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ORENO VALLEY, Calif. — It’s easy to dismiss the for-profit medical schools that dot many a Caribbean island as scams, set up to woo unqualified students who rack up huge debts, drop out in staggering numbers, and — if they make it to graduation — end up with an all but worthless degree. That’s been the rap against them for years.

But the schools are determined to change that image. Many are quietly churning out doctors who are eager to work in poor, rural, and underserved communities. Their graduates embrace primary care and family practice, in part because they’re often shut out of training slots for more lucrative specialties.

And they just might help solve an urgent physician shortage in California and beyond.

The deans of two of the Caribbean’s medical schools — Ross University School of Medicine in Dominica and American University of the Caribbean in St. Maarten — are on an aggressive campaign to improve their image. They’ve published a series of editorials and letters with titles like “Why malign overseas medical students?” and hired public relations giant Edelman to make the case that their humble, hard-working, and compassionate students may be precisely the kinds of physicians America needs most.

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“Our students have persevered. They haven’t had all the opportunities in life and they still want to help people,” said Dr. Heidi Chumley, dean of American University of the Caribbean School of Medicine. “Absolutely we want to get our story out.”

That story is unfolding on the ground in places like Moreno Valley, a city of about 200,000 in California’s Inland Empire, a former agricultural region just east of Los Angeles that grew explosively in the ’80s but has since fallen on harder times.

Here, the Riverside University Health System Medical Center rises from a stretch of largely undeveloped land once slated for luxury housing developments. The health system acts as the county’s public safety net for an ethnically diverse, mostly low-income population — including patients like retired carpenter José Luis Garcia.

Bajwa checks over a log documenting his patient’s blood sugar levels after meals.

On a recent clinic visit, Garcia, 69, came in to follow up on a urinary tract infection and his high blood sugar. He saw Dr. Moazzum Bajwa, 30, a second-year resident and graduate of Ross.

In a crisp white coat and bow tie, Bajwa entered the examining room and pulled up a low stool. Sitting eye to eye with Garcia, he spoke in a steady stream of fluent Spanish. The visit lasted nearly an hour.

In an attempt to keep his patient off insulin, Bajwa had asked Garcia to improve his diet and track blood sugar levels after meals. “Números fantásticos!,” Bajwa exclaimed, looking at the folded sheet of carefully written numbers Garcia had brought to show him.

“This is a very great doctor. Normally, I don’t feel important.”

José Luis Garcia, patient

Bajwa, a former middle school science teacher, then spent 10 minutes drawing a careful diagram — complete with neurons, intestinal walls, and red blood cells, or células rojas — to explain to a rapt Garcia exactly why certain foods raised his blood sugar. He then examined Garcia — noting he had a harmless but interesting muscle wall abnormality — and checked his medical records. Was there a colonoscopy report on file? Retinal photos?

As the visit was ending, Bajwa asked Garcia about stress. Garcia said his wife had recently had surgery for glioblastoma multiforme, one of the most malignant of brain tumors. “Wow,” Bajwa said quietly as he quickly scanned the medical summary Garcia handed him. “Wow.” He sat down again on his low stool.

Lo siento mucho, señor,” Bajwa said, clearly moved.

Then he gave Garcia a hug.

“This is a very great doctor,” Garcia said later, through a translator. “Normally, I don’t feel important.”

Bajwa, an American citizen raised in Michigan and North Carolina, is the grandson of Pakistani Nobel physics laureate Abdus Salam and holds two advanced degrees, one in neuroanatomy and one in public health. But he couldn’t get into an American medical school. So he attended Ross University in Dominica.

Bajwa joined the family medicine program after graduating from Ross University School of Medicine in Dominica.

“It was the only school that gave me an opportunity,” he said.

‘Second-chance’ schools under fire

There are some 70 medical schools throughout the Caribbean, most of them established in recent decades and run by for-profit businesses that cater to Americans.

These so-called “second chance” schools accept students with poorer grades and lower MCAT scores, or sometimes no MCAT score at all. Compared to American medical schools, their tuition and dropout rates are higher and their class sizes large: Ross enrolls more than 900 students per year.

Graduates can practice medicine in the United States after passing their American medical licensing exams and completing a residency. But the schools have come under fire for generating a stream of students who don’t end up as physicians, but do end up with crushing medical school debt because they flunk out or don’t win residency spots after graduating.

Heartbreaking stories abound: One graduate of St. George’s University School of Medicine took a poor-paying job drawing blood to help pay off $400,000 in medical school loans. Another graduate of AUC entered nursing school after failing to get a residency.

“Are Caribbean medical schools promising something they cannot fulfill?” asked Dr. Glenn Tung, an associate dean at Brown University’s Warren Alpert Medical School who has studied the schools. “What I’m concerned about is the cost to the students who don’t make it and the cost to the American taxpayer when loans aren’t repaid.”

The Riverside University Health System Medical Center in Moreno Valley, Calif.

Illinois Senator Richard Durbin, also concerned, has repeatedly introduced bipartisan legislation to strip the schools of Title IV federal funding for student loans. Three Caribbean medical schools — Ross, AUC and St. George’s — took in $450 million federal funding via student loans in 2012, Durbin said.

“These for-profit Caribbean medical schools need to be accountable to their students and to U.S. taxpayers,” he said in a statement.

Dean Chumley and Dr. Joseph Flaherty, the dean of Ross, take strong exception to such criticism.

They allow that many for-profit medical schools — which have proliferated in the past few decades because they are proven money makers — aren’t doing a good job training and developing students. But they argue that AUC and Ross, two of the oldest Caribbean schools — both owned by for-profit educational juggernaut DeVry Inc. — are creating successful doctors.

They say they are also giving a shot to students with humble backgrounds, often minorities, who can’t get near American medical schools that focus so heavily on test scores and grades.

“Obviously brains help, but judgement, empathy, intuition, that’s all part of it,” Flaherty said. “Our students are gung-ho. They want to practice medicine. That’s their dream.”

Just 54 percent of American medical graduates who trained overseas are matched with a residency program for further training in their first year of eligibility. That’s an abysmal record, compared to the 94 percent of graduates of US schools who get residencies. But Ross and AUC say they have a match rates higher than 86 percent. And they say a vast majority of students pass their step 1 licensing exams on the first try.

“Obviously brains help, but judgement, empathy, intuition, that’s all part of it… Our students are gung-ho.”

Dr. Joseph Flaherty, dean of a Caribbean medical school

(Critics say the schools manipulate the statistics by dismissing weak students shortly before they are allowed to take the exams. Chumley said the schools do weed out poor students early on to prevent their accumulating debt, but in no way encourage poor students to stay for five semesters and then prevent them from taking the exam. “I think that’s ethically wrong,” she said.)

Controversy erupts over deals with hospitals

The schools are also controversial because of their practice of buying their way into hospitals to train students. In 2012, Ross inked a contract — beating out rival St. George’s University School of Medicine of Grenada —  to pay $35 million over a decade to the cash strapped Kern Medical Center in Bakersfield in exchange for the lion’s share of the hospital’s roughly 100 rotation spots for third-year medical students.

Some critics fear such deals will squeeze American-trained students out of rotations; disputes have flared in New York, where St. George paid $100 million for rotation spots, and in Texas, where lawmakers attempted to entirely ban Caribbean students from training in the state.

But Flaherty, Ross’s dean, says the such deals are a win-win. A struggling hospital gets funds. His school, which has no teaching hospital, gets a place to train students. And he gets to show skeptical doctors how good his students really are.

“The doctors get to know our students and say, ‘These guys are good,’” he said. “Our students get there early. They stay late and do extra work. They value any opportunity.”

And they seize those opportunities where they can find them.

While their numbers are up, it’s still harder for international medical grads — known as “IMGs” — to get residency positions. They’ve heard all the jokes about studying anatomy on the beach with Mai Tais in hand. But when it comes to residency positions, they are deadly serious. For there is no practicing medicine without one.

“You have to apply very widely. There’s always a stigma that IMGs don’t get as good an education.”  said Rina Seerke-Teper, 31, a second-year resident who has wanted to be a doctor since she was six, graduated from the University of California at Berkeley and worked in stem cell research before attending AUC.

Dr. Rina Seerke-Teper, a resident at Riverside University Health System.

Many Caribbean graduates don’t even apply to residency programs that are filled only with American trained students. Instead, they look for “IMG friendly” programs like the family practice residency here, run in a busy clinic housed within the county hospital. The program is highly competitive — receiving about 800 applications for 12 positions each year — and of the three dozen current residents, 29 studied in a medical school outside the US.

Competition for the coveted slots is likely to grow even more as California, which just got one new medical schools and is slated to soon add another, starts spitting out more locally trained grads.

A desperate need for more doctors

More doctors are desperately needed: California will need an estimated 8,000 additional primary care doctors by 2030. The United States as a whole is projected to need some 30,000 additional primary care physicians in coming decades.

Dr. Michelle Quiogue works in one of the areas hit hardest by the shortage — rural Kern County. A graduate of a prestigious medical school — at Brown University — Quiogue says she’s worked alongside many foreign-trained doctors and “would never know what college they graduated from.”

In her mind, the problem is not a lack of medical students but a lack of residency programs to train them. The governor has proposed cutting $100 million for primary care residency training, and her organization, the California Academy of Family Physicians, is scrambling to get it replaced.

Those who do win residency spots say it seems to matter less and less where they went to school as they climb up the medical training ladder. And it seems to matter not at all in clinics where patients are grateful for any medical care they receive.

“I have never heard a patient ask where a physician is trained,” said Carly Barruga, a third year medical student at nearby Loma Linda University who said she is getting excellent training in her rotation here from Caribbean-trained doctors like Dr. Tavinder Singh.

Singh, 30, is chief resident here and also a graduate of Ross. While he traces his interest in medicine to the open heart surgery his grandmother had when he was a boy, Singh didn’t apply to American medical schools because his MCATs weren’t as strong as they should have been. He didn’t want to wait a year to retake them.

“I had the goal in mind I was going to be a doctor,” said Singh, a California native. “Nothing was going to stop me.” He’s loved his residency, especially the chance to work in needy communities where medical zebras — unlikely and rare diagnoses — can be common. “You see chronic disease that have never been treated,” he said. “You see rare diseases like Zika.”

Dr. Tarvinder Singh speaks with nurses between seeing patients.

While Singh was once the one begging for a chance, the tables have turned. In a state hungry for family practice physicians, he’s now fielding numerous job offers.

‘Honestly, he’s great’

Bajwa’s future is bright as well.

For now, though, he’s just happy to be practicing medicine, thrilled to be delivering babies and focusing on preventative care. He loves helping patients like Wendy Ocampo, a 19-year-old with limb girdle muscular dystrophy. During an appointment this month, Ocampo came in to see Bajwa with respiratory symptoms.

It was supposed to be a quick visit, but he ended up spending a half hour with her once he discovered bureaucratic hurdles had left her waiting seven months for the wheelchair she needs for her job and college. (Bajwa credits his clinic staff and nurses for working through lunch and juggling his schedule so he can offer longer visits.) Ocampo also hasn’t been able to get the physical therapy she needs for her ankle.

“It burns me up that these things are falling through the cracks,” said Bajwa, after taking a few minutes to compliment Ocampo’s “impressive new shoes” and ask if she was growing out her hair.

Though sick, Ocampo beamed. “Honestly, he’s great,” she said. “He calls me to check on me. I have, like, 30 doctors and none of them have ever done that.”

Correction: A previous version of this story misstated the population for Moreno Valley and the status of a proposed funding cut for residency training.

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  • $450 million in federal loans in 2012 alone? Ridiculous, considering what a poor return US taxpayers are getting. Sure, there will be a small percentage of these students who will become successful doctors, but I would bet most students who borrow and enroll never get to practice.

  • Some of you people should get your facts right–I am a physician and once shared a house in Palo Alto with a psychiatrist that went to Stanford –he got accepted without any physics courses –but his father was an alum famous for an artificial heart valve –so who you know can get you accepted anywhere as long as you have decent grades–you do not need to be a genius to get into any profession— being able to learn and apply it and have the knack is what counts and to never accept what everyone says –always question and have an open mind quit trying to be elite–also knew a kid that went to Stanford —told me he was on probation and not a good student—and told me he was selected because his grandfather was Head professor of History there–all the private schools are SELECTIVE and do not base everything on grades–UC schools in CA are based on grades more than anything else

  • Great information on Caribbean medical schools and the need for the residents to be offered more residencies for themselves and the future patients of the United States!

  • The Graham Center did a study of rural location and rural retention and previous studies of international medical graduates were exposed as inadequate. Only studies cherry picking the years immediate after graduation from residency and studies excluding the 20 – 30% who depart the US after training indicate higher distribution. Entire careers must be considered, not just a few years of a career. Lower levels are seen when graduates are exclusive across origins, medical school, training, and specialty choice. International graduates and Caribbean graduates tend to have limited distribution restricted to certain schools and certain US states. Exclusive origins (highest income, most urban, most educated parents, or all) also tend to defeat distribution from Asian graduates, whites, and minorities with these characteristics. Better distribution is seen in more normal graduates from more normal schools with more normal MCAT scores, and more normal career choices, that distribute more normally. US GME design has a particularly distorting impact upon international and Caribbean graduates as this is often their major and final location of trainign – shaping distribution to the states and exclusive locations where such graduates finish training.

    Maldistribution is mostly about failed finances for primary care that fail to a greater degree in 30 states that have had lowest payments and in 2621 counties lowest in physician concentrations as set by payer designs that hit the patient and provider hard – made worse by higher cost of delivery via innovation, regulation, and certification plus rapidly increasing complexity of patient, team member duties, and practice.

    No source is a solution until billions more a year are added to places in need of physicians specific to the team members to deliver the care – not fewer billions a year remaining after regulation, innovation, certification, turnover costs, and other higher costs of delivery for these settings.

  • Annual graduates from multiple MD DO NP and PA sources continue to increase at rates must faster than population growth or growth of the elderly, yet more sources all expanded have failed to address shortages. Where did the graduates go? Not surprisingly they follow the dollar directions shaped by health policy. Payment too low, often lower than the cost of delivery, plus higher complexity shapes shortages in ways that no training intervention can address. The 12 times expansion of NP graduates (1500 to 20000 since 1980) , two doublings of DO grads, multiple doublings of Caribbean graduates, a 6 times increase of PA graduates (1500 to 9000), and a 20% expansion of US MD have not worked. The design supports too few positions and team members with ever lower primary care proportions and with massive expansions of the high costs non-primary care workforce.

    http://basichealthaccess.blogspot.com/2017/05/no-more-federal-dollars-for-residency.html

  • Here’s the relevant portion of the Norcini article someone cited:

    “The differences in mortality of patients cared for by all international graduates and U.S. graduates (adjusted odds ratio: 0.99; 95 percent confidence interval: 0.94 to 1.04) were not statistically significant,

    *nor were the differences between U.S.-citizen international graduates and U.S. graduates (adjusted odds ratio: 1.07; 95 percent CI: 0.99 to 1.16).*
    (emphasis added)

    However, the patients of non-U.S.-citizen international graduates had significantly lower mortality than U.S. graduates (adjusted odds ratio: 0.91; 95 percent CI: 0.86 to 0.97). Likewise, their patients had significantly lower mortality than the patients of U.S.-citizen international graduates (adjusted odds ratio: 0.85; 95 percent CI: 0.78 to 0.93).

    Among the physician characteristics included in the analysis, the number of years since graduation was positively related to mortality, and the magnitude of the effect was substantial. Each additional year since graduation was associated with a 0.58 percent (95 percent CI: 0.34 percent to 0.81 percent) increase in the mortality of a physician’s patients. Specialty board certification was associated with a 5.62 percent (95 percent CI: −0.003 percent to −10.67 percent) decrease in mortality, and treatment by a self-reported cardiologist was associated with a 6.1 percent (95 percent CI: 0.005 percent to 12.04 percent) increase in mortality.”

    This shows it’s hard to make distinctions among very similar groups, and there’s something NOT mentioned- this was IN HOSPITAL mortality. Many studies have shown ‘the paradox of primary care’: for any single disease, comparing primary care docs vs. other specialists, the PCDs generally come off worse (though note the cardiologists had 6% HIGHER mortality)–however when you look at PEOPLE, the folks cared for by PCDs always do better.

    Moreover, the FMGs had slightly longer LOS- which, along w publication bias, may also explain their slightly higher mortality rates.

    The big story, which this article hints at but doesn’t mention, is that increasing the supply of primary care docs (but not other specialists) reduces population mortality (Starfield.) Adding one PCD/10,000 population prevents about one death a year. These folks will go out in the community and save lives.

    • Overall a good review, but correlation is not causation. Numerous assumptions have been made about primary care. Primary care leaders desperate for good news have seized upon this. Starfield acknowledged the social and other determinants of health as a major factor in outcomes. In the US in particular there is a much stronger relationship with these variables and outcomes because we are such a divided nation. Studies based on other countries tend not to apply because we are such an outlier in health spending, health disparities, and population disparities. Variations within a group also make it difficult to compare to other groups.

  • Good reporting on understanding what Caribbean schools are trying to do but as any US-medical student knows, their claims are phony. First of all, there’s no hardship factor because because as a medical student you can take out student loans so the cost of the school doesn’t matter. Second, the cost of prep is grossly over exaggerated. It only takes a summer and one book series/class. Third, yes, there may be a few model students in the Carribbean but the majority are White/Asian students from upper middle-class families who want to be Doctors so they can be like everyone else…which is fine, but if that’s the case get a high score and keep trying until you do, don’t take the easy route and demand respect. Good reporting, but let’s not be fooled. This is stuff all medical students are trained to do.

  • Ann, mu sympathy to you, but your analogies are flawed. Obviously, intelligence does mather, but there is only a certain level of intelligence that is required. The scale for that is continuous, of which there is no definite cutt-off. The rest with regards to practice involves skills, character, empathy, bedside manners etc etc. Consider a Harvard-trained doctor who is continuously sued, and cannot write a simple and correct prescriptive order, vs a a Caribbean-trained MG, who has the relevant knowledge, is there for his patient, can write an unambiguous rx, with fewer or non malpractice. Who would you go for? This whole argument has been beaten numerous times. A good doctor is a good doctor, a bad doctor is a bad one period. I think a competent residency training and character moulds a doctor much better than the medical school attended. The whole difference in ability to land a residency program in the US is almost entirely political. I’ve seen excellent and skillful doctors in the US who attended medical schools in Syria, Iraq, India, Pakistan, Iran and Ross. I’m sure the average patient may shiver when they show up to treat them. But it’s quite convincing to me based on available and unavailable evidence that residency, skills and character mold the average doctor, much more than the medical school attended or how high ranking their grades were.

    • If you die under the care of the Harvard doc at least you will die in perfect electrolyte balance.

  • My mother was a pediatrician trained at Duke. She was in good health, but had a brief bout of afib and was given an overdose of Warfarin by a Ross-trained doctor at Eisenhower Medical Center in Rancho Mirage. A second Ross-trained doctor failed to recheck her elevated INR, and she died 3 days later.

    The concern about quality is real. A 2010 study led by John Norcini showed that patients of US-born doctors who train at Caribbean schools have the highest mortality rates. The situation brings to mind the old joke: “What do you call the guy who graduates last in med school?”

    “Doctor.”

    So, what do you call the guy who can’t even get into medical school? A Ross doctor. While these doctors may fill a void in some communities, no patient who could freely choose would go to the guy who couldn’t get into med school. As Carly Barruga says, patients don’t ask where their doctors trained–but they should.

    The writer gives too much weight to hype promulgated by the for-profit offshore schools. “Follow the money” is still a good rule in journalism.

    • Based on the Norcini study the malpractice insurance companies should charge a “Ross Premium”. If you go to a Caribbean med school you should pay double the premium, with a rebate after 10 years if you haven’t killed anybody. These guys bought their way into med school; the “island jockeys” can afford the extra coverage.

    • sorry for your loss, but your facts and conclusions are completely false. As was reported by Harvard last week:

      “On February 3, a report in the BMJ from researchers at the TH Chan School of Public Health, Harvard University, Boston, Massachusetts, underscored the value of IMGs and USIMG’s. They found that hospitalized Medicare beneficiaries under the care of internists who graduated from medical school outside the United States had lower 30-day mortality compared with patients cared for by graduates of US medical schools.”

    • Michael, The Harvard study does not distinguish between foreign-born doctors trained at non-US schools and US-born doctors trained at offshore schools. Foreign-born doctors who train at non-US schools are on par with US-trained doctors. The ones we have to worry about are the US-born students who go offshore because of low grades and test scores. Some end up being good doctors, but if you want to max your odds of survival–go with the brainiac who went to a US school.

    • I feel horrible for your loss. I am sure those physicians that were involved with your mother’s case feel horrible as well. I went to Ross and feel that I am a very capable physician. The majority of my classmates are also excellent clinicians and truly have a passion for helping people. Medical errors unfortunately kill many people every year. To characterize a specific group of doctor’s as being incompetent just because they went to a specific school is amazingly unfair. As Chief of Staff, I encountered and had to deal with poor physician performance and frank incompetence. These were physicians from American medical schools, not Caribbean graduates. A bad doctor is a bad doctor no matter where they graduated… and yes, excellent doctors can make mistakes. Thank you!

    • Robert, Thank you for your sympathy. I agree that excellent doctors can make mistakes, and I agree that Ross doctors can be competent. Consider this analogy, though:

      You are about to board an airplane for an overseas flight. You have your choice of two pilots. One excelled at math and physics in college, and has excellent eyesight. The second failed at math and physics and has impaired vision. The #2 pilot did not qualify for standard training, but was able to go offshore and earn a license despite these deficits.

      Which plane would you get on?

      I do think the public should be aware that there’s a quality difference in the Caribbean schools–then patients can decide for themselves. In the case of the two doctors who cared for my Mom, they concealed their offshore training by saying in their bios they went to Ross University in New Brunswick, NJ.

      The studies looking at outcomes for offshore-trained doctors are not definitive, but the whole subject certainly needs more light on it. Ross-generated hype is not light.

    • Carly Barruga is wrong. I do ask my doctors where they trained. I’m also a PhD med school professor and am a reasonably good judge of competency.

  • I am a former CAF Medic, retired Physician Assistant; in the past I have worked with Physicians from the Caribbean, in different worldly settings. These doctors and nurses are some of the most considerate, compassionate, dedicated, loyal and thorough thinking practitioners, they have bedside management above and beyond. They listen to the patient! With the most basic medical diagnostic equipment at their disposal. in trauma situations I have worked with them, their calmness, collective thinking, evaluation and diagnostic skills are skills that can be achieved through impressive education!
    These professionals are not in the race for space, these professionals are dedicated, educated, skilled and artful. Rarely even in a trauma situation, have I ever seen them excited and aggressive; I have learned from them to be calm, collective and have compassion! As Dr. Yehuda well put, it is a good person that becomes a doctor! Caribbean doctors have it, they are good people!

    • As a Caribbean medical students,its already tough for us to acquired great medical schools since most Medical schools try to scam us,hence most residency programs or fellowships don’t accept us.However,they are good medical schools out here in the Caribbean who aim is to make sure the Caribbean student but the scam problem has hinder that and am glad that schools as Ross university is speaking out about it.

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