The view that Caribbean schools' American students aren't as competent as their U.S.-trained counterparts weighs on St. George Chancellor Charles Modica, who helped found the for-profit school in the 1970s.
"It's like an anchor around your neck holding you back," Modica said. "We have students with 4.0 averages, students from the Ivy League. The truth is, U.S. schools don't have enough slots."
Big Caribbean players insist that the vast majority of their students are qualified to get into U.S. schools but the country simply doesn't provide enough student slots despite its growing healthcare needs.
They argue there are more than 60 medical schools in the Caribbean and the top ones sending students to the United States shouldn't be judged by general statistics for the whole group. In fact, only about a third of those Caribbean schools are approved by the Medical Board of California, meaning their students can apply for U.S. licenses.
But concerns about the quality of Caribbean-educated students aren't completely unsubstantiated.
A 2010 study published in the peer-reviewed journal Health Affairs examined mortality rates of nearly 250,000 hospitalizations.
The patients of foreign-born international medical graduates had the lowest patient death rates while U.S. citizens who study abroad had the highest rates -- a difference authors called "striking."
As part of an explanation, authors referred to other journal articles pointing out U.S.-citizen international graduates receive lower scores on parts of the licensing exam sequence, as well as lower ratings from training program directors.
The study also pointed out that being board certified in one's specialty -- such as cardiology or OB-GYN -- was associated with lower mortalities and shorter patient lengths-of-stays. International graduates who are U.S. citizens, especially those who attend medical school in the Caribbean, do not perform as well as U.S. or other international grads on their speciality board exams, the study noted.
A Californian analysis of the Caribbean schools with the most graduates in Kern County revealed board certification rates fell below the national average of about 80 to 85 percent, according to the American Board of Medical Specialities. About 71 percent of Ross grads and 69 percent of St. George's grads practicing in Kern County were board certified in their specialty, which is about the average for all Kern-based international medical graduates.
Eight out of the most common 10 U.S. schools with graduates in Kern County have higher rates, with certification ranging from80 to 100 percent -- figures on par or above national averages. The remaining two U.S. schools had rates similar to the Ross and St. George Caribbean schools.
Joseph Flaherty, the chancellor of Ross University, questioned whether that specialty certification step reflected more on the doctors' residency program, where they receive specific training in a discipline, than one's medical school. He also pointed out that younger doctors might still be getting certified, though to account for that The Californian excluded Kern Medical Center residents and recent residency graduates from its calculations.
The Caribbean quality question has prompted Congress to look into U.S. students attending foreign schools since some of those students qualify for federal loans.
"Little is known about IMGs with respect to how much they borrow overall or the outcome of their medical studies, leading some policy makers to question the federal return on investment in IMGs," according to a 2010 Government Accountability Office report.
That report found Americans who attended medical school abroad have as a group passed their medical licensing exam at lower rates over the past decade than their U.S.-educated counterparts, though the gap has narrowed in recent years.
The government report recommended more data collection on graduation rates, especially since so little is known about the foreign medical schools that attract U.S. students.
The mixed bag of quality and consistency is troubling, especially when for-profit schools like Ross take in more students than the entire UC medical school system, said Dr. Patrick Dowling, chairman of UCLA's Department of Family Medicine. Ross takes nearly 1,000 students a year.
"It's a question of the graduates they produce," Dowling said. "Not all the graduates are not as good, but they do have the highest rate of failure. A lot of people get in, how many get out?"