Aug 012014
 

newyorktimes

By ANEMONA HARTOCOLLIS

JULY 31, 2014

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St. George’s University School of Medicine, on Grenada’s southwest corner, has been the training ground for some 7,700 doctors licensed to practice in the United States. Credit Joshua Yetman/St. George’s University

Sitting around an outdoor table at the Red Crab, a restaurant on the tropical island of Grenada festooned with palm trees and fiery bougainvillea, a dozen aspiring doctors bashfully conceded that they had been, at best, near misses when it came to getting into medical school in the United States.

Many of them had not earned A’s in college physics and organic chemistry. Many had tried other careers first — among them were a talent scout, a ballerina, a pianist and an engineer. And some had come tantalizingly close to the prize. The dancer, Corinne Vidulich, described the agony of being on the waiting list at Albert Einstein College of Medicine in the Bronx for nine months. “They let me know the week before the term started that I didn’t get in,” said Ms. Vidulich, wearing the telltale all-black of a New Yorker. “It was crushing.”

Now they were all students at St. George’s University School of Medicine, one of dozens of medical schools that have sprung up in the Caribbean over the last four decades to catch the overflow of Americans who cannot find a medical school in their home country willing to take them, who for years have contended with the stigma of not being good enough.

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A pathology tutorial at St. George’s. Credit Luvnish Karnani for The New York Times

St. George’s is their second chance.

Stephen Franco’s lax study habits had earned him C’s in freshman biology and chemistry at Binghamton University, not good enough for the medical schools he applied to in the United States. St. George’s offered him conditional admission, a four-month preview of courses, money back guaranteed if he didn’t pass. He passed. But in his first semester, he regularly woke his mother late at night to tell her he was terrified and might have to drop out. “If you want to be a science teacher, that’s O.K., too,” she would say to console him. Now 24 and entering his third year as an honors student, he is hoping to take over his father’s internal medicine practice in Brooklyn.

Ms. Vidulich is more than 10 years older than Mr. Franco. Her dancer’s frame is growing soft around the edges — she hasn’t performed for a decade — but she speaks as if projecting to the back row. As a teenager, she studied on scholarship at the Joffrey Ballet School, but a foot injury sidelined her to dancing “The Nutcracker” with provincial companies. Realizing she would never fulfill her dream to join American Ballet Theater, she stopped at age 25.

But she had another interest. An uncle dying of AIDS spent his last days living with her family, “so I had a very early obsession with viruses.” She enrolled at Hunter College, majored in biology and tied with two other students as valedictorian of the class of 2009, with a 3.98 grade-point average. “I thought I was a rock star,” she said. She applied to about 25 medical schools, and “basically I was wait-listed everywhere.” She blames her age, 33 at the time, and her abysmal score on the verbal section of the entrance exam. “The interviewer at Einstein asked me, ‘Are you a native English speaker?’ because my score was so low.”

From the beginning, her Hunter pre-med adviser had told students to apply to Caribbean safety schools. “I refused because I was too cool,” Ms. Vidulich said. “It was kind of like with American Ballet Theater. I didn’t want to leave New York. I felt like I deserved the best. I was humbled.”

One evening, a customer came into the Brooklyn bar where Ms. Vidulich worked holding a newspaper clipping describing a scholarship program between St. George’s and the New York City Health and Hospitals Corporation, which runs 11 public hospitals. Ms. Vidulich won a full scholarship in return for agreeing to work for four years in a city hospital serving the poor.

St. George’s had another asset. It has tried to ensure the success of its students by paying hospitals to take them for their third- and fourth-year clinical rotations, which lead to those all-important residencies. It has entered into a $100 million, 10-year contract with the corporation for 600 spots. Usually rotations are free, causing other medical schools to grumble that they are being squeezed out. Last academic year, St. George’s placed 2,326 students in rotations in 98 American cities.

Ms. Vidulich is about to return home for her rotations. She no longer scoffs at Caribbean schools.

“Now I am truly proud of it,” she said. “We wanted it more than anything.”

For decades, American medical schools have vilified their Caribbean counterparts for providing a substandard education for students who were weak to begin with. But some schools may be proving the medical establishment wrong.

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Many students in the Caribbean did not get into U.S. medical schools. Corinne Vidulich was on the waiting list at Albert Einstein College of Medicine in the Bronx for nine months. “It was crushing,” she said. Credit Luvnish Karnani for The New York Times

Thousands of Caribbean graduates — roughly 7,700 from St. George’s alone — are licensed to practice in the United States. They have seeded hospitals and physician practices across the country and are in a position to be mentors to the next generation of Caribbean attendees.

“I have sons and daughters of graduates coming down now,” said Charles R. Modica, St. George’s chancellor.

There are more than 70 medical schools across the Caribbean, about half of them catering to Americans. A handful — including St. George’s, Saba University, Ross University in Dominica and American University of the Caribbean in St. Maarten, all of which are for-profit — have qualified for federal financial aid programs by demonstrating that their standards are comparable to those in the United States. And they report that high numbers of their test-takers — 95 percent or more — pass the United States Medical Licensing Exam Step 1, a basic science test.

But quality is all over the map in the Caribbean. A 2008 study in the journal Academic Medicine looked at 14 schools and found that the first-time pass rate on the exam ranged from 19 percent to 84 percent. Countries whose schools performed lowest were the Cayman Islands, Haiti, Cuba, Aruba, Dominican Republic, Antigua and Barbuda and, the lowest, St. Lucia, which hosted four medical schools at the time. High performers were in Jamaica, Barbados, Dominica and, the highest, Grenada.

Still, the ultimate test is whether students meet the criteria to be eligible for residencies back home, the ticket to becoming a practicing physician. Between 1980 and 2000 at the 12 biggest Caribbean schools, the percentage of graduates who fulfilled basic requirements ranged from 28 percent to 86 percent, according to another study. This year only 53 percent of United States citizens who attended foreign medical schools (most of them in the Caribbean) were placed through the National Resident Matching Program, compared with 94 percent of students from U.S. schools.

The schools say that the match rate does not tell the full story, that many of their students find residencies outside the process, by going to hospitals directly. John R. Boulet, a co-author of both studies and a researcher at the Foundation for Advancement of International Medical Education and Research, said that more than 90 percent of American graduates of foreign medical schools who have passed the requisite tests find a residency position. “Through persistence they eventually get in,” he said.

Like St. George’s, Ross and American University have leveraged residencies by paying hospitals to accept their students for clinical clerkships in their third and fourth years of medical school. Those students get to know the residency directors, who may then favor them for residency positions.

At St. George’s, which has the largest network of clerkships, only 43 of its 672 American students applying for a residency last year did not receive one within a year. Students from foreign medical schools, however, are less likely to receive the most prestigious residencies, and many end up in rural or poor urban hospitals, and in less lucrative primary care specialties.

For those who do not obtain residencies, the economic consequences can be devastating. Caribbean students are typically saddled with higher debt than medical students in the United States, in part because tuition is generally higher.

Tuition and fees at St. George’s come to $246,400 for four years, compared with $190,500 at Albert Einstein, the highly selective school Ms. Vidulich had hoped to attend. Average federal loan debt in 2012 was $220,000 for St. George’s students, $191,500 for Ross’s and $234,600 for American University’s, according to the Education Department. But their federal loan default rates — 1 percent or less — are about the same as for graduates in the United States, whose debt was closer to $170,000.

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In a class covering chest and lung examinations, Sevwandi De Silva, left, practices on Jahan Manjur, a fellow student at St. George’s. Credit Luvnish Karnani for The New York Times

With no centralized databank of information, or even a single accrediting body, it’s hard for consumers to judge the schools.

“Like anything else, you pays your money and you takes your chances,” Dr. Boulet said. “It would be nice to have, like, a U.S. News & World Report on foreign medical schools. It doesn’t exist.”

The only schools for which statistical comparisons can be easily made are those participating in financial aid programs with the Department of Education, which posts debt burden, exam passage rates and completion rates of American students. The statistics show that about half of Ross’s 2012 graduates failed to graduate on time; at American University it was almost a third, and at St. George’s just under a fifth. But the federal methodology doesn’t follow a cohort, or take into account those who leave a program. If it did, results would look much different. Of students who entered St. George’s program in fall 2009, 10 percent dropped out, 1 percent transferred and 65 percent made it to graduation in four years. Twenty percent more took five years and an additional 4 percent took six or more years.

All three of these schools have tutoring and remedial programs to help students adjust to the workload and improve their study habits.

Admission criteria at Caribbean schools are also more lenient, even at the top schools. The average undergraduate G.P.A. at St. George’s is 3.4, compared with 3.69 stateside. The average score on the M.C.A.T. is 26, compared with 31 for schools in the United States. St. George’s accepts about one of four applicants.

College advisers are wary. Julie Chanatry, president of the National Association of Advisors for the Health Professions, and director of premedical advising at Colgate University, worries about the low-tier Caribbean schools where the profit-oriented business model is to “reject no one,” regardless of a person’s chances of practicing medicine. She advises students to try an osteopathic school or to strengthen their résumés with a post-baccalaureate degree and extracurricular experiences. She might also suggest becoming a nurse practitioner or a physician assistant. But this is not what they want to hear.

“Most of the kids that don’t get in are pretty darn good, too,” Ms. Chanatry said, “and that’s why we have those schools in the Caribbean that say, ‘Hey, these kids are still good doctors.’ ”

St. George’s University School of Medicine is a sprawling collection of peach-colored neocolonial buildings with orange-tiled roofs perched on a hill. Fishing boats bob in a small turquoise cove below the administrative buildings. In a historical footnote, it is here that, in 1983, the United States led an invasion after a military coup ousted government leaders, setting the nation’s eyes on the evacuation of St. George’s students.

Today, young people stroll the grounds in shorts and backpacks, play basketball and do homework at picnic tables.The campus is so self-sufficient that it has its own water desalinization plant. And the facilities are “state of the art,” or so Dr. Eric Manheimer, an emissary from New York’s public hospital system, reported back to his bosses after visiting in 2007.

The campus may be grand, but the opportunities to practice medicine in Grenada are, at best, old-fashioned, at worst, primitive. Near the end of their second year, students go once a week for 10 weeks to Grenada General Hospital, 200 beds housed in a small cluster of yellow buildings just below a stone fort.

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Grenada General Hospital, where students get a close-up look at doctoring, is decidedly low-tech. But simplicity has its benefits. “The patients, they’re so patient with us,” says one student. Credit Luvnish Karnani for The New York Times

The hospital is as quaint as a picture postcard. The wards are segregated by sex. Inside the entrance, a sign reads “Female Medical.” Metal-frame beds are separated by flowered cloth curtains. Ceiling fans spin languidly overhead, and a cool breeze wafts in from Carenage harbor below. The sheets are mismatched — some patients have brought theirs from home. Most striking, though, is the tranquillity. The ubiquitous monitors, the beeping and blinking lights of American hospitals, are not there. But there is an in-house neurosurgeon for head injuries, said Dr. Dolland Noel, an associate dean, adding with a sly smile: “We are the only trauma center. We are the Level 1, 2 and 3.”

Uncontrolled diabetes is a typical complaint. One day last spring, a clutch of interns could be found examining a diabetic woman with an abscess on her foot. Working at Grenada General has taught them medicine at the most primal level, students say.

“There may not be enough insulin bags, but it’s very patient-oriented,” Ervand Kristosturyan, a pianist from Washington, D.C., said. He recalled seeing a woman who had been losing weight and feeling weak. When she was found to have metastatic cancer, he realized that she was a textbook case. “I thought, God, this is what cancer looks like.”

Chelsey Burke, who rejected her family’s dry cleaning business in favor of St. George’s, thinks the simplicity has its benefits. “The patients, they’re so patient with us,” she said. “They let us examine them and ask them questions for, like, two hours.”

Clinical skills are a big part of the curriculum. The department chairman, Dr. Winston Mitchell, is a retired surgeon from SUNY Downstate Medical Center in New York. A slim bantam of a man with white hair and walnut skin, he returned to his homeland to cultivate organic cherry, passion fruit, mango and lime trees. But after Hurricane Ivan decimated his farm in 2004, he turned to teaching.

In one lesson, he taught a small group of students how to conduct a chest examination, a skill they will need to demonstrate on their licensing exam. As he watched, a student playing the doctor asked the student pretending to be the patient to whisper “99,” and listened to the vibration in his chest. “This is what you need to practice when you go to the middle of Timbuktu and you don’t have an X-ray,” Dr. Mitchell told them.

The largest academic department, with 80 staff and faculty members, is anatomical sciences, headed by Dr. Marios Loukas, a Greek national who trained in Poland and taught anatomy at Harvard Medical School. Wearing Hawaiian-print scrubs, he hovered protectively over a female cadaver as students teased out the sciatic nerve. Dr. Loukas tries to keep them from becoming inured to death by holding a ceremony of prayer, poetry and music at the end of the course, to honor the people who have donated their bodies.

He finds St. George’s students less entitled than others he has taught. “We don’t see attitude,” Dr. Loukas said. Some would say their mood reflects their circumstances, but he disagrees. “It’s very hard to change the character of someone.”

Chancellor Modica, who founded the university with three investors, understands his students’ predicament firsthand. He wanted to be a doctor but was forced to attend medical school in Spain when the home schools he applied to rejected him. He dropped out after a year, and published a slender guide to getting into foreign medical schools. It sold for $8.95, and helped pay his way through law school. When he hawked the book, the most common question was how to find a foreign medical school in an English-speaking country.

Sensing an opportunity, Mr. Modica sent proposals to “every English-speaking country in the world.” Grenada bit, he says, in the euphoria of having just attained its independence from Britain.

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The price of services is posted at Grenada General (in local currency). Credit Luvnish Karnani for The New York Times

One of his first hires was C.V. Rao, a Ph.D. who is now dean of students, through a classified ad for an anatomy teacher. They met in New York. “He offered me the job on the spot,” Dr. Rao recalled. “He had a contract and an airplane ticket. He was very upfront about it. He said, ‘If you don’t like it, I have a return ticket.’ He didn’t paint a rosy picture of this place.”

When Dr. Rao interviews prospective students, he tries to make sure they will not have a chip on their shoulder. “I ask them, ‘How will you take it when somebody says you are one of the Caribbean medical school students?’ Most of them say, ‘I want to be as good or better than them.’ That’s the spirit.”

Dr. Rao, a dapper man with a droopy mustache, keeps thumb shots of all the students tacked to a wall in his office. “These are mug shots,” he said in all seriousness. If a student shows disrespect to a worker or groundskeeper or maid, the student can be identified.

It’s a sign of the social divide here.

Pretty houses on stilts decorate the hillsides, and luxury hotels in groomed gardens flank white-sand beaches. The university dominates the island, and is deeply entwined in the local economy, vying with tourism and remittances from Grenadians working abroad as a leading source of gross domestic product.

But the campus is a gated community. A short stroll outside the automatic gates finds children in raggedy clothing and, on one evening, a little girl squatting to urinate in a drainage ditch. Students have been warned not to walk alone at night because of the danger of being mugged at machete point, or worse. Shuttle buses take students to off-campus housing and to the supermarket.

Immersion in island life breeds a certain cynicism.

The IGA market that caters to foreigners is overpriced and sometimes runs out of milk and vegetables. “Tomatoes are more expensive than beer,” Iana Gueorguieva, an Ohioan who just finished her first year, said disgustedly.

“Cigarettes are cheap,” said her friend, Rachel Lewis, from Colorado.

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“You have to have a burning, unending desire, to put yourself through something like this,” says Rachel Lewis, an Amherst graduate attending St. George’s. Credit Luvnish Karnani for The New York Times

“Rum is cheaper than cereal,” Ms. Gueorguieva said.

Rent near campus is high; Ms. Lewis pays $950 for a studio. But those who live farther away, in the same buildings as the locals, pay less. Mr. Franco’s rent is $300 a month, including $18 a week for mandatory maid service, which apartments routinely come with because labor is so cheap.

The culture shock can be hard.

“You kind of have to survive,” Ms. Vidulich said. “You’re so far from everyone and you’re dealing with a lot of island antics.” For instance, the Internet goes down when demand is high, typically during finals week. “Our first term, we didn’t have anatomy books for a while. They were lost on a boat in St. Lucia. They gave us PDFs. It was kind of a weird adjustment.”

That first year was an academic hazing. By her third term, Ms. Vidulich said, her ability to master the material had grown so much that it seemed like “a joke” by comparison.

Many students hole up in the library and never explore the island. Some find more balance. Ms. Gueorguieva dashes around on a blue Hussar scooter, and proudly wears a scar from a fall. She parties at Bananas, a bar that lives up to its name. She is proud of having eaten iguana at a local restaurant, though once was enough. She has rented a catamaran and hiked to the Seven Sisters falls. She is active in the Women in Medicine club, performing community service like helping pregnant girls continue their education.

They are here, the students say, because American medical schools do not see beyond G.P.A.s and test scores to underlying attributes like intellectual curiosity. To get into one, they say, it is better to go to an easy college and not risk mistakes.

Ms. Lewis, poised, athletic and casual in a “Love” pendant and flip-flops, graduated from Amherst College as a political science major. Sipping Stag beer one evening with two friends at Options, an outdoor food court near campus, she said that she originally resisted going into medicine, like her father, and wanted to be a lawyer, like her mother. But she changed her mind after working as a paralegal after college.

To meet the science requirements, she took a premedical post-baccalaureate program at New York University, where she was a B student, and then at the University of Colorado, Denver, where she got straight A’s. She applied to more than a dozen medical schools. None of the admissions officers seemed to care very much that she had gone to a highly selective college, she said, or had been captain of the lacrosse team or had worked at a clinic for homeless families.

She was invited for only two interviews, at George Washington University and St. George’s, which she applied to after noticing an ad on the New York City subway. St. George’s was her only acceptance.

“If you get B’s in half your coursework, like me, that’s an easy way for them to cut out all those people,” she said. “There’s just not enough spots.” Now 29, she has finished her first semester and is “incredibly grateful” for the chance to become a doctor. “You have to have a burning, unending desire, to put yourself through something like this,” she said.

Ms. Lewis would like to be an eye surgeon like her father, but her ambition is tempered by the reality that the most competitive specialties are often closed to Caribbean graduates. Still, she believes that once she has clawed her way through and is a full-fledged doctor, no one will care where she went to medical school. It will have been just one step along the road. She will hang her diploma next to her residency, perhaps a fellowship and board certification. But, she says, she will not hide it.

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