Updated October 14, 2021. The article was updated to correct minor grammatical errors and to update formatting.
Whenever I start working with a student who is applying to medical school “in the Caribbean,” I ask them to think about several factors. Some students who attend Caribbean medical schools earn excellent residency positions in the United States; however, prospective students should be aware that the path to becoming a physician as a Caribbean medical student poses unique challenges. As a result, graduating and earning a residency match as a Caribbean medical student requires extra focus, planning, and initiative.
There are so many Caribbean medical schools!
It is essential to realize that all Caribbean medical schools are not created equal. While several well-known Caribbean medical schools have graduated many physicians who now practice, I am always amazed by the number of “new” schools that are established. All international medical graduates must receive accreditation from the Educational Commission for Foreign Medical Graduates (ECFMG®); however, currently, the only requirements for ECFMG certification are passing the USMLE Step 1, Step 2 CK, Step 2 CS exams and having at least four credit years from a medical school listed in the International Medical Education Directory (IMED).
Don’t assume, if you are accepted to “a Caribbean medical school,” that this guarantees a residency match. Caribbean medical schools are for-profit entities and, based on my experience, some schools accept students whose backgrounds and academic records predict a likelihood of failing the USMLE Steps 1 and 2 (CK) which all students must pass before they start residency training. Caribbean medical schools will not reveal how many students enroll as first-year students yet fail out and never “make it off the island” for third-year rotations.
Gauging the quality of the medical education you will receive at a particular Caribbean medical school isn’t easy, but you can get an idea of how successful graduates are in obtaining residency training positions in the United States by considering several factors.
What are the school’s average USMLE Step 1 scores?
The results of the USMLE Step 1, which is taken after the preclinical years, become an extremely important factor for residency match success. Why? The USMLE Step 1 score is the only objective piece of data that program directors can use to compare medical students and residency applicants. The USMLE Step 1, which was initially designed as a qualitative test to evaluate competency, has evolved into a quantitative test, so the higher your score, the better. When I was a medical student, it was not the norm for US medical students to prepare for the USMLE by taking “prep courses.” I find that because of the technology now available, however, most students enroll in courses, often online, and are achieving high scores. A great USMLE Step 1 score will not, however, guarantee a match in the more competitive specialties. It is important to consider the other “ingredients” that lead to success.
Where do students complete third and fourth year clerkships?
It isn’t enough if a Caribbean medical school promises “rotations in US hospitals.” Prospective students should know where, specifically, students rotate, the number of students on each rotation, and the process for designing the clinical schedule. Completing a rotation in internal medicine at a hospital with an ACGME approved residency program, for example, would be considered more challenging and would most likely yield a better foundation of knowledge and skills in internal medicine than a program without this affiliation. “Academic rotations” are looked upon most favorably by residency admissions committees, and letters of reference from academic faculty also carry more weight than those from community physicians.
Some Caribbean students also complain to me that rotations are becoming too crowded; they feel they are competing for patients and procedures and are receiving little teaching. Thus, it is important to know how many students rotate at each clinical site and how many other schools also rotate through those sites since many hospitals have students rotating from several medical schools at one time.
A recent article in The New York Times outlines how New York State medical schools currently are addressing these issues by trying to limit the rotations that Caribbean medical students complete at New York hospitals. New York medical school officials are concerned that the large numbers of Caribbean students at these hospitals dilute US medical students’ education and cause rotations to be crowded. It is unclear how this “turf war” will play out; Caribbean medical schools pay hospitals large sums of money for their students to rotate. St. George’s Medical School, for example, recently signed a 10-year, $100 million contract with the New York City Health and Hospitals Corporation (HHC) and sends about 1,000 students to these hospitals each year. Under New York State’s proposal, Caribbean medical students would be permitted to do only fourth elective rotations at New York hospitals, which poses special challenges that the article did not address. (Read Dr. Freedman’s published letter to the editor in response to the New York Times article.)
Does the Caribbean school encourage away electives?
Doing “away electives” at hospitals where students hope to do residency is often a key to success. Students complete away electives not only as “audition electives” but also receive letters of reference from faculty at these programs. All international students, whether they are US citizens or not, sometimes find it difficult to obtain away electives at their “ideal” hospitals; being aware of this fact is essential for planning.
US medical students use the Visiting Students Application Service (VSAS) to obtain many away electives. Because this service is run by the Association of American Medical Colleges, Caribbean students cannot use it and therefore must apply individually to each hospital at which they want to rotate. And even if their residents are international medical graduates, many hospitals have policies that prohibit them from allowing these students to rotate. Some hospitals, including some HHC hospitals that recently contracted with St. George’s, will allow St. George’s students to rotate but won’t allow other Caribbean medical students to do rotations. Individual departments within a hospital also may have specific policies regarding international rotators. For example, one department within a hospital might allow international students to rotate while another might not. Therefore, it may require a tremendous amount of persistence for Caribbean medical students to obtain away rotations, and students should start seeking out information regarding which hospitals accept international medical students as rotators when they choose their desired specialty.
Where do the Caribbean school’s students match?
The be-all and end-all indicator of success is a medical school’s match list, many of which are published on schools’ websites. But, interpret these lists carefully. First of all, you want to know what percentage of graduating fourth-year students obtain categorical matches. Why is this significant? Preliminary positions are only one year and do not guarantee a specialty match or board eligibility. Categorical positions, on the other hand, are specialty matches and do guarantee board eligibility. Many published school lists do not distinguish between preliminary versus categorical matches. One major Caribbean medical school recently disclosed at a faculty meeting that 15% of its graduating students did not obtain categorical positions last year. This information is not easy to obtain, however, and for obvious reasons schools rarely disclose this raw data to prospective students and their parents.
How do US citizen IMGs perform nationally?
It is also essential to review the national data to see how US citizen IMGs fare in the match. In the past, the National Residency Matching Program (NRMP) released data that divided applicants into only two categories: US seniors and independent applicants, which limited interpretation of this data. Recently, however, the NRMP has started to further categorize this data, clarifying how each group performs. There is now a category for “US Citizen IMGs” and, even though this includes all US citizen international graduates, a large number of this group are Caribbean students.
The number of active US citizen IMGs in the 2010 Match was 3,695, which is 1,260 more than five years ago; 1,749 were matched to PGY-1 positions, down 0.5 percentage points from last year. This data may be misleading, however, since it is not clear how many of these 3,695 students received “prematch” offers and therefore did not go through the match. Only international medical students and international medical graduates can accept “prematch” offers; US medical students cannot receive prematch offers.
Reviewing this data further, most US citizen IMGs match in internal medicine and family medicine; it is extremely difficult to match in competitive specialties. In 2010, for example, only one US citizen IMG matched in plastic surgery, otolaryngology, and dermatology.
The ECFMG announced that effective in 2023, all applicants and physicians “will need to graduate from a medical school that has been appropriately accredited” to receive ECFMG certification. This means that the medical school will need to be accredited through the Liaison Committee on Medical Education or other organizations such as the World Federation for Medical Education (WFME). Physicians must be ECFMG certified to take the USMLE Step 3 and to obtain an unrestricted license to practice medicine in the United States. Therefore, holding the Caribbean and all international medical schools to higher standards will force schools to create curriculums that lead to better medical educations and graduates’ success.
Dr. Jessica Freedman, a former emergency medicine associate residency director and medical school admissions member at the Mount Sinai School of Medicine, is president of MedEdits Medical Admissions. MedEdits offers advising and professional editing for applicants to medical school, residency, fellowship, and post-baccalaureate and special master’s programs. Like MedEdits on Facebook.