Advice and cautions for premeds considering applying to an international, foreign, or "off-shore" medical school
It is a hard fact that U.S. and Canadian medical schools select who they feel are the best candidates to become future physicians. This leaves many highly qualified medical school applicants behind. Although most applicants do not choose off-shore medical schools as their first choice, applicants who are turned down by U.S. medical schools, or who do not have the competitive GPAs or MCAT scores may be forced to consider this route. This site summarizes the recommendations of pre-health advisors, pre-health advisor organizations such as the National Association of Advisors for the Health Professions (NAAHP), and the American Association of International Medical Graduates (AAIMG). The largest concentration of international medical schools for citizens of the United States is located in the Caribbean. Other international schools that cater to U.S. citizens are located in Australia, Ireland, Israel, Mexico, the Philippines, Poland, Uganda, the United Kingdom, and other locations. According to Iserson (2003) several excellent medical schools outside the United States and Canada that routinely take U.S. students include: Sackler School of Medicine, Tel Aviv, Israel; Tour College/Faculty of Medicine of the Technion-Israel Institute of Technology, Haifa, Israel; and the Royal College of Surgeons, Dublin, Ireland.
Medical schools outside of the U.S. that cater to U.S. citizens are referred to as foreign, off-shore, or international. Many of the agencies that work with graduates of these schools are shifting toward the "international" designation. Within the international category most U.S. applicants consider only schools where the curriculum is taught in English. Graduates of international medical schools are referred to as "IMGs" as opposed to "USMGs," for graduates from U.S. medical schools. United States citizens who are graduates of international schools are referred to as "USIMGs." It is important to recognize that many countries have medical schools for their own citizens in the national category. These "national" medical schools are not open to admission by citizens of other countries.
A ton of questions and considerations
Preface Statement: It is mandatory that all applicants to international medical schools know all the steps, hurdles, and requirements for medical school and graduate medical education, as they apply as USMGs or IMGs. A complete understanding must include the extra steps to be eligible for an accredited residency program in the U.S., board specialty certification, and state licensure. Also, the applicant must consider the extra challenges and personality characteristics that are required to be successful in such a program. These considerations must include an honest self examination of the reasons for seeking admission into an international medical school over that of working to gain entry into a medical school in the United States.
- Is the program accredited and recognized by the United States Department of Education?
- How established is the program?
- Has the program graduated at least one class?
- How many years have they been operating and have their graduates been successful in passing the USMLE and obtaining residencies in the United States?
Generally, residency directors do not look favorably on IMGs, particularly in specific residencies such as surgery. Most IMGs go into less competitive specialties such as internal medicine and family practice.
- Is the school found and listed in the World Health Organization (WHO) directory as qualified for its students to sit for the USMLE, steps 1 and 2?
- How do students perform on the USMLE I and II?
- In recent years what are the first-time and total "pass rates" for students from the school?
- Where are the clinical rotations (clerkships) set up and do they include at least 72 weeks of clerkship training?
Many off-shore schools do not have enough or adequate clinical teaching facilities, which is the major drawback of many foreign schools. Make sure you know where you will do your clinical rotations before attending a school, and that clinical rotations are permitted in the United States. Having clinical rotations in the United States may provide valuable recommendations that help the student get into ACGME-accredited (Accreditation Council for Graduate Medical Education) residency programs in the United States. Having the school make the arrangements or have the agreements to provide clinical rotations in the United States is important. Three states (PA, PR, TX) ban IMGs from taking clinical clerkships in their hospitals. Seventeen states regulate IMGs in clinical clerkships and several have restrictions on the length of total clerkship experience in their state.
- Although IMGs may not get residencies at the most prestigious sites, do IMGs have difficulty getting the residencies in the areas they desire?
- Since there will always be some difficulty, what is the degree of difficulty?
- Can the graduate get licensure in that country in which the foreign medical school is located?
- Can the graduate get M.D. licensure in the state or Canadian province where the graduate wishes to practice? States may require one, two, or three years of residency before granting a license to practice. Often, the number of years for IMGs is longer. For example, Missouri requires only one year for U.S. medical graduates, but three years for IMGs. Some states require certain coursework in the undergraduate curriculum and certain minimum scores on the MCAT
- What percentage of the courses are taught in English?
- If some courses are taught in a different language does the applicant have command of that language?
- Is the program licensed in the country where it is located?
- Does the school have admission criteria for selecting students? The MCAT, GRE, or a comparable diagnostic instrument should be required.
- Does the basic science and clinical curriculum conform to acceptable standards of licensing board in the United States? The entire program of study leading to the Doctor of Medicine degree should not be less than 38 months.
- Can the graduate from the IMG gain certification from the ECFMG (Educational Commission for Foreign Medical Graduates)? The school must be listed in FAIMER's on-line International Medical Education Directory (IMED). FAIMER stands for the Foundation for Advancement of International Medical Education and Research. Remember that being "eligible" for ECGMG certification doesn't mean that graduates can actually pass the examinations necessary to get the certificate.
- What are the mean Science and Overall GPAs for the previous entering class?
- Who are the staff and administration?
- Where were they trained and where are they from?
- What are the academic credentials of the faculty teaching the basic science courses?
- Where were they educated?
- How easy is it to contact the school by telephone, fax, e-mail, or on the World Wide Web?
- Does the school speak negatively of other schools?
- Does the program offer "credit" for "life experiences?" Clerkship credit should not be automatically given for "on the job training" as a past allied health professional. Advanced placement should not be given to physician assistants, chiropractors, podiatrists, nurse practitioners, or other applicants with allied health backgrounds. Watch out for these.
- What is the student attrition rate for matriculated students?
- What are the reasons for drop-out?
- How do students fund their education?
- Are students eligible for loan programs and scholarships? US citizens at many international medical schools are eligible for U.S. Government Guaranteed Student Loans.
- Are claims and statistics provided by the school supported and backed up by data from independent sources?
- What is the social and political stability of the country and the environmental hazards where the school is located?
- Does the school show a high pass rate for the Boards, but limit those of its students who can take the Boards?
- What percentage of students at a particular school apply for transfer to a medical school in the United States and are successful? Of thousands of students, only 40-55 international students are able to transfer to U.S. medical schools each year from all international medical schools. Nearly all foreign schools discourage such transfers and may balk at providing necessary transcripts.
- Students at most non-U.S./Canadian medical schools are not eligible for U.S. Government education loans. Are your lenders willing to make government-backed loans to students at that school?
- What are the estimated annual expenses including tuition and fees, books, supplies, study materials, housing, food, travel, and other living costs?
Some other considerations
- There is an admissions office with a qualified staff.
- The school catalog lists the composition of the faculty, clerkship training sites, and campus facilities. Stated goals and objectives for each course and a detailed syllabus with evaluation criteria are available to the student at the beginning of each term. Total tuition and fee costs are published in the school catalog.
- There is a minimum class attendance requirement in the school catalog.
- Students must be physically present at the basic science campus for the entire term with the exception of semester breaks or school vacations. Neither distance learning nor shortened basic science terms nor home self study options are acceptable. Standard medical textbooks are required for each course and clerkship rotation.
- Minimum laboratory facilities should include a gross anatomy lab, a microbiology lab, a separate microscope lab for pathology and histology. A physiology lab is highly desirable.
- The school should have a medical library area with a book and periodical collection that meets the minimum standards of small medical school. On-line resources such as Medline should be available to students and faculty free of charge. Students have free access to internet and email facilities.
- The school promotes an atmosphere of tolerance for religious and cultural diversity.
- The teaching and clerkship faculty have reasonable teaching loads, usually no more than two courses, and no courses outside of their areas of expertise. Faculty are encouraged to conduct scholarly research.
- Student evaluations of courses are conducted on a regular basis.
- Sufficient and affordable housing is available to accommodate the student and/or family members. Dormitory accommodations at a reasonable rate are available for students requesting this type of accommodation. A student health clinic and/or local health care resources are readily available for routine health care needs.
- The school offers a school catalog containing a curriculum with course descriptions and semester hours that are listed.
**A full listing of the American Association of international Medical Graduate evaluation criteria can be found on the AAIMG website.
Are you up to the challenge? Perform this self examination
The following suggestions are excerpted from a handout at a panel session on Foreign Medical Schools at the NAAHP 2004 convention in Washington, DC. I believe the author was Suzette Combs of the University of Cincinnati. These are not "yes or no" questions. As you answer them, use specific, relevant personal experiences to illustrate your answers. If you have had no experiences that are an exact match, think of any experiences that may have allowed you to develop transferable skills. This is the time to be perfectly honest with yourself.
On a scale of 1 to 10, how much do you want to be a health care professional?
- Have you investigated other career choices?
- Have you investigated several schools?
- What type of medicine do you plan to practice?
- How extensively have you traveled?
- Do you require an "American" standard of living in terms of housing, food, transportation, entertainment, climate control, creature comforts, and communication?
- Do you have significant experience functioning outside of your physical, emotional, and cultural comfort zone?
- Are you able to embrace adventure and unexpected events and see them in the larger context of medical training?
- Have you ever dealt with a major issue without the physical presence of close family or friends?
- How do you deal with obstacles?
- How important is it to you that everything always goes "according to plan?"
- How do you react when things do not go as planned?
- Have you consulted with your pre-medical advisor about your decision?
- Will your family and friends support your decision to attend an international medical school?
- Are you prepared to spend a significant period of time away from your family and friends?
- Are they prepared for you absence?
- Have you spoken with current students and graduates of the schools you are investigating?
- Will your financial situation support the necessary monetary investment?
- Do you understand the financial consequences of not finishing the program?
- Is it possible to visit the school before you make a decision?
- Are you in relatively good health?
- Do you have the maturity to accept sole responsibility for the completion of your medical education and the actualization of your career goals?
- Do you possess adequate and positive experiences interacting with people who differ from you academically, philosophically, culturally, and/or socio-economically?
- Will your motivation, tenacity, academic ability and work ethic sustain this endeavor?
Some advice and several statistics to consider before making a final decision
(Taken from an article by Crosby and Cannon, The Advisor, March 2004). 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 an allopathic or osteopathic medical school in the United States. Statistics indicate that most students (55%) who were attending foreign medical schools with the hope of obtaining their residencies in the United States never applied to a medical school in the United States. Only 65% ever took the MCAT. If candidates believe that they are not competitive, they should consider strengthening their competitiveness by retaking courses in which they did not perform well, going further in their science coursework, retaking the MCAT, considering a post-baccalaureate program, and gaining more healthcare experience. If they are residents of states where the applicant to openings ratio is high, they might explore gaining residency in a state where the ratio is lower. Even if these candidates eventually choose to attend an international school, further academic preparation, additional practice taking standardized tests, and more life experience and maturity will improve their changes of completing a medical education.
The exact number of U.S. citizens who go to international medical schools is not known. The number of graduates who can obtain residencies within the United States is dependent on the number of available residency opening over and above that for the allopathic and osteopathic graduates. This number can change and the availability of residencies in certain specialty areas may be very limited.
In 2002, 4,186 U.S. citizens registered for Step 1, and 2,520 for Step 2 of the USMLE. U.S. citizens had lower overall USMLE pass rates (42% for Step 1 and 68% for Step 2) than non-citizens (59% for Step 1 and 75% for Step 2). The overall pass rate for U.S.-trained students from allopathic schools was 88% for Step 1, and 95% for Step 2. The overall pass rate for U.S.-trained students in osteopathic schools was 67% for Step 1, and 88% for Step 2. Students should be aware that there is a high correlation between success on the MCAT and success on the USMLE. Students with low MCAT scores may be only gaining a high debt and wasting time by attending a foreign medical school. Experts recommend that you should consider a foreign medical school only if your individual MCAT scores are at least 10 or your total is 30. Students with an MCAT total of 26 seem to do well at LCME- (Liaison Committee on Medical Education) and AOA- (American Osteopathic Association) approved schools.
Listing of foreign medical schools
The list below is not intended to imply an endorsement of any foreign medical school. Use Google to locate web resources. Students are urged to carefully consider all the perspectives presented above, to carefully research any school before applying, and to work with their pre-medical advisors before making a final decision.
American University of Antigua College of Medicine
American University of the Caribbean School of Medicine
Flinders University of Medicine
Karol Marcinkowski University of Medical Sciences
Medical School for International Health
Medical University of the Americas
Ross University School of Medicine
SABA University of Medicine
Sackler School of Medicine
St. George's University School of Medicine
St. Matthew's University School of Medicine
Technion American Medical Student Program
Universidad Autonoma de Guadalajara
University of Health Sciences, Antigua School of Medicine
University of Sint Eustatius School of Medicine
University of Queensland Medical School
Xevier University School of Medicine
American Association of International Medical Graduates (AAIMG): http://www.aaimg.com/criteria/index.html
Crosby, P.J. and Cannon, R.E. International medical schools for U.S. Citizens: Considerations for advisors and prospective students. The Advisor, 24(1):36-42.
Iserson, K.V. Iserson's Getting Into a Residency: A Guide for Medical Students (6th ed.) Tuscon, AZ:Galen Press; 2003.
Iserson, K.V. Chapter 17: Foreign Medical Schools. In Get Into Medical School! A Guide for the Perplexed (2nd ed.). Tuscon, AZ: Galen Press 2003 McLoughlin II, P.J., Harvey, B., and Smulders, A.P. Foreign medical schools from the premedical advisor point of view. Handout presented at the National Association of Advisors for the Health Professions National Conference, Las Vegas, NV. June 2002.
Sen, N. The Complete Guide to Foreign Medical Schools in Plain English. Wayland, NY:Indus Publishing Company: 1997.
For more information
Department of Biomedical Sciences
Missouri State University
Springfield, MO 65897