Correspondence
Nonaccredited Medical Education in the United States
N Engl J Med 2000; 343:1120-1123October 12, 2000
- Article
To the Editor:
In their Sounding Board article on nonaccredited medical education in the United States (May 25 issue),1 Drs. Kassebaum and Cohen make several inaccurate and misleading statements.
The common definition of “accreditation” is review and approval by recognized evaluative bodies made up of external experts, independent of the institution under review. Ross University School of Medicine is accredited by the appropriate accrediting agency recognized by the Department of Education. Kassebaum and Cohen dismiss the review conducted by the National Committee on Foreign Medical Education and Accreditation (NCFMEA) of the Department of Education. This committee, which includes representatives of the American Medical Association and the Educational Commission for Foreign Medical Graduates, medical school deans, and other medical-education experts, made an extensive review (including a site visit) of the standards used by the Dominica Medical Board, the body responsible for reviewing and accrediting Ross University School of Medicine. It found the standards to be comparable to those used by the Liaison Committee on Medical Education (LCME) to evaluate programs leading to the M.D. degree in the United States.
The article also dismisses reviews and approvals by individual states. The reviews of Ross University School of Medicine by the states of New York and New Jersey were very similar to — and just as extensive as — those of the LCME. They included all elements involved in accreditation: review of a comprehensive “self study,” an extensive data-base document (which used the LCME questionnaire), and a site visit. To state or infer without specific knowledge that all such external reviews and approvals do not meet acceptable standards is clearly inaccurate and irresponsible.
Kassebaum and Cohen erroneously state that the clinical-clerkship sites where our medical students train are not reviewed. In fact, the Dominica Medical Board and Ross University School of Medicine make periodic reviews of these sites. The authors also claim that arrangements with U.S. hospitals are “informal” and lack oversight. In reality, the affiliations of Ross University School of Medicine with teaching hospitals (with approved residencies) include formal agreements with defined, written educational objectives. These same hospitals often also provide clinical training to U.S. medical students. The quality of the program of Ross University School of Medicine is documented by the high passing rates of our students on the U.S. Medical Licensing Examination, the students' rates of acceptance into prestigious residency programs, and the rates of board certification of our graduates.
What is omitted from the article is that Ross University School of Medicine had recently requested review by the LCME. In a letter to Neal Simon, president of Ross University, that was signed by Dr. Kassebaum and dated February 4, 1999, this request was denied on the basis that the LCME does not review foreign medical schools. Although such a policy may be understandable, it cannot be used as the basis for labeling institutions “nonaccredited.” The LCME is a private, nongovernmental body, as are most U.S. accrediting agencies. Currently, alternative pathways to accreditation are available for U.S. universities, and none can claim exclusivity. Therefore, it is inaccurate, if not presumptuous, to maintain that the LCME is the only body qualified to make determinations regarding the accreditation of medical schools. In fact, the Department of Education no longer recognizes the LCME accreditation owing to its close association with and dependence on the Association of American Medical Colleges (AAMC) and the American Medical Association.
Overall, Kassebaum and Cohen fail to distinguish between schools that have not received external approval and schools, including Ross University School of Medicine, that have been reviewed and approved by recognized U.S. agencies. This oversight does a disservice to Ross University School of Medicine, its graduates, and the federal and state agencies that have approved our program.
1 ReferencesEvan T. Angelakos, M.D., Ph.D.
Ross University School of Medicine, New York, NY 100011
Kassebaum DG ,Cohen JJ . Nonaccredited medical education in the United States. N Engl J Med 2000;342:1602-1605
Full Text | Web of Science | Medline
To the Editor:
Drs. Kassebaum and Cohen inaccurately suggest that Ross University School of Medicine is unaccredited and that its graduates are ill prepared to practice medicine in the United States. This is far from the truth, as noted by Dr. Angelakos in the preceding letter.
The authors fail to disclose that Dr. Kassebaum was a past principal secretary of the LCME, which has a policy of considering applications for accreditation only from medical schools chartered and operated in the United States and Canada. Dr. Kassebaum was personally involved in the decision by the LCME not to consider Ross University's application for accreditation on this basis. The LCME is sponsored by the American Medical Association and the AAMC. Dr. Cohen is the current president of the AAMC, which states that, “in order to decrease the number of physicians entering the workforce, the AAMC believes that the number of graduates of non-U.S. medical schools entering the country's graduate medical education system should be sharply curtailed.”
The article is not only biased but also unfair. The authors appear to believe in restricting the opportunity of able and energetic people to practice medicine in the United States. Ross University School of Medicine is committed to the proposition that such cartels are not in the public interest. The university has a history of educating American students to become productive and accomplished doctors and is proud of its graduates.
Benno C. Schmidt, Jr.
Ross University School of Medicine, New York, NY 10001To the Editor:
Drs. Kassebaum and Cohen complain that schools with foreign charters avoid accreditation-related oversight. Dr. Kassebaum has acknowledged that St. George's University School of Medicine ranks among the finest non–LCME-accredited schools in the world. But despite our conformity with LCME standards and the fact that thousands of our students have been lawfully trained and are practicing in the United States, the LCME refuses to accept our application for accreditation. The committee insists that schools have a U.S. or Canadian charter. Why? The LCME indicated that it was not necessary to divulge the discussion that led to these interpretations. Yet countries throughout the world accept foreign institutions on their soil. American institutions have an ever-expanding presence overseas. Contrary to all the trends indicative of a shrinking world, the LCME recommends that states change their laws to accommodate its restrictive, self-imposed policies. An infinitely more practical solution would be for the LCME to evaluate international medical school programs that are already operating in the United States.
St. George's University meets or exceeds the averages of LCME-accredited medical schools.1 In the period from 1997 to 1999, students entering the university had grade-point averages that ranged from 3.3 to 3.4, their Medical College Admission Test scores were 8 and 9, and 80 percent had baccalaureate degrees, 17 percent had master's degrees, and 2 percent had doctoral degrees. Twenty-five percent of the entering students were not U.S. citizens, and these students had received their undergraduate degrees from 56 institutions in 54 countries. The U.S. citizens were from 44 states, Washington, D.C., and the Virgin Islands. During these years, 2.6 percent of the students left the university. In terms of outcome, in 1998 and 1999, more than 90 percent of the students taking the U.S. Medical Licensing Examination Step 1 examination for the first time passed it, as did over 80 percent of those who took Step 2. In 1998, the matching rate for the residency-training program was 86 percent.
Although the U.S. population has both increased and aged in the past two decades, there are fewer U.S. medical students. St. George's University seeks to fill that gap and asks only to be evaluated on the quality of its education. Dr. Cohen believes there are too many doctors.2 We urge the LCME to reform its closed policies and restricted access.
Finally, there are a few factual errors in the article. St. George's University maintains written affiliation agreements in compliance with LCME standards and not “informal arrangements.” Also, a director of medical education oversees a one-to-one ratio of faculty to students.
2 ReferencesBernard Ferguson, J.D.
St. George's University School of Medicine, Westerly, RI 02891-35181
AAMC data book: information related to medical schools and teaching hospitals. Washington, D.C.: Association of American Medical Colleges, 1999.
2
Cohen JJ . Too many doctors: a prescription for bad medicine. Acad Med 1996;71:654-654
CrossRef | Web of Science | Medline
To the Editor:
Drs. Kassebaum and Cohen portray the guidelines used by the NCFMEA as reflecting “only a fraction” of the standards and procedures of the LCME. As chairman of the NCFMEA, I question that portrayal.
The NCFMEA is an advisory panel of experts appointed by the secretary of education to evaluate standards of accreditation for foreign medical schools, including whether the standards are considered comparable to the standards of accreditation applied to medical schools in the United States. The NCFMEA formulated its guidelines to evaluate the comparability of accreditation standards within the context of two assumptions. First, the standards used by a foreign country to accredit medical schools had to be comparable, not identical, to those used in the United States, and second, the standards and processes used by foreign countries to accredit medical schools should be expected to vary somewhat as a natural outgrowth of differences in governmental structure and among educational systems. The NCFMEA concluded that, to the extent possible, the guidelines should allow for some flexibility without compromising integrity.
The NCFMEA's guidelines focus on the standards that the foreign accrediting body has for its schools, as well as its procedures (for example, the regular reevaluation and ongoing monitoring of schools). The NCFMEA considered each LCME standard when crafting, and later revising, its guidelines, looking carefully at whether the LCME standard addressed a critical core component of medical education that should be present in any medical program, regardless of where it is located, or whether the standard instead addressed a nonessential aspect or involved an issue unique to the structure of higher education in America.
The NCFMEA's concern for student outcomes is evidenced by the requirement in its guidelines that the accrediting body must ensure that all its accreditation decisions are based, in part, on an evaluation of the performance of students after graduation from medical school. As countries submit annual reports, the NCFMEA will examine the ways in which foreign accreditors are implementing their standards and procedures, including an evaluation of data on student outcomes, in granting accreditation to medical schools.
The NCFMEA is committed to ensuring that its assessment of the comparability of the accreditation standards of foreign countries provides the appropriate oversight, as is implicit in the NCFMEA's mission; flexibility in evaluation is appropriate internationally, where diverse systems have evolved to serve the educational needs of many cultures.
William B. Deal, M.D.
University of Alabama School of Medicine, Birmingham, AL 35294-3293To the Editor:
In 1981, regulations were approved in New York concerning students enrolled in unaccredited or unregistered medical schools who are engaging in clinical clerkships. Such students may serve in clinical clerkships of more than 12 weeks provided that the medical school is approved by the state education department. In addition, students must have passed Step 1 of the U.S. Medical Licensing Examination, and clerkships may take place only in teaching hospitals with which the medical school has an approved affiliation agreement.
The process for evaluating unaccredited or unregistered medical schools requires the institutions and programs to examine their goals, operations, and achievements and to be evaluated by peers within the context of general standards. This process is distinguished from registration and accreditation by its more limited scope.
The department's system for the evaluation of these schools is based on accepted procedures for program review. The institution provides information concerning curriculum, faculty, students, resources, and administration that is reviewed by the department. A site visit to the campus and clinical facilities provides an opportunity to verify data and permits a detailed review of the components of the program. Evaluators use specific guidelines to review each program.
In conclusion, the New York State program to regulate clinical clerkships of students from unregistered or unaccredited medical schools defines conditions under which clerkships may be performed and also exerts quality control over the educational programs. The use of U.S. Medical Licensing Examination Step 1 as a screening device allows directors of medical education as well as state officials to assess students' performance in the basic-science areas after two years of medical school, and it provides at least an initial index by which to measure the student's beginning skills in clinical diagnosis. Through an ongoing system of program review, New York State is able to ensure that students in approved medical schools are receiving a reasonable education.
The currently approved medical schools are St. George's University School of Medicine, Grenada; Ross University School of Medicine, Dominica; the Autonomous University of Guadalajara, Mexico; Fatima College of Medicine, Manila, the Philippines; and the English programs at the Medical University of Lublin, Poland, and the Medical University of Silesia, Poland. The American University of the Caribbean has not been approved. The English program at Semmelweis University in Budapest, Hungary, is currently under review.
Thomas J. Monahan, M.A.
New York State Board for Medicine, Albany, NY 12230To the Editor:
As a U.S.-born physician educated at a foreign medical school, I agree with Drs. Kassebaum and Cohen that allowing foreign medical schools to have branch campuses in the United States raises questions. Whether or not it ultimately happens, however, will probably be decided in the courts rather than by professional or voluntary accrediting organizations.
The real lament, however, that I sense throughout their paper is that U.S.-born citizens actually have opportunities to obtain the M.D. degree at a foreign medical school, perhaps complete some clinical clerkships at U.S. hospitals in the process, and eventually obtain medical licensure in the United States. By inference, it would appear that Drs. Kassebaum and Cohen would also like to eliminate opportunities for training and licensure in the United States for all foreign-born and foreign-schooled physicians unless they intend to return to their own countries. This closed-shop attitude to international medical graduates has been around for decades.
It is a fact that many qualified students are denied admission to U.S. medical schools because of lack of space. Instead of lamenting the fact that 722 international medical graduates (presumably U.S. citizens) obtained certification by the Educational Council for Foreign Medical Graduates in 1998 at three foreign medical schools in the Caribbean, perhaps it would be better for Drs. Kassebaum and Cohen to applaud the dedication and efforts of students who went to such great lengths to fulfill their dreams of becoming physicians.
Ronald E. Domen, M.D.
Pennsylvania State University College of Medicine, Hershey, PA 17033To the Editor:
I agree with Drs. Kassebaum and Cohen that there should be more rigorous accreditation of graduates of foreign medical schools. However, the authors are erroneous in their belief that the current methods of accrediting U.S. medical-education programs are adequate. I can readily document that several U.S. medical schools give M.D. degrees to students whose failing grades have been converted to passing grades by deans or by teachers who have been pressured to do so by deans. Also, students have graduated even though it took them more than three years to complete the first two years of medical school and seven to nine years to complete the entire four years and they failed national examinations several times. It is difficult not to believe that graduates of this type have a major role in errors by physicians. However, to my knowledge, problems of this nature have never resulted in a loss of accreditation by the LCME.
Leonard Fahien, M.D.
University of Wisconsin–Madison, Madison, WI 53706To the Editor:
According to Drs. Kassebaum and Cohen, only students who graduate from an LCME-accredited program are eligible for state medical licensure. But osteopathic physicians are licensed by their states. Osteopathic medical schools are accredited by the Bureau of Professional Education of the American Osteopathic Association,1 the osteopathic equivalent of the American Medical Association. The association's accreditation standards and procedures can be found on the Web (http://www.aoa-net.org/Accreditation/accreditation.htm). Although Kassebaum and Cohen raise important questions about medical-education accreditation and the importance of quality control of the educational process, they stop short of providing a complete analysis of all U.S. medical schools (both allopathic and osteopathic).
1 ReferencesPhillip McDaniel, B.S.
University at Albany, Albany, NY 12222Author/Editor Response
The authors reply:
To the Editor: We remind Dr. Angelakos that our frame of reference is the accreditation process for allopathic medical schools that has been the standard for the measurement of educational quality in the United States for nearly a century. From an examination of the guidelines of the NCFMEA and the documentation about foreign countries considered by this committee, we stand by our opinion that the NCFMEA has deemed as “comparable” accreditation standards that are far below the standards applied to U.S. schools by the LCME. We agree that differences in educational systems in other countries may call for different ways to structure learning. However, we believe that the fundamental practices ensuring the quality of education are universal, and we differ with Dr. Deal's opinion that NCFMEA guidelines are comparable even when they water down the measures of program accountability that are demanded of U.S. medical schools.
In response to Mr. Schmidt: our respective positions, current and past, were fully disclosed to the Journal. Dr. Kassebaum previously served as secretary — not a voting member — of the LCME and was responsible for transmitting the committee's decisions, policies, and interpretations. Ross University School of Medicine was treated no differently from any other foreign medical school according to the LCME policy that its accreditation purview is limited to schools chartered in states and provinces of the United States and Canada (Canadian medical schools also are accredited by the LCME).
Mr. Monahan confirms that the reviews of foreign medical schools by state authorities are of limited scope and are intended not as accreditation, but for the purpose of approving the enrollment of students in clinical clerkships.
In lieu of attempting to apply U.S. and Canadian accreditation standards to foreign medical schools, the LCME has assisted a number of countries in establishing systems of educational quality assurance that fit their national environments — most notably Australia, the Republic of Georgia, Mexico, Poland, the Czech Republic, Switzerland, Chile, and Argentina. In the case of foreign schools whose students receive their clinical education largely in the United States already, it should be possible to move beyond argument about whether proxy measures are adequate warrants of quality. Such schools should obtain a state charter and see how their programs measure up to unadulterated U.S. accreditation standards.
Donald G. Kassebaum, M.D.
P.O. Box 468, Gleneden Beach, OR 97388-0468Jordan J. Cohen, M.D.
Association of American Medical Colleges, Washington, DC 20037- Citing Articles (1)
Citing Articles
1
Devinder Singh, Lalit Kumar, Atul Sharma, M Vijayaraghavan, Sanjay Thulkar, N Tandon. (2004) Adrenal Involvement in Non-Hodgkin's Lymphoma: Four Cases and Review of Literature. Leukemia & Lymphoma 45:4, 789-794
CrossRef
