passing Steps 1 and
2 of the USMLE, can become eligible for residency programs and
eventual licensure in many, but not all, states. For more details
about the Fifth Pathway, the American Medical Association has posted
some information at www.ama-assn.org/ama/pub/category/10255.html.

ECFMG Certification

To be eligible for ACGME accredited residency programs in the United
States, and for licensure in many states, students who graduate from
an international medical school must gain ECFMG certification. Some of
the most important conditions include proving they graduated from a
medical school listed in the Foundation for Advancement of
International Medical Education and Research's (FAIMER) online
International Medical Education Directory (IMED), and passing Steps 1
and 2 of the USMLE, the Test of English as a Foreign Language (TOEFL),
and the ECFMG's Clinical Skills Assessment (CSA). For more details,
see the ECFMG website at www.ecfmg.org.

Residency Matching, Specialty Certification & Licensure

Eligibility for accredited residency programs is not enough.
International medical school graduates (IMGs) must still successfully
gain a position in a residency program, and some residency directors
do not look favorably on IMGs. It helps to attend a well-established
international medical school, perform well on Steps 1 and 2 of the
USMLE, and earn strong recommendations from the directors of clinical
rotations in the United States. While in medical school, it is
important for students to strategically plan their clinical clerkships
in the United States, ideally arranging rotations in the same settings
as preferred residency programs. Some students also gain an advantage
through their network of family and friends of family. Though students
are sometimes able to line up a residency outside of the National
Resident Matching Program (NRMP), it is important to plan on
participating in this process. It is not completely impossible for an
IMG to match in a highly competitive area, like a surgery specialty,
but it is very difficult. Proportionally more IMGs go into less
competitive specialties, like internal medicine or family practice.
For more information, advisors can refer interested students to the
NRMP website at www.nrmp.org, and to Iserson's Getting Into A
Residency: A Guide for Medical Students.8

Beyond residency, IMGs may have to contend with some extra board
specialty certification and state licensure difficulties. As mentioned
before, if students enter through a Fifth Pathway program, without
also earning ECFMG certification, they will not be able to practice in
some states. Although the quality of one's residency training usually
carries more weight than where one went to medical school, IMGs may
also be disadvantaged when they apply for highly desirable positions
in medical organizations.

Important Personal Qualities

To successfully contend with all the extra demands placed on students
and graduates of international medical schools, candidates who take
this path must be extraordinarily determined, motivated and resilient.
To handle the basic science curriculum and pass all of the steps of
the USMLE, they must be capable students and competent test-takers.
They should have the adaptability and independence needed to thrive in
another country, ideally already developed through a significant study
or service abroad experience. If a substantial part of the curriculum
is taught in a language other than English, they should gain at least
a basic proficiency in the language before attending the medical
school. They should take initiative, especially when planning their
clinical rotations, and be flexible, especially when applying for
residency programs. And, they should be prepared to graciously explain
their decision to attend an international medical school.

Gathering Information about International Medical Schools

In addition to encouraging students to develop the personal qualities
needed to succeed in medical school, and letting them know some of the
difficulties pursuing their education in another country could pose,
health professions advisors can also help their advisees learn more
about individual international medical schools. For those students who
decide to go abroad, finding a good fit is very important!

The largest concentration of international medical schools for U.S.
citizens is in the Caribbean, but there are medical schools with
programs for U.S. citizens in Australia, Ireland, Israel, Mexico, the
Philippines, Poland, the United Kingdom, and in many other countries.
Beyond location, international medical schools differ from each other
in many respects, including physical environment and living
conditions, safety and security, availability of health care,
admissions requirements and procedures, tuition, eligibility for U.S.
Government Loan programs, class size, language of instruction,
qualifications of faculty, quality of teaching and clinical
facilities, level and breadth of academic supports, number and
location of affiliated clinical rotation programs at U.S. hospitals,
curriculum length and structure, and the rate at which students
graduate and successfully match with U.S. residency programs.

As mentioned previously, to be eligible for ECFMG certification,
students must graduate from an international medical school listed in
the FAIMER's International Medical Education Directory, and the
listings do include some very introductory information about each
medical school. Students can search the directory by region, country,
city, or name of a medical school.

Interested students should also collect information from websites,
articles, reference books, and admissions brochures. They may, for
example, want to tune in to the Student Doctor Network's online
international medical school discussion forums which are available
through a link at www.studentdoctor.net. It is also very important for
prospective students to talk with admissions representatives, current
students and graduates. For balance, it can also be enlightening to
talk with disgruntled former students. Every source will have some
biases. Admissions people want to recruit new students, and current
students may be rationalizing their decision to attend an
international medical school. Graduates have more perspective, but few
have actually attended multiple medical schools, so it is still
difficult for them to make accurate comparisons.

Prospective students should be on guard. Not all sources of
information are reliable, and there have been some serious deceptions,
including phantom medical schools set-up to scam desperate, want-to-be
medical students out of their seat reservation deposits and
first-semester tuitions, and, worse yet, diploma mills that sell
medical degrees while providing little or no education or training.
So, buyers must beware!

Although some students at international medical schools feel their
leap of faith got them past first impressions which might discourage
visitors, it is important to make a fully informed decision. If
possible, it is wise for prospective students to visit the
international medical schools that they are most interested in
attending, to look before they leap. Some international medical
schools also sponsor visits by health professions advisors, and these
adventures can be both informative and entertaining.

As McLoughlin II, Harvey, and Smulders pointed out in their Foreign
Medical Schools from the Premedical Advisor Point of View interest
session at the 2002 NAAHP National Conference, even after visiting
foreign medical schools, advisors may be left with many questions.9

Advising is a form of teaching. Advisors guide students in selecting
courses and discuss the requirements for the myriad of health careers
that are available to them. The goal is to guide rather than dictate.
One of the most effective and straightforward ways that advisors can
help students learn about international medical schools is to pose
questions for which both advisors themselves and their students can
seek answers. Box 1 contains questions that both students and advisors
should be asking, and Box 2 has questions that possibly have more
relevance for advisors alone. Although not an exhaustive list, it is a
starting point. Advisors are encouraged to post additional questions
to the HLTHPROF list serve, so everyone can benefit from the expertise
that many have developed over years of advising. Additionally, there
are plans to create an advisor-only section of the NAAHP website in
which advisors can share their impressions and experiences with
international medical schools.

Some Questions Students Should Ask

1. How long has the International Medical School (IMS) been in existence?

2. How can I contact the IMS – telephone, fax, e-mail, WWW?

3. Who is the Dean of Admissions?

4. What are the entrance/admissions requirements?

5. Is an undergraduate degree required in order to start school (matriculate)?

6. Are there specific residency or foreign language requirements?

7. Is the MCAT required or optional?

8. If interviews are required, where are they held?

9. What are mean Science and Overall GPAs for the previous entering class?

10. How many classes of students enter each year, and when are the
application deadlines?

11. What are estimated annual expenses, including tuition and fees,
books, supplies, study materials, housing, food, travel and other
living costs?

12. How do students fund their education? What loan programs and
scholarships are students eligible for?

13. How many students are enrolled in each class? What is the
attrition rate for matriculated students, i.e., how many typically
dropout before finishing? What are common reasons for dropping out?

14. What is the length and structure of the entire curriculum?

15. What are the academic credentials of the faculty teaching basic
science courses? Where were they educated?

16. Where do students do their clinical training?

17. How do students perform on USMLE I and II? In recent years, what
are the 1st time and total pass rates for students from this school?

18. How many students graduate each year?

19. Where did students in the most recent graduating class match for
residency? In what specialties?

20. How can I contact some former IMS graduates who are practicing in
the U.S. in my area?

In Addition, Health Profession Advisors Should Ask

1. Does the IMS provide detailed statistics about admissions, student
population, financial expectations, which advisors can use to help
students make decisions?

2. Are there web addresses, brochures, videotapes, CD-ROMs, DVDs or
other materials advisors can give to interested students?

3. How is the IMS financed? Who owns/operates the IMS?

4. Are there graduates of the IMS in the advisor's local area who
would be available for presentations to students?

5. Are there opportunities for health advisors to visit the IMS?

Conclusion

At their best, international medical schools give their students the
education and training needed to enter a residency program in the
United States, and those graduates who become physicians go on to
serve many patients. At their worst, international medical schools
take unfair advantage of desperate students, by accepting candidates
who are woefully unprepared for the rigors of medical education, the
USMLE, or the practice of medicine.

Much about the individual schools and the education of their students
is unknown, but there is hope that both advisors and students will
have more information in the near future. The ECFMG and AAMC have
recently begun a three-year project to determine which international
medical schools U.S. citizens attend, and to learn more about the
educational content and experiences at these schools (see the
following article).

Health professions advisors may never learn enough to feel completely
at ease with this topic, but they can invite interested students to
talk with them about the possibility of attending medical school in
another country. Advisors can help them anticipate some of the extra
challenges they might face, and gather information about different
schools. If an extra effort is made to stay in contact with students
who do attend international medical schools, advisors can learn much
more. When advisors visit international medical schools, they can
develop their own perspectives. HLTHPROF discussions, and
international medical schools interest sessions at regional and
national health professions advisors meetings are also extremely
useful. By sharing what they have learned with each other, all
advisors can become more effective in aiding their students.

References

1. Educational Commission for Foreign Medical Graduates. 2002 Annual
Report. Retrieved December 31, 2003 from the World Wide Web:
www.ecfmg.org/annuals/2002/.

2. Johnson, D. G., Swanson, A. G., Jolly, P., Teich, J., & Asper, S.
P. United States Citizens Studying Medicine Abroad: Their Backgrounds
and Test Performance. New England Journal of Medicine, 1986; 315:
1525-1532. (From The Advisor, 1987; 7(summer): 8-18.)

3. Dublin, T. D., Bloom, B.S., Knorr, R.S., & Casterline, R.L. Where
Have All the Students Gone? Journal of the American Medical
Association, 1985; 253: 376-381. (From The Advisor, 1985; 5(summer):
7-12.)

4. Pestana, C. Foreign Medical Schools for U.S. Citizens. San Antonio,
TX: Pestana; 1983.

5. Iserson, K. V. Chapter 17: Foreign Medical Schools. In Get Into
Medical School! A Guide for the Perplexed. Tuscon, AZ: Galen Press;
1997.

6. Sen, N. The Complete Guide to Foreign Medical Schools in Plain
English. Wayland, NY: Indus Publishing Company; 1997.

7. Whiton, J., AAMC Enrollment Services Manager, personal
communication, January 13, 2004.

8. Iserson, K. V. Iserson's Getting Into a Residency: A Guide for
Medical Students (6th ed.). Tuscon, AZ: Galen Press; 2003.

9. McLoughlin II, P. J., Harvey, B., & Smulders, A. P. Foreign Medical
Schools from the Premedical Advisor Point of View. Handout presented
at National Association of Advisors for the Health Professions
National Conference, Las Vegas, NV. June, 2002.

__________________
Moderator - State Licensing Forum

Still skeptical after all these years.
This is it. There are no hidden meanings.WYSIWYG

http://www.internetmedicalschool.homestead.com

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