The Embrace of Overseas Medical Schools

as the man ahead of her berated a teller and caused a sudden and loud scene in the Detroit bank. This was far from the first time that Essad experienced a clash of cultures while visiting home—a home 1500 miles northwest of her classrooms at the American University of the Caribbean (AUC) on the 34 square-mile island of Saint Martin.

To her childhood friends, Kate was now George, as in the titular character from George of the Jungle—a sun-kissed, dreadlocked visitor from faraway tropics with no Western sensibilities. Somehow, as a medical student, she was calmer and more able to find resolve in issues that would’ve normally eaten away at her for days. In just a few years, everyday stressors became as foreign and averse to her as the Michigan winters. Island living changed her, but it wasn’t until she was watching this man scream at his teller that she realized how far along she had come.

“You learn patience, and to respect others in the community,” Essad told MD Mag. “Being in St. Martin, you could slow down and realize things aren’t as big of a deal.”

There are very obvious stigmas attached to overseas medical schools. Their average tuition cost and acceptance rates imply they serve as back-up options for students rejected by competitive schools in the continental US. The beaches, islands, and getaway destinations where many are located seem to imply a lighter workload. The New York Times outright declared that schools such as St. George’s University School of Medicine, on Grenada, are “second-chance” institutions.

But these stigmas often point to the reasons students apply to and attend those schools­—there’s little acknowledgement of the graduates they produce. To Heidi Chumley, MD, MBA, executive dean of AUC, the physicians that come from faraway places only differ in the paths that lead them there.

“When you deviate from a very standard career path of becoming a doctor, it’s pretty challenging to get into medical school,” Chumley told MD Mag. “We get so many non-traditional students, and they’re of such an exceptional quality.”

Now, the large number of physicians coming from these foreign programs has become a benefit to a US health care system facing a steep physician shortage.

Importing Exports

This year, 6862 international medical graduates (IMGs) were matched in the annual Main Residency Match at US institutions, according to the Educational Commission for Foreign Medical Graduates (ECFMG). This is notable because, despite IMG match participation dropping 2% from 2017, total matches were on the rise.

The makeup of these graduate classes has also evolved into predominately domestic students: in 2007, there were 1828 US-born students from international medical schools who were certified to enter the country’s residency and fellowship programs, versus 2734 classmates born in India. A decade later, there were 3298 US students, versus just 1140 Indian students.

At AUC, the disparity has become more distinct. Chumley said of the approximate 400 students admitted annually, about 85% are from the United States, 10% from Canada, and the remainder from various countries across the globe. Chumley, who moved to the island after 8 years at the University of Kansas School of Medicine, noted Kansas accepts about 200 new students annually. They also reject about 100 qualified in-state students.

Chumley wondered where those students went. Eventually, they may have found themselves overseas.

“They create a great counterpoint to the makeup of the medical school experience,” Chumley said. “There are experiences exclusive to here featuring what they’ll have to do as doctors.”

One driving difference is in faculty. International medical schools do not require professors to sustain their position with clinical rotations or published research, Chumley said. Her staff is comprised of doctors singularly driven to the field of teaching, who are more freely at the attention of students than those in the United States.

Another experience, particularly exclusive to the Caribbean schools, is hurricanes. Hurricane Irma’s eye passed directly over St. Martin last September, and a combination of about 700 students and visiting parents present for the first week of the semester sought shelter in an athletic building. Students joined emergency responders treating people out of the facility, rescue crews monitoring the island, and public health officials who were tasked with managing the logistics of housing the hundreds of people delegated to the campus.

Those experiences stick with the students, Chumley said, and it’s common for them to extend their public health work into the local community.

“They see the island in a different way,” Chumley said. “They roll up their sleeves and help. It’s amazing.”

Eventually, many of these students are matched into primary care residency roles in the US—in part because of their extracurricular all-hands-on-deck work while at school, and in part because the primary care field has become less competitive among incoming residents than other specialties. The field is in dire need of increased interest, and Chumley—a former family physician—sees her students assuming that role.

“One in 4 doctors is trained overseas,” Chumley said. “We feel like we’re playing a very necessary role.”

This year, institutions offered a record-high rate of primary care and internal medicine specialty residency positions, according to the National Resident Matching Program. In coming years, even more students will be making their way from the islands to the US for residency, including Matthew Fordham, who is hoping for training in internal medicine.

Worth the Risk

Fordham, a second-year student at St. George’s University School of Medicine (SGU) on the island of Grenada, actually agrees with the labelling of overseas schools as second-chance institutions. He admitted that his qualifications weren’t up to the standard of most US medical programs. But he told MD Mag that he wouldn’t let the blemishes on his transcript stop him from becoming a physician.

That said, SGU was so far from a first pick that Fordham actually had to look up where the school was when he considered applying. He made contact with alumni and scoured Wikipedia for information not only about the school, but also the country. As much as he was preparing for medical school, he was preparing for life in a foreign country and culture.

“It’s both scary and exciting at the same time, and your mind can really run rampant with the classic ‘what if’ scenarios,” Fordham said.

School was an easier transition than he could have imagined. He receives financial aid while completing an MD program that places him for 2 years in Grenada, then 2 years at a US-based institution. For clinical rotations, he’ll get the chance to return near his home in New Jersey and graduate not too far from where he first started his application process. Having rolled the dice on an international life, Fordham feels that SGU understands the gamble students like him are taking and are doing their part to ensure a payout.

“It just goes to show how you can travel so far to give yourself a shot at your dream, but that same adventure can still find a way to bring you home,” Fordham said.

Medical school has repeatedly been shown in surveys and comprehensive analyses to be a time of significant stress and burnout, sending graduates into a field rampant with similar challenges. But like Essad, Fordham felt the campus culture at SGU changed him for the better. He describes himself as being more open-minded, with many stories to tell from his time on the island.

“Education is heavily influenced by your perspective, and broadening your cultural and social experiences is an invaluable tool,” Fordham said.

The Real Network

Essad actually had a choice between continental schooling and AUC. About 10 years ago, she was all but committed to a medical school in Florida when she visited a friend at AUC. It was a fit for her academic criteria, and the potential for adventure away from home was enticing.

She earned her degree, along with stories of life on an island, like Fordham. She recalled the flooding and blistering winds of Hurricane Omar rattling outside her windows as 16 relocated classmates bunked up in her apartment. She once started a running club with her classmates that would trek through nearby towns in the morning, always catching the attention of locals who would joke about the students running late to class.

Even quieter moments—a then-unknown classmate going out of his way to talk to her after realizing she was homesick—stick with Essad, as she remembers her time in the Caribbean as significantly less competitive and more collaborative than her friends’ memories of medical school in Michigan.

The support network only grew as Essad came home and completed a transitional internship year at Henry Ford Hospital, then 3 years of a neurology residency at Dartmouth-Hitchcock Medical Center in New Hampshire. The irony isn’t lost on Essad: a Caribbean medical school graduate—misconceived of as lower caliber—picking a residency from multiple Ivy League options. Even better, she met multiple Caribbean medical school alumni in Dartmouth’s neurology department on her first day.

Right now, Essad is wrapping up her last week of fellowship at The Sports Neurology Clinic in Brighton, MI. She’s set to lead a new sports neurology program at Aurora Health Care in Milwaukee, WI. From the moment she began researching medical schools over a decade ago until today, she’s been aware of the stigmas that come with overseas medical school. She waited for someone to look down on her or her degree, but no one ever did. When she realized that fear had no merit, her path became as normal as anyone’s.

She stopped worrying about such little things. The island can have that effect.