A Caribbean remedy for financially sick N.Y. hospitals & the primary care shortage

By Oleg Pavlov, Ph.D. and Vladimir Gotlieb, M.D., M.B.A.

Vladimir Gotlieb

Vladimir Gotlieb

Graduates of offshore medical schools fill some of the most needed physician slots in New York State,and the monetary contributions of offshore schools are helping financially strapped teaching hospitals here. Yet, there is an effort being made to restrict these medical students — 90 percent Americans – from taking clerkships at state teaching hospitals. The vast majority of them will remain in the state when they are done with their training.

Oleg Pavlov

Oleg Pavlov

Facing offshore competition, local medical schools have been lobbying the state Board of Regents, which supervises all educational activities in New York, for tighter limits on the use of state teaching hospitals for clerkships by offshore medical students.

Evidence shows that foreign-trained doctors are competent and beneficial to the state’s health care delivery. According to a research brief, New York-s Primary Care Workforce, by New York’s Center for Health Workforce Studies, of the 87,000 physicians licensed in New York, 40 percent attended a foreign medical school.

The Association of American Medical Colleges reports that in 2011, there were 43,919 discrete applicants to U.S. medical schools, 56 percent of whom were rejected. Many of them opt to attend accredited for-profit medical schools in the Caribbean, which offer curriculum commensurate to their American counterparts.

The rigorous clinical training and the U.S. medical licensing process ensure no differences in clinical outcomes between foreign-trained and U.S. graduates, according to a 2010 study by John Norcini and others published in Health Affairs. Upon graduation, both U.S. and foreign medical students must undergo several years of intensive post-graduate medical training — commonly referred to as residency — at a U.S. teaching hospital. Both groups also must take a three-step United States Medical Licensing Examination (USMLE). Caribbean graduates earn high scores on these exams.

It is worth noting that while a quarter of U.S. graduates go into primary care, family practice and pediatrics, the majority of foreign-trained doctors chooses those fields. U.S. graduates tend to pick areas of specialization that have more prestige and higher pay. As state and federal reforms are likely to increase demand for primary care services, offshore students are well-positioned to meet the anticipated increase in demand. More than 90 percent of students at Ross University, St. George University, American University of the Caribbean School of Medicine, and Saba University School of Medicine — all among top schools — are Americans, and thus have no difficulty relating to their American patients, leading to high patient satisfaction rates.

The Association of American Medical Colleges recommended increasing medical school enrollment by 30 percent by 2015 in order to meet demand. Recently, eight new U.S. medical schools opened and 20 more are under development. Even so, enrollment is not expected to grow by more than 20 percent even after all new domestic medical schools open. The slow ramp-up is due to the high cost of adding medical school capacity in the U.S. Spared of many expenses of their U.S. counterparts, Caribbean medical universities have healthy profit margins, as high as 20 percent, that allow them quickly adjust capacity in response to demand.

There is also hospital economics to consider. After a recent review, the Brooklyn Health Systems Redesign Work Group concluded that Brooklyn’s 15 hospitals — situated in a borough of 2.5 million people — are in a difficult financial situation and are in a dire need of private investment. The Group concluded that six of those hospitals are especially vulnerable. By paying hospitals around $450 a week per trainee, Caribbean medical schools pour millions of dollars into financially distressed New York hospitals. St. George’s alone committed $100 million to New York public hospitals in 2008, when it signed a 10-year contract with the New York City Health and Hospitals Corp. for 11 New York hospitals to provide training for St. George’s students. The revenue from trainees to teaching hospitals is likely to become more critical as federal and state funding to hospitals is cut as a part of deficit reduction efforts.

The bottom line is that New York needs students from the Caribbean medical universities. Restricting their access to New York hospitals would be a mistake. Many of the students will stay in New York as physicians. As many studies have shown, foreign-trained doctors are knowledgeable and willing to work in specialties and geographic areas that are eschewed by U.S. graduates. It is also important to remember that the revenue that offshore medical trainees bring in helps keep struggling New York hospitals afloat.

Oleg V. Pavlov, Ph.D., is an associate Professor of Economics at the Healthcare Delivery Institute at Worcester Polytechnic Institute. His expertise is in multi-sector computational analysis that accounts for feedback and resistance to change often exhibited by complex systems.

Vladimir Gotlieb, M.D., M.B.A., Vladimir Gotlieb is the chief of hematology and oncology and a fellowship director at the Nassau University Medical Center. He is also an assistant clinical professor of medicine at Weill Cornell Medical College and associate clinical professor of medicine at New York College of Osteopathic Medicine.

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