Caribbean Showdown

Offshore Medical School Threatens Texas Training   

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Medical Education Feature – June 2012

Tex Med. 2012;108(6):49-53. 


By Ken Ortolon
Senior Editor

Indisputably, Texas needs to train more physicians. The state's population is growing rapidly, and many areas face significant physician shortages. 

But a Caribbean medical school's proposal to bring its third- and fourth-year students to Texas for clinical training is drawing fire from the state's medical schools, some influential state lawmakers, and the Texas Medical Association. 

Earlier this year, the American University of the Caribbean (AUC) – a for-profit medical school owned by DeVry, Inc. – applied to the Texas Higher Education Coordinating Board (THECB) for a certificate of authority to grant medical degrees in Texas. If approved, AUC could contract with Texas hospitals and other health care facilities to provide clinical training for third- and fourth-year students from the school, located on the Caribbean island of St. Maarten. 

While DeVry officials say the move could bring more physicians to Texas, medical educators here fear it would displace Texas medical students from existing clinical clerkships. In a March 9 letter to THECB, TMA Council on Medical Education Chair Cynthia Jumper, MD, warned that the proposal "would negatively affect the quality and affordability of education for Texas medical students, residents, and other health professionals – all who need and deserve first priority to clinical training in our state." 

Despite a recommendation from THECB's Strategic Planning and Policy Committee to approve the application, the board voted April 25 to seek an opinion from Attorney General Greg Abbott about its legal authority to grant a certificate of authority to a private professional program. 

That move likely has delayed final action on the matter for at least six months, but the issue is far from over. DeVry officials say they will continue working with the Coordinating Board on the matter. 

At the meeting, THECB member David Teuscher, MD, who also serves on the TMA Board of Trustees, said Texas needs to take care of Texas medical students' clerkships first and foremost. He added that the issue deserves more study before granting any training slots to entities outside of Texas.

Meanwhile, four influential state lawmakers asked the Coordinating Board to postpone further action on the matter until after the Texas Legislature convenes again in January 2013. 

Starting a Bidding War

AUC is not the first Caribbean medical school to seek authority to provide clinical training for its students in the United States. Marcia Collins, director of TMA's Medical Education Department, says Caribbean schools seek clinical training space in American teaching hospitals because they simply do not have the facilities for training on their home islands. 

David Wright, MD, a member of TMA's Council on Medical Education and director of The University of Texas Medical Branch's family medicine clerkship program at Austin's University Medical Center Brackenridge Hospital, says offshore medical schools already have contracts for clinical clerkships with hospitals and other facilities in several other states, most notably New York. 

According to data from a 2008 New York Times article and the 2011 legislative program of the Medical Society of the State of New York, one New York medical school was unable to secure a core rotation site within its county because for-profit offshore medical schools bought up previously existing clinical training slots from local hospitals. 

That data, presented in a resolution by the Medical Student Section of the American Medical Association in 2011, also said the New York City Health and Hospitals Corporation has a 10-year exclusive contract with St. Georges' Medical School. The offshore for-profit school pays $400 to $425 per student per week for training slots.  

New York, unlike Texas, has an overabundance of clerkship and residency slots. 

The AMA House of Delegates will consider the resolution at its annual meeting in Chicago this month.  

The resolution asks AMA to encourage local teaching hospitals to secure access to clinical clerkship positions for medical students educated in medical schools accredited by the U.S. Liaison Committee on Medical Education or Commission on Osteopathic College Accreditation before allocating positions to students from nonaccredited schools. It also asks AMA to oppose "extraordinary payments" by any medical school for access to clinical rotations. 

While AUC officials say they would not displace Texas students from existing clinical training experiences, medical educators are still worried.  

In a March 20 letter to Texas Higher Education Commissioner Raymund Paredes, Texas medical school officials warned of a potential bidding war for clinical training slots. 

"Tuition in Texas medical schools is 50 percent of the national average for American medical schools," the officials wrote in the letter. "We cannot compete with for-profit schools to pay for hospital experiences." 

The letter was signed by Don N. Peska, DO, dean of the Texas College of Osteopathic Medicine at the University of North Texas Health Sciences Center; Paul Klotman, MD, president and chief executive officer of Baylor College of Medicine; Kenneth I. Shine, MD, executive vice chancellor for health affairs for The University of Texas System; T. Samuel Shomaker, MD, JD, dean of medicine and vice president for clinical affairs at Texas A&M University Health Science Center; and Steven L. Berk, MD, dean of the school of medicine and executive vice president and provost at Texas Tech University Health Sciences Center. 

An additional concern, Dr. Peska says, is that Texas medical schools are attempting to comply with an Association of American Medical Colleges recommendation that U.S. medical schools increase enrollment by 30 percent by 2015. 

Texas schools have increased enrollment significantly over the past few years which, in turn, has strained the state's teaching hospitals' ability to accommodate any additional third- and fourth-year students. 

"In so doing, we have saturated all of the currently developed teaching sites for third- and fourth-year students," Dr. Peska said. 

What's more, Texas needs roughly 200 more training slots within the next three years as new medical students progress into their third and fourth years. Plus, at least three new medical schools are proposed for Texas, including one in South Texas that has considerable support in the legislature. 

"If even two of the three medical schools that are on the drawing board come into fruition over the next couple of years, then by 2020 we could see another 400 to 600 students who need these resources," Dr. Peska said. "And we haven't yet developed all the hospitals and training sites we need to accommodate our own students." 

Training Slot Squeeze 


Dr. Wright says Texas must preserve its clinical clerkship slots for Texas medical students. 

"The third- and fourth-year rotations are probably the most critical aspect of a medical student's education," he said. While the first two years focus on the basic sciences, students really get exposure to clinical medicine during their third and fourth years, he says. 

But finding opportunities for more medical students is growing increasingly difficult in an era when major teaching hospitals are downsizing, and the trend is to move patient care out of the inpatient setting and into physician offices and outpatient clinics. 

"What has happened is the mega teaching hospitals, for all kinds of different reasons, have had to downsize. So the capacity and the bed space have gone down. Therefore, that has some effect on the ability to slot students into these particular rotations," he said. "A perfect example is what takes place here in Austin, where UTMB sends a number of its students here in the third and fourth years. It has to do with the fact that they cannot place all of their students into these critical rotations, either at the teaching hospital in Galveston or in the teaching hospitals that they use in South Houston." 

Drs. Peska and Wright say competition from offshore medical schools for available training slots could jeopardize training for Texas students with no benefit to the state of Texas. 

"… as we struggle to address the physician shortages in our state, we have no assurances that these students from offshore schools who would train in Texas hospitals and take up valuable clinical training space are committed in any way to providing care for our citizens," the medical school officials wrote Commissioner Paredes. "There is no data to support that medical students from offshore schools who complete any training in Texas will establish their practices here." 

Getting a Second Opinion 


Despite objections from the medical schools and TMA, it appeared the Coordinating Board might approve the AUC request. However, the board chose to delay action after House Speaker Joe Strauss (R-San Antonio), state Rep. John Zerwas, MD (R-Richmond), and state Sens. Judith Zaffirini (D-Laredo) and Robert Duncan (R-Lubbock) all wrote letters voicing opposition. 

In a letter to THECB Chair Fred Heldenfels, Speaker Strauss urged the Coordinating Board to delay action. 

"Because the proposal could have consequences that extend far beyond the immediate decision and could impact the ongoing investment made by the Texas Legislature for the expansion of our own state medical schools to produce enough in-state physicians to meet the needs of our growing population, I respectfully request that you postpone action on this proposal in order to allow the Texas Legislature to consider the issue in the broader context of our state's medical schools and overall health care system and workforce," he wrote. 

In separate letters to Mr. Heldenfels, Senator Zaffirini, who chairs the Senate Higher Education Committee, and Senator Duncan, chair of the Senate State Affairs Committee, argued approving the AUC request would open the door to other foreign medical schools to compete for training slots in Texas and questioned the board's authority to approve the request. 

"There are also legal and statutory questions revolving around the board's authority regarding certificates of authority for professional programs," Senator Duncan wrote. "These questions need to be addressed and resolved by the legislature prior to any further action on this matter." 

In addition, the Coordinating Board also asked its staff to study the state's clerkship capacity and the extent to which it could accommodate students from foreign institutions. 

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

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