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GAO Recommends Greater Oversight of Foreign Medical Schools

Created June 30, 2010 by Laura Turner
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In a report released Monday, the Government Accountability Office (GAO) recommended that the Department of Education collect additional data on borrowing and graduation rates and improve monitoring of U.S. medical licensing exam pass rates for students of foreign medical schools.

Currently, one quarter of the U.S. physician workforce is composed of International Medical Graduates (IMGs), including both U.S. citizens and foreign nationals.  Some members of Congress have questioned whether the federal government is getting its money’s worth from its investment in the education and training of IMGs.  In 2008, Congress ordered the GAO to study the performance of IMGs as part of the Higher Education Opportunity Act (H.R. 4137).

As a part of the study, the GAO examined the following areas:

  • Amount of federal student loan dollars awarded to U.S. students attending foreign medical schools
  • Pass rates for IMGs on licensing exams
  • Department of Education monitoring of the licensing pass rates
  • Foreign medical school performance with regard to pass rate requirements
  • Where IMGs obtain residencies and the types of medicine they practice
  • Discipline and malpractice involving IMGs

The Department of Education administers the federal student loan program and is responsible for monitoring foreign schools that participate in the program.  The report states that U.S. students at foreign medical schools borrowed $1.5 billion in Federal Family Education Loan funds from 1998 to 2008.  As with U.S. medical schools, student borrowing has increased significantly in recent years due to rising tuition rates.

Foreign medical students interviewed by the GAO stated that finding information on expected debt level and pass rates at different schools was difficult to obtain, even when schools were asked explicitly about the information.  “[The school’s] marketing statement says that the school’s pass rate is 98 percent on Step 1.  Even U.S. schools don’t hit this mark.  But [the school] only counts those students who actually sit for the exam and don’t drop out,” one focus group participant reported (school not identified in report).

Dr. Jessica Freedman, an admissions consultant, has seen first-hand the difficulties students face in obtaining consumer information from foreign medical schools.  “I agree with the GAOs recommendation to require closer monitoring of foreign medical schools that receive federal aid and to hold these schools to higher standards,” she says.  “Consumer data from foreign medical students who receive federal loan money would allow the GAO to obtain information that is otherwise nearly impossible to acquire.  As this article pointed out, many foreign medical schools will not release data about actual USMLE pass rates, graduation rates or residency match results. Thus, it is unclear what percentage of matriculating foreign medical students, many of whom receive federal student loans, make it beyond their first two years of medical school, graduate or receive residency matches. Some starting classes at foreign medical schools are often much larger than graduating classes and these attrition rates also are not disclosed.”

She continues, “Some of the schools that are guilty of having large entering classes are ‘statutorily exempted from the pass rate requirement in view of their existing approved U.S. clinical training programs,’ as stated in the GAOs presentation on this topic. This data should be obtained from all matriculating students regardless of which schools they attend.”

In order to be eligible for federal student loans, foreign medical schools are currently required to have a licensing exam institutional pass rate of 60 percent.  However, the report found that the Department of Education did not fully enforce federal requirements for pass rates because the private organizations that administer the three steps of the exam have refused to release student score data, which they claim is proprietary.

The GAO found that IMGs consistently pass licensing exams at a lower rate than U.S. educated students, but that the gap has narrowed over the study period from 1998 to 2008.  IMGs also required more attempts to pass the exams.

Effective July 2010, Congress increased the institutional pass rate required for access to federal student loans to 75 percent.  Only 11 percent of foreign medical schools are anticipated to meet the new requirement, and thus continue to be eligible for federal student loans.

The study also looked at where IMGs complete residency and the types of medicine they practice.  According to George A. Scott, Director of Education, Workforce, and Income Security, GAO, “(IMGs) are concentrated in the eastern United States, and a larger proportion tend to practice primary care than do U.S.-educated graduates…IMGs go into residencies in primary care fields (at a rate of ) 68 percent compared to 37 percent of U.S. medical graduates.”

Dr. Freedman has also seen the struggles some IMGs face in attempting to successfully match to a U.S. residency.  “At a recent faculty meeting of one major Caribbean medical school, it was revealed that 15% of graduates did not match in 2010, and some graduates only matched into preliminary positions. So, while some foreign medical schools may boast impressive match lists, these lists are often not comprehensive and do not indicate preliminary versus categorical matches. Thus, some graduates may have MDs but are not trained to actually practice medicine.”

Few differences were found between IMGs and U.S.-educated physicians in the area of disciplinary actions and malpractice payments.  The rate of license suspension and revocation was slightly higher for IMGs than their share of the workforce, but this difference was not found to be statistically significant.

Based on the findings of the report, the GAO recommended that the Department of Education complete the following actions:

  • Collect consumer data on students at foreign medical schools receiving federal funds including aggregate student debt level and graduation rates
  • Require foreign medical schools to report aggregate pass rates for licensing exams annually and verify this information independently, possibly against information provided by testing organizations
  • Evaluate the impact of the 75 percent pass rate on school participation in the loan program

“I am a firm believer that students can do extremely well by attending some foreign medical schools,” concludes Dr. Freedman.  “However, these are for-profit institutions that accept some students whose past academic performance suggests they are unlikely to succeed when faced with a rigorous, scientifically based curriculum. A large percentage of these students likely use federal loan money to support their education and the schools that accept them offer false hope. This is not only an issue about money; it also is an issue about ethics.”

A complete copy of the report is available online:
http://www.gao.gov/new.items/d10412.pdf

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