By USHA LEE MCFARLING From Stat News

Photography by DANIA MAXWELL for STAT

ORENO VALLEY, Calif. — It’s easy to dismiss the for-profit medical schools that dot many a Caribbean island as scams, set up to woo unqualified students who rack up huge debts, drop out in staggering numbers, and — if they make it to graduation — end up with an all but worthless degree. That’s been the rap against them for years.

But the schools are determined to change that image. Many are quietly churning out doctors who are eager to work in poor, rural, and underserved communities. Their graduates embrace primary care and family practice, in part because they’re often shut out of training slots for more lucrative specialties.

And they just might help solve an urgent physician shortage in California and beyond.

The deans of two of the Caribbean’s medical schools — Ross University School of Medicine in Dominica and American University of the Caribbean in St. Maarten — are on an aggressive campaign to improve their image. They’ve published a series of editorials and letters with titles like “Why malign overseas medical students?” and hired public relations giant Edelman to make the case that their humble, hard-working, and compassionate students may be precisely the kinds of physicians America needs most.

“Our students have persevered. They haven’t had all the opportunities in life and they still want to help people,” said Dr. Heidi Chumley, dean of American University of the Caribbean School of Medicine. “Absolutely we want to get our story out.”

That story is unfolding on the ground in places like Moreno Valley, a city of about 200,000 in California’s Inland Empire, a former agricultural region just east of Los Angeles that grew explosively in the ’80s but has since fallen on harder times.

Here, the Riverside University Health System Medical Center rises from a stretch of largely undeveloped land once slated for luxury housing developments. The health system acts as the county’s public safety net for an ethnically diverse, mostly low-income population — including patients like retired carpenter José Luis Garcia.

On a recent clinic visit, Garcia, 69, came in to follow up on a urinary tract infection and his high blood sugar. He saw Dr. Moazzum Bajwa, 30, a second-year resident and graduate of Ross.

In a crisp white coat and bow tie, Bajwa entered the examining room and pulled up a low stool. Sitting eye to eye with Garcia, he spoke in a steady stream of fluent Spanish. The visit lasted nearly an hour.

In an attempt to keep his patient off insulin, Bajwa had asked Garcia to improve his diet and track blood sugar levels after meals. “Números fantásticos!,” Bajwa exclaimed, looking at the folded sheet of carefully written numbers Garcia had brought to show him.

“This is a very great doctor. Normally, I don’t feel important.”

Bajwa, a former middle school science teacher, then spent 10 minutes drawing a careful diagram — complete with neurons, intestinal walls, and red blood cells, or células rojas — to explain to a rapt Garcia exactly why certain foods raised his blood sugar. He then examined Garcia — noting he had a harmless but interesting muscle wall abnormality — and checked his medical records. Was there a colonoscopy report on file? Retinal photos?

As the visit was ending, Bajwa asked Garcia about stress. Garcia said his wife had recently had surgery for glioblastoma multiforme, one of the most malignant of brain tumors. “Wow,” Bajwa said quietly as he quickly scanned the medical summary Garcia handed him. “Wow.” He sat down again on his low stool.

“Lo siento mucho, señor,” Bajwa said, clearly moved.

Then he gave Garcia a hug.

“This is a very great doctor,” Garcia said later, through a translator. “Normally, I don’t feel important.”

Bajwa, an American citizen raised in Michigan and North Carolina, is the grandson of Pakistani Nobel physics laureate Abdus Salam and holds two advanced degrees, one in neuroanatomy and one in public health. But he couldn’t get into an American medical school. So he attended Ross University in Dominica.

Bajwa joined the family medicine program after graduating from Ross University School of Medicine in Dominica.
“It was the only school that gave me an opportunity,” he said.

‘Second-chance’ schools under fire

There are some 70 medical schools throughout the Caribbean, most of them established in recent decades and run by for-profit businesses that cater to Americans.

These so-called “second chance” schools accept students with poorer grades and lower MCAT scores, or sometimes no MCAT score at all. Compared to American medical schools, their tuition and dropout rates are higher and their class sizes large: Ross enrolls more than 900 students per year.

Graduates can practice medicine in the United States after passing their American medical licensing exams and completing a residency. But the schools have come under fire for generating a stream of students who don’t end up as physicians, but do end up with crushing medical school debt because they flunk out or don’t win residency spots after graduating.

Heartbreaking stories abound: One graduate of St. George’s University School of Medicine took a poor-paying job drawing blood to help pay off $400,000 in medical school loans. Another graduate of AUC entered nursing school after failing to get a residency.

“Are Caribbean medical schools promising something they cannot fulfill?” asked Dr. Glenn Tung, an associate dean at Brown University’s Warren Alpert Medical School who has studied the schools. “What I’m concerned about is the cost to the students who don’t make it and the cost to the American taxpayer when loans aren’t repaid.”

Illinois Senator Richard Durbin, also concerned, has repeatedly introduced bipartisan legislation to strip the schools of Title IV federal funding for student loans. Three Caribbean medical schools — Ross, AUC and St. George’s — took in $450 million federal funding via student loans in 2012, Durbin said.

“These for-profit Caribbean medical schools need to be accountable to their students and to U.S. taxpayers,” he said in a statement.

Dean Chumley and Dr. Joseph Flaherty, the dean of Ross, take strong exception to such criticism.

They allow that many for-profit medical schools — which have proliferated in the past few decades because they are proven money makers — aren’t doing a good job training and developing students. But they argue that AUC and Ross, two of the oldest Caribbean schools — both owned by for-profit educational juggernaut DeVry Inc. — are creating successful doctors.

They say they are also giving a shot to students with humble backgrounds, often minorities, who can’t get near American medical schools that focus so heavily on test scores and grades.

“Obviously brains help, but judgement, empathy, intuition, that’s all part of it,” Flaherty said. “Our students are gung-ho. They want to practice medicine. That’s their dream.”

Just 54 percent of American medical graduates who trained overseas are matched with a residency program for further training in their first year of eligibility. That’s an abysmal record, compared to the 94 percent of graduates of US schools who get residencies. But Ross and AUC say they have a match rates higher than 86 percent. And they say a vast majority of students pass their step 1 licensing exams on the first try.

“Obviously brains help, but judgement, empathy, intuition, that’s all part of it… Our students are gung-ho.”

(Critics say the schools manipulate the statistics by dismissing weak students shortly before they are allowed to take the exams. Chumley said the schools do weed out poor students early on to prevent their accumulating debt, but in no way encourage poor students to stay for five semesters and then prevent them from taking the exam. “I think that’s ethically wrong,” she said.)

Controversy erupts over deals with hospitals

The schools are also controversial because of their practice of buying their way into hospitals to train students. In 2012, Ross inked a contract — beating out rival St. George’s University School of Medicine of Grenada — to pay $35 million over a decade to the cash strapped Kern Medical Center in Bakersfield in exchange for the lion’s share of the hospital’s roughly 100 rotation spots for third-year medical students.

Some critics fear such deals will squeeze American-trained students out of rotations; disputes have flared in New York, where St. George paid $100 million for rotation spots, and in Texas, where lawmakers attempted to entirely ban Caribbean students from training in the state.

But Flaherty, Ross’s dean, says the such deals are a win-win. A struggling hospital gets funds. His school, which has no teaching hospital, gets a place to train students. And he gets to show skeptical doctors how good his students really are.

“The doctors get to know our students and say, ‘These guys are good,’” he said. “Our students get there early. They stay late and do extra work. They value any opportunity.”

And they seize those opportunities where they can find them.

While their numbers are up, it’s still harder for international medical grads — known as “IMGs” — to get residency positions. They’ve heard all the jokes about studying anatomy on the beach with Mai Tais in hand. But when it comes to residency positions, they are deadly serious. For there is no practicing medicine without one.

“You have to apply very widely. There’s always a stigma that IMGs don’t get as good an education.” said Rina Seerke-Teper, 31, a second-year resident who has wanted to be a doctor since she was six, graduated from the University of California at Berkeley and worked in stem cell research before attending AUC.

Many Caribbean graduates don’t even apply to residency programs that are filled only with American trained students. Instead, they look for “IMG friendly” programs like the family practice residency here, run in a busy clinic housed within the county hospital. The program is highly competitive — receiving about 800 applications for 12 positions each year — and of the three dozen current residents, 29 studied in a medical school outside the US.

Competition for the coveted slots is likely to grow even more as California, which just got one new medical schools and is slated to soon add another, starts spitting out more locally trained grads.

A desperate need for more doctors

More doctors are desperately needed: California will need an estimated 8,000 additional primary care doctors by 2030. The United States as a whole is projected to need some 30,000 additional primary care physicians in coming decades.

Dr. Michelle Quiogue works in one of the areas hit hardest by the shortage — rural Kern County. A graduate of a prestigious medical school — at Brown University — Quiogue says she’s worked alongside many foreign-trained doctors and “would never know what college they graduated from.”

In her mind, the problem is not a lack of medical students but a lack of residency programs to train them. The governor has proposed cutting $100 million for primary care residency training, and her organization, the California Academy of Family Physicians, is scrambling to get it replaced.

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Those who do win residency spots say it seems to matter less and less where they went to school as they climb up the medical training ladder. And it seems to matter not at all in clinics where patients are grateful for any medical care they receive.

“I have never heard a patient ask where a physician is trained,” said Carly Barruga, a third year medical student at nearby Loma Linda University who said she is getting excellent training in her rotation here from Caribbean-trained doctors like Dr. Tavinder Singh.

Singh, 30, is chief resident here and also a graduate of Ross. While he traces his interest in medicine to the open heart surgery his grandmother had when he was a boy, Singh didn’t apply to American medical schools because his MCATs weren’t as strong as they should have been. He didn’t want to wait a year to retake them.

“I had the goal in mind I was going to be a doctor,” said Singh, a California native. “Nothing was going to stop me.” He’s loved his residency, especially the chance to work in needy communities where medical zebras — unlikely and rare diagnoses — can be common. “You see chronic disease that have never been treated,” he said. “You see rare diseases like Zika.”

While Singh was once the one begging for a chance, the tables have turned. In a state hungry for family practice physicians, he’s now fielding numerous job offers.

‘Honestly, he’s great’

Bajwa’s future is bright as well.

For now, though, he’s just happy to be practicing medicine, thrilled to be delivering babies and focusing on preventative care. He loves helping patients like Wendy Ocampo, a 19-year-old with limb girdle muscular dystrophy. During an appointment this month, Ocampo came in to see Bajwa with respiratory symptoms.

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It was supposed to be a quick visit, but he ended up spending a half hour with her once he discovered bureaucratic hurdles had left her waiting seven months for the wheelchair she needs for her job and college. (Bajwa credits his clinic staff and nurses for working through lunch and juggling his schedule so he can offer longer visits.) Ocampo also hasn’t been able to get the physical therapy she needs for her ankle.

“It burns me up that these things are falling through the cracks,” said Bajwa, after taking a few minutes to compliment Ocampo’s “impressive new shoes” and ask if she was growing out her hair.

Though sick, Ocampo beamed. “Honestly, he’s great,” she said. “He calls me to check on me. I have, like, 30 doctors and none of them have ever done that.”

Correction: A previous version of this story misstated the population for Moreno Valley and the status of a proposed funding cut for residency training.

IMAGES:
Dr. Moazzum Bajwa meets with patient José Luis Garcia at the Riverside University Health System Medical Center.
Research bldg – Dell medical
Dr. Rina Seerke-Teper, a resident at Riverside University Health System.
Dr. Tarvinder Singh speaks with nurses between seeing patients.
The Riverside University Health System Medical Center in Moreno Valley, Calif.
Bajwa checks over a log documenting his patient’s blood sugar levels after meals.

For more on this story go to: https://www.statnews.com/2017/02/17/caribbean-medical-schools/