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.

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.

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.

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.

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.

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.

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.

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.

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.

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?

 

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.

Foreign Medical Schools

American University of Antigua College of Medicine: www.auamed.org

American University of the Caribbean School of Medicine: www.aucmed.edu

Karol Marcinkowski University of Medical Sciences: www.mdprogram.com

McGill University: www.med.mcgill.ca

Medical School for International Health:
www.cumc.columbia.edu/dept/bgcu-md

Medical University of the Americas: www.mua.edu

Ross University School of Medicine: www.rossu.edu/medical-school

SABA University School of Medicine: www.saba.edu

Sackler School of Medicine (Tel Aviv): www.tau.ac.il/medicine

St. George’s University: www.sgu.edu

St. Martinus University Faculty of Medicine: www.martinus.edu          

St. Matthews University School of Medicine: www.stmatthews.edu

Technion American Medical Student Program: teams.technion.ac.il/

Universidad Autonoma de Guadalajara: www.uag.mx

University of Health Sciences, Antigua School of Medicine: www.uhsa.ag

University of Sint Eustatius School of Medicine: www.eustatiusmed.edu

Xavier University School of Medicine: edu.xusom.nl

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.