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Earlier this year, Gov. Andrew Cuomo announced that the Sophie Davis School of 

Biomedical Education would expand into the CUNY School ofMedicine and become 

New York's newest four-year medical program. It will affiliate with St. Barnabas Health 

Center in the Bronx, a teaching hospital in one ofthe poorest and sickest counties in the 

United States. 

St. Barnabas is an excellent place for medical school students to observe doctors in 

action, and offers students a chance to interact with patients who are in poorer health; 

face greater health challenges because ofincome, race and environment, and who are 

more likely to require regular care that the average New Yorker. 

One reason Sophie Davis administrators sought the relationship with St. Barnabas is 

that it was becoming harder for the school to secure clinical rotation spots for its 

students. 

Most medical schools have two years of classroom education followed by two years of 

clinical rotation in a hospital where students trail doctors and observe procedures. But 

competition from foreign medical schools, which often pay hospitals in New York and around the country for rotation spots 

in their hospitals, has been a challenge for New York medical schools for years. 

Though international medical school deans say MORE ON POLITICO 

there are enough rotation spots - also known • POLITICO New York Politics Digest: 

as clinical clerkships - for everyone, the Jan.4,2016 

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for SUNY workers 

The Association ofAmerican Medical Colleges 

published a survey showing the number of 

schools reporting problems because of 

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' doubled between 2009 and 2013. 

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New York State has thousands of international PLAYBO$K students training at its hospitals. 

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Corporation signed a ten-year contract worth 

DELIVERED DAILY TO YOUR !NBOX  up to $100 million from St. George's University 

in Grenada. The deal gave St. George exclusive 

rights among international schools to HHC facilities, though about halfofHHC's 

clinical clerkship spots remain for U.S. students. So far, the perennially cash-strapped 

HHC has received $37 million from St. George's. (The HHC board member who 

proposed the contract, Dr. Daniel Ricciardi, was also on St. George's faculty. He resigned 

from HHC after the deal became public.) 

The same year, American University ofthe Caribbean (AUC) on St. Maarten reached a 

10-year, $19 million deal with Nassau University Medical Center. 

Ross University has agreements with ten teaching hospitals in New York, including St. 

John's in Far Rockaway, New York Methodist in Brooklyn and Jamaica Hospital. 

In total, the New York State Education Department has approved 14 international 

medical schools, ofwhich seven are located in the Caribbean. 

Caribbean schools look to the U.S. because they don't have the quantity or quality of 

hospitals that a state like New York or California has. The agreements also serve as a 

recruiting tool, enticing U.S. students who believe they need only spend two years 

abroad before they can train in the same hospitals where they might become residents. 

"The students being trained in New York are being booted from where they had always 

gone," said Barbara Ellman, associate director for policy for the Medical Society ofthe 

State ofNew York. "The deans are getting calls from the hospitals telling them they can 

no longer send them there." 

The problem offinding clinical rotation spots had become so severe that state officials 

felt Sophie Davis either needed to find a hospital partner or shut down its program. 

And while Sophie Davis is now secure, many other medical schools in New York face a 

similar challenge, they say. 

"I have MDs spending enormous amounts oftime trying to find hospitals that will let 

students do rotations," said Dr. Edward Halperin, chancellor and CEO ofNew York 

Medical College. "I thoughtthe problems I'd be facing at this stage ofmy career would 

be how we use computers in the classroom, and instead I'm spending time worried I 

can't get enough clinical spots." 

Some medical schools share a governance structure with a hospital (Icahn School of 

Medicine and Mount Sinai; NYU, Columbia and New York-Presbyterian) and that allows 

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Med students squeezed amid wider competition for rotation space IPOLITICO Page 3 of7 

them a preferred place to send students during their third and fourth years ofmedical 

school. 

But many medical schools do not have their own hospital and are completely reliant on 

affiliation agreements with hospitals for rotation spots. That makes the competition all 

the more fierce. 

Einstein used to send students to Bronx-Lebanon hospital until an offshore medical 

school bought their slots. 

"The result was, we had to go hunting for an alternative option," said Dr. Michael 

Reichgott, the former senior associate dean for Graduate Medical Affairs at Einstein. 

Competition doesn't only come from overseas. New York schools do this to one another 

as well. When Mount Sinai purchased Continuum, Columbia students were told they 

could no longer have clinical rotation spots at St. Luke's Hospital. 

It isn't just about inconvenience or competition, Reichgott said. One large concern the 

New York deans have is that the quality of education at offshore schools is not on par 

with what local schools provide. Specifically, they worry that the clinical rotations are 

not supervised with the same rigor. 

"There's no curriculum," he said. "No relationship between the [hospital] faculty and 

the school. Does anyone take attendance? Does anyone know if [ the students] are 

present?" 

New York State's Department ofEducation, which oversees medical education, is 

currently engaged in a review of all international medical schools that have been 

approved or are seeking approval to send students to New York State to complete longterm clinical clerkships. 

The review began in 2014, Reichgott said. There is no timetable set for its completion, 

and its findings have not been made public. 

That's left both the New York medical schools and the international schools in limbo. 

Neal Simon, the president of the American University ofAntigua (AUA), said he had an 

agreement with a hospital in Westchester County, but the New York education 

department told him that he was not allowed to send his students there. He was told 

there was a moratorium. 

Charles Modica, chancellor ofSt. George's University in Grenada, said he was told by 

the state education department that his school was not allowed to expand its footprint 

in New York, meaning no new contracts could be signed with teaching hospitals. 

"We are operating as if there is a moratorium," he said. 

The Association ofMedical Schools New York, which represents 16 medical schools, 

believes that existing clerkships may be renewed in New York but that foreign medical 

schools may not expand, though they are not aware of any regulation to that effect. 

The state's education department did not respond to requests for clarification. 

Despite, or perhaps because of, the opacity ofthe current rules, the local medical 

schools and Caribbean schools are each lobbying the state, making their case for why 

New York does or does not need more foreign medical students. 

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The New York school officials argue that paying for clerkships offers foreign schools a 

competitive advantage. They say that it keeps their students out, and allows for a lower 

quality student, who was likely rejected by U.S. schools, to attend. 

There is also a fear, which the international schools believe is unfounded, that New 

York's teaching hospitals will begin to demand cash payments from local schools as 

well, something New York deans say they cannot afford. 

"To match them we'd have to raise our tuition significantly," said Robert Goldberg, 

executive dean ofthe Touro College ofOsteopathic Medicine. "$20,400 per student in 

their clinical years." 

The Caribbean schools counter that there is plenty ofroom for their students and that 

no U.S. student is pushed out because ofthem, that their cash helps pay for clerkships 

that benefit everyone, and that their students are more likely to enter primary care and 

work in lower-income neighborhoods. 

"We're not taking any spots from their programs," Modica said. "In any case where they 

want spots, the hospital would ask our school to cut down on our students and allow a 

greater number ofU.S. students." 

Further, the international deans argue, they are supplying a physician pipeline at a time 

when most experts agree the nation, which has an aging population, is expecting a 

doctor shortage. 

"The international medical school agreement with St. George's complements the valued 

relationships we have with U.S. based medical schools and supports the public 

healthcare system's mission in a number ofways," said Ana Marengo, a spokeswoman 

for HHC. "HHC values the diversity of our workforce and St. George's is a good pipeline 

of qualified physicians of diverse backgrounds, cultures, languages, who are also more 

likely to practice at HHC." 

N 

ew York is one ofseveral states where foreign medical schools are looking to send their 

students. California, Nevada, Florida and New Jersey have all seen a growing influx as 

well, and medical school deans across the country have voiced their concerns and 

lobbied their legislators with various levels ofsuccess. 

The state ofTexas recently passed a law prohibiting its state board of education from 

issuing certificates of authority to foreign schools offering professional degrees, ending 

any chance for overseas students to head to Texas for their clinical rotations. 

Texas legislators said the foreign medical schools had an unfair advantage when 

competing with some ofthe state's public universities. 

"[As] has been experienced in New York and New Jersey, these foreign, for-profit 

institutions charge a large amount oftuition and can afford to reimburse hospitals at a 

greater amount than state schools," the authors of the Texas legislation wrote. "As a 

result, when clinical rotation slots are in demand, hospitals contract with partners that 

offer the greatest reimbursement." 

The issue has gained attention from federal lawmakers as well. 

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The bipartisan pairs ofU.S. Senators Dick Durbin ofIllinois and Bill Cassidy of 

Louisiana and Representatives Elijah Cummings ofMaryland and Michael Burgess of 

) Texas have introduced The Foreign Medical School Accountability Fairness Act, which 

• ·· requires at least 60 percent ofthe enrollment to be non-U.S. citizens or permanent 

residents, and 75 percent ofstudents to pass the U.S. Medical Licensing Exam if the 

schools accept students loans backed by U.S. taxpayers. 

The idea behind that legislation is to limit the ability offor-profit schools to capitalize 

on desperate students who have no hope ofbecoming residents but still take out 

hundreds ofthousands ofdollars in loans to finance their dreams. 

Many schools do prey on students like that, Modica acknowledged, but there are 

Caribbean schools that have high standards as well. 

He says the fact that roughly half ofinternational medical school students are not 

accepted to a U.S. residency program, compared with only 6 percent ofU.S. medical 

students who fail to match, merely highlights the need for more residency slots. It's a 

point that has also been argued by the Association ofAmerican Medical Colleges and 

the American Academy ofFamily Physicians. 

Most students who attend a Caribbean school failed to enroll in a U.S. school either 

because their college grades were subpar, their MCAT score was lacking or because they 

decided to become doctors later than the average student. 

Both are imperfect indicators of candidates' potential, Modica says, pointing to the 

growth of allopathic and osteopathic schools that are filling their classrooms with many 

ofthe students that are turned down by MD programs. 

"The arguments ofthose who maybe in organized medicine that the quality is not ofthe 

level it should be could easily be used against some ofthe U.S. based schools and, 

therefore, should be viewed as to what it really is - and that is nonsense," he said. "We 

believe ofthe 20,000 students unable to obtain admission, that three-quarters ofthem 

are easily qualified." 

Halperin and Goldberg also make a moral argument. 

"Medical education is a privilege, not a business," Halperin said. "What do I say to 

[hospital] administrators? You should be ashamed ofyourself. You shouldn't be able to 

sleep at night." 

It isn't so simple. Hospitals, particularly community hospitals, public hospitals and 

hospitals in poorer neighborhoods are strapped for cash. Margins are as tight as they've 

ever been, and a few million dollars can go a long way. 

That's one reason states across the nation are reluctant to curtail the practice. Instead, 

there are efforts to standardize the curriculum so that state education departments and 

U.S. hospitals can say, with some degree of certainty, what kind of student they are 

receiving. 

The New York education department's efforts may not be public but they are rigorous, 

international deans say. 

The Educational Commission for Foreign Medical Graduates (ECFMG) announced that 

beginning in 2023, physicians applying for ECFMG Certification, a prerequisite to 

entering the U.S. health care system, will be required to graduate from a medical school 

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that has been accredited using criteria comparable to those established for U.S. medical 

schools by the LCME. 

That should help allay concerns over quality but it will do little to address the fear over 

competition, which is only likely to become more intense. Already, more than one 

quarter ofphysicians in the United States trained at a medical school outside the 

country and that number is expected to grow. 

And both the New York schools and the Caribbean schools are looking to expand their 

class size even as hospitals in New York and across the country close, consolidate and 

see declining inpatient rates, which only serves to exacerbate the problem offinding 

clinical clerkship spots. 

At the same time, there has been a large increase in the number of students attending 

allopathic schools across the country, which have grown by about 30 percent over the 

last decade. Those students need clerkship spots as well. 

Between 2006 and 2014, 17 new U.S. medical schools opened up, and enrollment at the 

nation's medical schools reached an all-time high last fall, with 20,343 students 

entering medical school in 2014. And there are now 66 medical schools in the 

Caribbean, up from 54 in 2007. 

Something has got to give, Halperin believes. 

"The gravy train is going to end I think eventually," he said. "This is not sustainable." 

This article appears in the new issue of POLITICO New York magazine. 

MORE: ALBANY CITY HALL HEAL TH CARE MAGAZINE HEALTH AND HOSPITALS COl<PORATION HEAL fH 

CARE NEW YORK MEDICAL. COLLEGE Nl"W YORK STATE EDUCATION DEPARTME'NT POLITICO NEW YORK 

MAGAZINE: FALL 2015 

Iii Author: DAN GOLDBERG 

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POLITICO New York Politics Digest: Jan. 4, 2016 

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