Push factor: shortages of physicians in the US and Canada

Offshore medical school websites prominently feature information regarding physician shortages in the US and Canada. It is implied or explicitly stated that students interested in studying medicine should study in the Caribbean in order to become qualified to address physician shortages at home. For example, the website for Ross University School of Medicine in Dominica states: “With the serious threat posed by a looming physician…shortage, Ross University’s mission of preparing highly trained doctors…has never been so critical…there will be a shortage of approximately 55,000 physicians in the US by 2020.” In general, websites position offshore medical schools as a way to alleviate physician shortages. For example, the American University of Antigua dedicates a webpage to physician shortages in the US, suggesting that the offshore industry is a promising solution: “Caribbean medical school graduates help fill the void of much needed primary care physicians… The realities of the physician shortage may seem bleak but by enrolling in a Caribbean medical school, you can be a part of the solution.” Claims of physician shortage can appear multiple times on a given website, including in mission statements, frequently asked questions, or dedicated webpages. Discussion of physician shortage was limited to the US and Canada; there is no mention of physician shortages in any of the Caribbean countries where offshore schools are located, nor other source countries for international students (e.g., India, Pakistan, or Nigeria).

Push factor: domestic schools are highly competitive

The competitive applicant pools for US and Canadian medical schools serve as a fundamental push factor behind the Caribbean’s offshore medical school industry. Statements positioning this competition as a rationale for seeking training abroad are common across the offshore medical school websites we reviewed. For example, the website for the Saint James School of Medicine, with campuses in St. Vincent and Anguilla, states:

There has been no significant increase in the intake of U.S. medical schools in decades, while the number of qualified candidates increases every year. As a result, some students with the potential to become excellent physicians miss out on a medical education.

Similarly, the The American University of Integrative Sciences St. Maarten School of Medicine states:

Statistics show that…85 out of 100 Canadian Pre-Med students do not gain admission into medical school in Canada. Many students give up on their dream of becoming a physician. But you don’t have to! There is a completely reasonable and proven alternative to American and Canadian medical schools.

These excerpts stress that offshore medical schools provide an opportunity for students who will otherwise “miss out” on medical education due to the competiveness of American and Canadian medical schools. Messages regarding competitive domestic medical school admissions are sometimes positioned alongside claims of physician shortages, suggesting an acknowledged relationship between these two push factors. For example, the website for the University of Medicine and Health Sciences in St. Kitts and Nevis states: “Canada faces a growing shortage of physicians…[yet] more than 30,000 Canadian [medical school] applications are denied annually. The University of Medicine and Health Sciences offers an alternative path to becoming a MD in Canada.”

Pull factor: financial benefits

We found that offshore medical school websites typically make three common financial claims regarding the benefits of attending such schools: (1) competitive or low tuition rates; (2) the potential for access to government-backed student loans from students’ home countries; and (3) the possibility of private financing options. Reported tuition fees vary considerably, ranging from under US$50,000 to over US$250,000 for a four-year degree. These fees do not include textbooks, required supplies, or room and board in the Caribbean during classroom learning nor abroad during clinical rotations. For schools with low reported tuition rates, emphasizing cost-savings compared to medical school at home or other offshore medical schools in the region is a clear means to compete for prospective students. For example, the website for Avalon University School of Medicine located in Curaçao states that “tuition fees are substantially lower than medical schools in Canada, [US] and other Caribbean medical schools” while the International University of the Health Sciences in St. Kitts and Nevis suggests that its low tuition rates “mean that you will not be burdened with large loans after graduation.”

The second financial claim references the opportunity to secure federal or provincially-backed student loans, for US and Canadian students respectively. For example, the website for Ross University in Dominica states:

The US Department of Education has certified [Ross University] as an eligible institution for Title IV Federal Direct Student Loans. [Ross University] students who qualify are eligible to receive US student loans in order to attend the university. [Ross University] is one of only four medical schools located in the Caribbean to earn this distinction.

At the time the data were collected, students enrolled in one of only four offshore medical schools were eligible to receive US federal student loans. Perhaps unsurprisingly, these four schools also have some of the highest reported tuition fees. That said, there are reports that some schools encourage students to enroll in an online master’s program while concurrently enrolled in the MD program, in order to access student loans from their home countries [21, 22]. With regard to Canadian students, many of the websites reviewed include content aimed at Canadians who are eligible for provincially-backed student loans, claiming that these students are able to bring their loans abroad to their institutions. For example, the College of Medicine and Health Sciences in St. Lucia states: “Canadian students who are interested in medical school may be able to receive Canadian Government financial support when attending the College of Medicine and Health Science, St. Lucia.”

The third type of financial claim made on offshore medical school websites that relates to the overall pull factor of ‘financial benefits’ pertains to the availability of private financing options as a reason to attend specific offshore medical schools. Private financing includes the potential for scholarships or awards and assistance in securing private loans. For example, the All American Institute for Medical Sciences in Jamaica states:

Students are eligible to apply for private educational loans from various private loan lenders. [Students] are eligible to apply on their own as long as they are credit worthy (no co-signer). It is highly recommended to apply with a co-signer. [The school’s] administration is committed to provide all the possible help from our end to facilitate the process for you.

Other forms of assistance include payment schemes, which may make the process of financing a medical education more accessible. For example, the American International School of Medicine in Guyana outlines their payment plan on their website: “Students can benefit from the AISM Payment Plan which requires an initial 100% payment on the first semester tuition which is paid one month prior to the commencement of the 1st semester.”

Pull Factor: geographic location and environment

Touristic discourse and images on offshore medical school websites are often deployed to highlight the beauty, if not even the exoticism, of the Caribbean region. Websites commonly use photo galleries with images of beaches and sunsets, alongside classrooms and laboratories, to convey a particular ‘Caribbean aesthetic.’ Accompanying text encouraged potential applicants to consider the promise of studying in a tropical setting. For example, the Caribbean Medical University School of Medicine, located in Curacao stated that its “campus provides both a beautiful and comfortable environment for new experiences.” Beyond characterizing the Caribbean as a beautiful place, some websites went as far as to suggest that the region is as a particularly attractive and pleasant environment in which to study medicine. As the American University of Antigua College of Medicine put it:

Location is surprisingly a lot more important than you think. When you’re studying medicine in Connecticut, you’re probably not thinking about brutal winters or having to dig your car out of the snow. At a Caribbean medical school, you’ll be studying in a tropical paradise and that means no worries about crazy weather fluctuations. Seriously, winter is the worst.

Websites are also quick to highlight close by tourist amenities and attractions. For example, the Saba University School of Medicine website states:

Saba is a beautiful country—its nickname is the “Unspoiled Queen”— and is also extremely safe. Discriminating tourists have long sought out Saba for its diving, its restaurants, charming inns and stunning Caribbean vistas. Because Saba is small and off the well-worn tourist track, it lacks many of the distractions that can interfere with studying. Yet there is plenty to do, from hiking to deep sea diving.

Interestingly, this excerpt paradoxically promotes the tourist activities available nearby, but uses the island’s lack of popularity among tourists as a point of competition, implying that students can be distracted at other offshore locations that have more prominent tourist sectors.

In addition to the potential of studying in the beauty of the Caribbean, the close geographic proximity of many offshore medical schools to the US and Canada is also an important aspect of the ‘geographic location and environment’ pull factor. For example, the website for St. Matthew’s University in Grand Cayman suggests potential flight plans:

Grand Cayman is not only a beautiful location…it is also one of the safest… Grand Cayman is less than an hour’s flight from Miami, and also has direct flights from Atlanta, Chicago, Dallas, Charlotte, Houston, New York, Tampa, Toronto, and other international locations.

These geographic pull factors present Caribbean offshore medical schools as a desirable and convenient location to study medicine, particular for US and Canadian students.

Pull factor: training quality and effectiveness

We found that offshore medical school websites typically make three distinct claims regarding the quality and effectiveness of their medical training: (1) the rate of graduates passing medical licensing exams on their first attempt; (2) the presence of faculty trained in the US and Canada; and (3) the use of small class sizes. Offshore medical school websites make extensive reference to the United States Medical Licensing Examination (USMLE) which medical graduates – including those who trained internationally – are required to pass to practice in the US. In Canada, international medical graduates must pass the Medical Council of Canada Evaluating Examination (MCCEE), although reference to this exam appears much less frequently than to the USMLE. Offshore websites typically make reference to both graduates’ first time USMLE pass rate and curriculum that will prepare students to pass the exam. Some offshore medical school websites, like that of St. George’s University in Grenada, put pass rates in context:

St. George’s 2012 performance on USMLE Step 1 was an improvement on the outstanding results from 2011, a year in which [the school’s] first-time test takers achieved a pass rate of 95% overall and 96% among those from the US and Canada. By contrast, the first-time taker pass rate for students at US and Canadian schools was 94% in 2011.

Reported first time USMLE pass rates vary greatly across schools. For example, Spartan Health Sciences University of Medicine in St. Lucia reports a 70% USMLE Step 1 pass rate, while the International University of the Health Sciences reports “Proven success: USMLE Step 1 pass rate of 87%.”

Many offshore medical schools claim to have curriculum designed to prepare students for the USMLE exam. For example, the Avalon University School of Medicine in Curaçao states that the school’s “program is designed for USMLE preparation and success. The curriculum is designed to incorporate USMLE style format questions in curriculum quizzes and exams.” While websites make explicit claims regarding preparing students for passing the USMLE, some schools offer claims defending their commitment to quality by explaining that they do not simply train students for success on licensing exams. For example, the Xavier University School of Medicine in Aruba prominently states that its “students typically score high on the USMLE, although we do not ‘teach for the test’.”

Claims regarding the presence of faculty trained in the US and Canada are prominent on offshore medical school websites, and they intend to demonstrate the high quality of education. For example, the website for the University of Medicine and Health Sciences in St. Kitts and Nevis that its “faculty is highly credentialed and recruited primarily from the United States. They love to teach and dedicate virtually 100% of their time to students.” Although the presence of faculty members trained in Canada or the US seems to be an indication of quality, almost none of the sites distinguish between the diverse roles played by the faculty members listed on their websites (e.g., board members, teaching faculty, clinical faculty abroad, guest lecturers, visiting scholars, former instructors, laboratory supervisors, etc.), nor the start and end dates of their affiliations. This is significant because faculty members reported to have been trained in Canada or the US and listed on offshore medical school websites may in fact be those who oversee clinical placements abroad rather than those who actually teach on-site at the schools.

Small class sizes are frequently brought forward as a benefit to attending some offshore medical schools, and are framed as an incentive for seeking medical education at a small institution abroad. Many offshore schools that claim to have small class sizes make comparisons to other institutions with larger student bodies. For example, the website for the American University of St. Vincent School of Medicine states:

With a small class size we are able to provide the much needed one on one attention to all the students. This makes for a more effective in-class, experience---you won’t find the anonymous, big lecture hall experience at [this school] the way you do at many schools.

Similarly, the Aureus University School of Medicine in Aruba website suggests that small class sizes enable “professors and staff…to provide you with a personalized educational experience as you work within your program.” These quotes clearly frame small class size as an indication of the potential for high-quality and effective training at offshore medical schools.

Pull factor: potential to practice in home country

As illustrated in the websites we reviewed, graduates’ abilities to return to Canada or the US to practice seems to be a central mandate of the offshore medical school industry. As such, claims regarding students’ abilities to return to their home countries for residency and to practice upon graduation are prolific and present across all offshore medical school websites. Schools generally reference students’ abilities to practice medicine in Canada or the US by making general statements about the experiences of former graduates. For example, the website for St. Matthew’s University in the Cayman Islands website states:

Our graduates have earned residencies and/or permanent licensure in more than 40 states in the U.S., Canada, and numerous other countries. Our students achieve exceptional scholastic success, with U.S. licensing examination pass rates comparable to U.S. schools and well above the average of other non-U.S. schools.

This quote is representative of the types of statements made across offshore medical school websites about the successes experienced by former graduates that are intended to attract future students. Such statements are noticeably absent from the sites of schools too young to have had a graduating class, in which case these schools focused on the potential for future graduates to ultimately practice abroad. In the US, several states, including California, Florida, and New York, have state-specific licensing requirements that do not include all offshore medical schools. As a result, the websites of offshore medical schools whose graduates cannot practice in all 50 states typically discussed practicing in the US in broad terms, while the few whose graduates are able to practice across the US made this explicitly clear on their websites. For example, the website for the American Global University School of Medicine in Belize, whose graduates are unable to practice in all 50 US states, asserts: “In general all our graduates are eligible for licensure in the United States. Each State in the four territories that make up the United States have individual State licensing requirements.” Meanwhile, the website for the American University of the Caribbean located in St. Maarten, whose graduates are approved to practice in all 50 states, proclaims: “Some states, such as New York, California, and Florida, require approval for international medical schools. [This school] is proud to be approved in each of these states.”

American and Canadian students are the clear focus of push and pull factors

It is clear from our findings that the push and pull factors presented on offshore medical school websites are oriented towards US and Canadian students. In fact, very few references were made to other origin countries from which students are known to leave to attend Caribbean offshore medical schools, such as India or Nigeria [23], on the websites we reviewed. Furthermore, despite the fact that these schools do attract small numbers of students from the Caribbean region [24], little effort was made to ‘speak to’ this local market on institutional websites. In other words, offshore medical school websites clearly identify Canadian and American students as those who are highly desirable and thus worthy of being marketed to via their websites. This was also reflected in the ubiquitous mentions of the USMLE across all websites, which is exclusively used in the US. Subtler references, such as featuring references to US and Canadian trained faculty, using the word ‘American’ or ‘America’ in the title (see Table 1), or comparing offshore medical school tuition fees to US tuition, are other ways in which offshore medical school websites signal to potential applicants that they are marketed towards students from these countries.

Because little research exists on offshore medical schools, it is difficult to say why offshore medical school advertisements are heavily directed at students from Canada and the US. Perhaps it is the fact that there is currently high demand for medical education among residents of these countries. Internationally-focused advertisement may also be a reflection of socioeconomic conditions in the Caribbean region, as high tuition fees and limited post-secondary opportunities can act as a barrier for local Caribbean students to attend medical school. It is also possible that the presence of students from the Global North is thought to lend credibility to these schools, as is the case with other globalizing phenomena such as in the practice of international physician voluntourism. International physician voluntourism often involves medical students from the Global North travelling to low-resource settings via ‘medical missions’ for clinical and research electives [25, 26]. As such, perhaps offshore medical schools similarly view students from these same Global North nations in high regard, and thus as a focus of online marketing. In other words, by marketing towards US and Canadian students, regardless of whether these students actually attend, offshore medical school websites signal a level of quality by association.

Push and pull factors draw connections to health systems elsewhere

By heavily marketing themselves to potential US and Canadian students, positioning themselves as a solution to perceived physician shortages in these countries, and training students to do well on the USMLE, offshore medical school websites suggest an association with these countries’ health systems despite whether any formal relationship actually exists. In this way, offshore medical schools work to actively situate themselves as an extension of the US and Canadian medical training and healthcare systems, rather than those of Caribbean the nations in which they are located. We contend intentional marketing and positioning of offshore medical schools as extensions to the US and Canadian medical training and healthcare systems sets these offshore Caribbean medical schools apart from other international medical schools that US and Canadian students have a long history of attending, such as those in Ireland, Australia, and Eastern Europe [1, 27]. Further to this, medical schools conventionally exist to train physicians to serve the local population [28]. Some have characterized this as a social contract that medical schools enter with the public, exchanging dollars and subsidies to support biomedical and graduate research for benefits to public health [29, 30]. Meanwhile, it is clear from the marketing on offshore medical school websites that physicians are being trained to treat patients elsewhere. This sets offshore medical schools apart from other regional Caribbean medical schools, such as the University of the West Indies, that exist to train physicians to serve the needs of local populations [30]. In contrast, offshore medical schools exist to serve patient populations outside the Caribbean region, and our analysis shows that they are framing themselves as being a continuous part of a medical training and ultimately healthcare system in operation elsewhere.

Offshore medical schools share many similarities with other health-related offshoring practices or products operating in the Caribbean, such as medical tourism (i.e., the private movement of patients across international borders to purchase medical care). Specifically, both of these health care-related offshoring practices raise questions about if and how local populations actually benefit from the presence of these industries in the region [31]. With regard to the parallel offshoring sector of medical tourism, much research has suggested that this practice may encourage health workers in destination countries to cater to foreign patients instead of serving a local population, thereby exacerbating local health system inequities [32–34]. Similarly, while it is known that many Caribbean countries are facing physician shortages [35, 36], the push and pull factors we identified on offshore medical school websites do not reference that these schools are involved in addressing this local health human resources challenge by training physicians for local practice. Nor do they promote the potential for international graduates to aid in addressing this regional problem, while simultaneously encouraging US and Canadian students to train at these institutions to address physician shortages at home. Beyond not contributing to the supply of health workers in the Caribbean, these schools may actually exacerbate shortages when local physicians take up positions as lecturers at these schools or local students opt to enroll in order to ultimately establish a career in the US or elsewhere.

Push and pull factors reveal competition between schools

Attempts to attract US and Canadian students via promotional websites, as well as intentionally positioning offshore medical schools as extensions to the US and Canadian healthcare systems, have produced an environment in which offshore medical schools seem to actively compete for students and tuition dollars, both against schools in the US and Canada and other offshore medical schools in the Caribbean. These competitive discourses, which as we discussed in the findings come through in these schools’ websites, convey a sense of the entrepreneurial nature of this offshoring industry and reveal that offshore medical schools are, in fact, businesses selling a product. This analysis shows that offshore medical schools, as illustrated through their websites, explicitly compete for students on a variety of points that are embedded in the push and pull factors they advertise. One clearly marketed point of competition is tuition fees, which are sometimes directly compared against competing institutions. For example, the Avalon University School of Medicine located in Curaçao states “tuition fees are substantially lower than medical schools in Canada, [US] and other Caribbean medical schools.” Tuition would certainly be of importance to prospective students, and research has established that such fees are critical to decision-making among university students [37–39], particularly in contexts in which offshore medical students are unable to secure government-backed student loans.

Discussions of first-time USMLE pass rates on offshore medical school websites reveal that this is another source of competition for students between schools, and especially those training students wanting to practice in the US. As we showed in the findings, many schools with strong pass rates promote this on their websites as a way to pull students to their campuses. However, what this rate does not show is that some Caribbean offshore medical schools reportedly allow only a subset of their students (i.e., high-achieving students) to write the USMLE Step 1 exam in order to maintain high first-time pass rates [21]. Such a practice demonstrates the importance of this comparative metric among offshore medical schools in attracting future students – a metric that has been criticized elsewhere for its inability to actually predict residents’ performance outside the exam [40, 41].

What push and pull factors reveal about What’s not being advertised

We believe the push and pull factor lens we have used in the current analysis is useful for helping to understand offshore medical schools and the students who choose to attend them because it broadly encourages consideration of social, economic, and political conditions in both origin and destination countries that help us to understand why someone, including a student seeking medical training abroad, may choose to migrate [14, 42]. As Kline notes, the push–pull framework also maintains that, in addition to will, facilitating forces, such as the absence of legal constraints, must be in operation in order to enable movement [14]. Here lies a notable omission from offshore medical school websites: while no legal constraints impeded the migration of US and Canadian students to the Caribbean to study medicine, there are actually many de facto constraints that may impact their attempts to return home to practice. Unsurprisingly, mentions of these constraints are largely unaccounted for in the websites these schools use to market their training to international students and the push and pull factors we have identified here.

US and Canadian students who study abroad return as international medical graduates must compete for necessary residency placements alongside other international medical graduates [11, 43]. Currently, there are far fewer available postgraduate residency placements than there are applicants in both countries, especially in Canada [42]. For example, CaRMS reports that in 2013, only 499 international medical graduates matched to residency positions in Canada, a fraction of the 2962 international medical graduates that participated in the residency match [44]. Furthermore, 2013 was the first year “in CaRMS history in which more IMGs (2,962) participated in the match than [Canadian medical graduates] (2,837)” ([44], p.2). While it is unclear what proportion of these international medical graduates were Canadian or US citizens, it follows that as studying medicine abroad becomes increasingly popular the competition for these limited residency placements will also increase. As such, many offshore medical school graduates will be unmatched with residency placements and will not fulfill the promises laid out by these schools’ marketing messages, which suggest they can practice in their home countries and assist with lessening health worker shortages.

The possibility of American and Canadian students attending offshore medical school with the intent of practicing in one’s home country, and being told by these schools’ promotional websites that doing so is realistic, only to find out that residency placements are very limited in availability is particularly concerning given the high financial burden of attending an offshore medical school and reports of some offshore medical school graduates being left with unmanageable student debts [21]. For example, Canadians who studied medicine abroad had a median debt of CAD$160,000, compared to CAD$71,000 median debt held by graduates of domestic medical schools [45]. This represents a significant financial hardship without strong job prospects. As such, return migration after finishing medical school abroad, as suggested by pull factors advertised on Caribbean offshore medical school websites, may not be as unconstrained as it appears. Indeed, the journey to return home and practice after graduation is uncertain for many [46].

Future research directions

This analysis brings forward new understanding into how offshore medical schools market themselves to prospective medical students using a ‘push’ and ‘pull’ framework commonly used in migration and mobility research [12]. We consider institutional websites to be a valuable source for understanding how offshore medical schools operate because post-secondary websites are known to greatly influence students’ choice of any particular institution [19], are a primary means to market to prospective students directly, and are readily accessible. There is ample opportunity for meaningful future research on this important topic, including using other sources of data. We outline some of these opportunities in this sub-section.

An important question for future research related to the current analysis is: what push and pull factors are brought forward by other marketing mediums, such as promotional posters or flyers, social media, and in-person information sessions? If meaningful differences are found in the push and pull factors used across different types of marketing materials, then these differences warrant examination and explanation. Drawing connections between the multiple marketing mediums used by offshore medical schools can assist in uncovering the complex networks at work to recruit potential students. Another available source of data about offshore medical schools are the readily accessible online blogs written by past, current, and future students. These blogs may reveal new insights into the push and pull factors identified here, including how offshore medical school students navigate the realities of these factors (e.g., studying in a tourist setting; coping with the practicalities of receiving student loans from home that can be used abroad; engaging in discussion with other students about the hopes and realities of being able to practice at home upon graduation). This analysis brings up wider, pressing research questions that relate to issues we have touched upon in the discussion. We believe that important questions include: what economic- and health-related impacts (both positive and negative) do offshore medical schools have on their Caribbean host countries; both from an ethical and practical perspective, should students’ home countries be playing any role in tracking students attending offshore medical schools, in providing them with financial support, and/or with reserving residency placements specifically for them; and what impacts do increasing numbers of offshore medical students actually have on the US and Canadian physician workforce, including addressing maldistribution.