Addressing the Ugly Truth about Caribbean Medical Schools: Why They're Not All the Same

Caribbean medical schools have had a complicated history. As schools of opportunity for the 60% of US medical school applicants that find themselves rejected at home, they are a vital and proven path to practicing medicine as a doctor in the US. Nearly 3,000 US IMGs (US citizens that earned their MD in the Caribbean or other parts of the world) match into residencies back home every year, all of whom weren’t even given a chance in the US school system.

With no shortage of qualified people wanting to be doctors, and a marked shortage of doctors, it’s no wonder the Caribbean became an alternate path to success. It's a way to address the needs of these future doctors' communities at home. It also underscores not just an economic demand, but an actual need, for Caribbean medical schools built to train US physicians.

Today, we’re going to go through some of the ways newer, smaller schools like Trinity are taking steps to change what it means to attend a medical school in the Caribbean, and a few things to look for when you’re considering your own options.

The past forty years of Caribbean schools training US doctors has shown us the right and wrong way to go about it. In many cases, the schools strive to duplicate the best-practices model of US schools to create a seamless transition for their graduates and ensure the material and teaching methods are up to par. That said, sometimes the other elements of a US medical education stop at the water’s edge. These shortcomings have historically come from two directions.

The first is the school’s ability or interest in meeting standards above and beyond the minimum required of them to maintain operation, e.g. US quality standards applied to the curriculum, student outcomes, etc. Fortunately, Caribbean medical schools that fail to meet this standard will be either improving or closing in masse starting next year, per the ECFMG 2024 rule (to which Trinity is fully compliant).

The second is schools investing in the number of students over the quality of students. It’s a simple idea, but the ripple effect it has on the quality of education, access to unique medical experiences, and quality of life is immeasurable.

‍We want to answer the question, what does it take to help students from failing or dropping out?

1) Students aren’t mashed into a lecture hall

As mentioned, traditionally, the commitment of Caribbean medical schools to model themselves on their US and Canadian counterparts falls short of one of the gold standards of academic practices: low enrollment leads to greater support, and greater support leads to greater student success.

Adding more faculty or having students interact with them in smaller groups doesn’t do the job, either. It’s not about simulating a more intimate environment, it’s about actually providing one.

A smaller medical school increases the amount of time students can spend in local medical facilities, it deepens the relationship with faculty, it lessens the burden on faculty office hours allowing for more direct work with students. It’s the reason both Trinity School of Medicine and US MD school enrollment are around 140-150 students per year.

Finally, it makes everyone a known quantity to each other, whether administration, staff, faculty or fellow students. Anyone that has ever attended both small and large schools knows the difference it can make to be not just recognized but understood by those around you. The benefits of limiting enrollment can’t be faked. Anyone considering their choices among the top Caribbean medical school should ask themselves: do they want their “homeroom” professor to know their name? Or do they want the radiology attending at the local teaching hospital to know them so well they ask how they did on their last exam?

‍2) The lectures are engaging, the faculty hold daily office hours for everyone, and students work together, freely sharing study guides and tutoring each other.

‍“Gunners need not apply.” Of all the factors directors consider when selecting a candidate for the residency match, class rank isn’t even in the top 5. The deciding factor in academic records when matching into even the most prestigious residencies always comes down to personal performance. To that end, grasping a topic well enough to effectively communicate it to a struggling classmate not only further cement the topic in your own brain, but it’s also arguably a practical test of your ability to convey information to a patient.

Caribbean medical schools need to embrace this as part of their admissions process and campus culture. Beyond just looking for students that will elevate these principles, it means hiring faculty that give their time and energy freely to their students. This manifests in how they present the material and their accessibility for additional guidance. It also means involving students in the curriculum design because, while they are still learning, they are as “in the weeds” as anyone can get with the material and can offer incredibly valuable, unique insights into the impact of decisions.

Finally, it means encouraging students to help each other and work together to rise above their individual and collective challenges to show what they’ve learned and match back home. After all, it’s about their dream, but it’s also about the patients they’ll collectively serve.

3) Student housing is private apartments with full kitchens with campus amenities like round-the-clock security and shuttle services.

There’s no denying that medical school, wherever you study, is a stressful life with an enormous amount of hard work. Schools need to be well equipped to provide a more than adequate amount of housing and that housing has to be of a quality that enhances a student’s success, not detracts from it. This doesn’t mean over-the-top amenities and resort living, but an opportunity to relax, privacy, a full kitchen, air conditioning, and high-speed internet. These are not difficult things to achieve, nor should they be considered anything but the bare minimum of what Caribbean medical school students should expect from their school.

Large medical schools that have overrun their capacity to comfortably house their students, relying on a ruthless attrition rate of 40% to “make room” in later terms, are not putting their students’ best interests at the center of their priorities. Putting student overflow in a hotel, on a cruise ship, or simply putting too many in a single living space is counterproductive to their success and no way for a school to operate. This is simply not a factor when small classes are a priority at the enrollment level.

4) The Top Criteria for matching is the USMLE Step-1 exam. A curriculum that incorporates structured and private time (supported by resources) is a vital part of medical school.

A commonality between US and Caribbean medical schools is that their curriculum is in a constant state of evolution. They need to do everything possible to teach students the latest and greatest understanding of the human body and the science that goes into regulating its functions. At the same time, medical schools need to ensure that their students are adequately prepared to shine in their licensing exams. These two major elements, while similar in goal, do not always have the same best methods of teaching. As a result, schools (operating under strict guidelines to not teach the test) must still ensure that time and resources are available to help students effectively understand the same material from two different perspectives. This means traditional lab and lecture as well as a practical study that is emphatically focused on the concepts and day-to-day life as a doctor. It also means using authorized preparation approaches (typically towards the end of basic sciences) to help students score as high as possible on the USMLE Step-1 exam, to not only ensure that students have a thorough working grasp of what they’ve learned, but to make sure they shine when it comes time to match (as always, Step-1 is the top criteria in matching).

Similarly, Caribbean medical schools must be transparent from day one about the importance of this exam, in demonstrating to students what scores are expected of them to have a strong residency match, and what their path will look like as an IMG. This can include an accessible, school-supported alumni network, extensive integrated USMLE preparation like Trinity’s fifth term, and additional instruction from faculty as well as outside resources like Kaplan. The licensing exams are not wolves students are thrown to, they are a metric by which a school should judge its own ability to navigate that tension between pure academic material and practical, legal recognition for the work the students have done and the benefit they can offer their future patients.

5) Students who struggle with self-study and teaching themselves the material are supported by their fellow students, faculty, and the curriculum infrastructure itself.

A school’s approach to its students needs to extend beyond the classroom, whether a domestic or an international medical school. Smaller schools are more equipped to handle this, for sure, but the size isn’t enough. The administration and faculty must still go that extra mile for their students. To that end, as most faculty are MDs, they understand the value of both preventative and interventionist approaches to challenges. Preventatively speaking, while Caribbean medical schools are schools of opportunity willing to “take a chance” on students that were shut out of the US MD system, they still have years of data and professional insight into who can be helped via a school’s unique approach to medical education. Students should be admitted with an admission department’s confidence first and foremost. Similarly, have programs in place ahead of time that help students move into the material in a way that makes the most sense for them. In Trinity’s case, we use the ILP program to great effect, here.

Interventionally, this means keeping a careful eye out for academic difficulty, and not using a low test score as an excuse to dismiss a student, but rather to offer them additional support. This can come in the form of student tutoring, extended faculty office hours, or even a formal approach like Trinity’s Academic Progress Committee. The APC meets regularly to evaluate and guide students that may be facing challenges in the material and coming up with new approaches to help them to develop better study habits or simply gain a firmer grasp of the material.

Attrition rates in the Caribbean of 40% to even a jaw-dropping 70% are simply not okay. A smaller school, with greater opportunity to support its students, will have a much lower attrition rate. Trinity’s, for example, is 12%. A high-volume school with a high attrition rate may overall produce more doctors, but the equation is not just about the most people practicing medicine, it's also about the opportunity extended to the students themselves. It's about their dreams, too. The cost of education is inevitable, and nearly everyone will have student loans to pay back. The more prepared they are with a fair borrowing program and the best support to help them succeed in the residency match, the better.

6) Emotional distress/burnout/sickness is addressed with mental health care and a foundational culture of support, not competition.

Medical school is incredibly demanding, no matter how thoughtfully designed a school’s culture and curriculum are. It’s intrinsic to the field of medicine, from the high stakes of decisions made in practice to the sheer volume of practical and theoretical material that students need to absorb. Most of what was covered above goes a long way to address unnecessary burnout endemic to large, legacy Caribbean schools. There’s still additional support schools can, and should offer to their students, though. In this case, it includes a culture among the administration, staff, and faculty that they are there for one purpose only: to make good on the promise of the institution to turn their students into doctors, that the belief in them extended through an admissions offer persists through the entire program of study. This means helping students adapt to unexpected trauma with understanding and encouragement, never telling people to give up or threatening dismissal without a heartfelt inquiry into a student’s well-being. More formally, it means addressing acute and chronic mental health issues with on-campus access to professional help and an openness that recognizes just how stressful medicine is, and that students are already experiencing that stress.

The era of “bury your feelings and pretend you’re fine” is coming to an end. As medical practitioners themselves, our faculty and our graduates know the benefit of good “mental health hygiene.” They know firsthand how appropriately processing stress and emotional discord leads to healthier selves and greater outcomes for themselves and, ultimately, the patients. That needs to be at top of mind for any medical school and extended to the students from day one.

It ultimately comes down to this. No matter how difficult a medical school experience may be, students who “make it” against overwhelming odds and unnecessarily difficult circumstances are always going to say it was worth it. They’re not the only students, though. A school with an annual intake of over 1,000 students that loses 40% of them to attrition is abandoning 400 students a year. That means for the students that survive at a large, legacy Caribbean school and declare it all worth it, they’re ignoring the twelve hundred of their colleagues who were let down and failed by their institution that prioritized volume over quality. A smaller school can, should, and in the case of Trinity, will offer more.

Caribbean schools are only improving in quality. Those that aren’t will be hard-pressed to remain in operation very soon thanks to very exciting and welcomed changes to the ECFMG and accreditation standards.

Caribbean schools like Trinity will always be about opportunity. And that will always mean taking an informed chance on students that were left out in the cold by the US and Canadian medical school systems. That said, for the community of schools as a whole, it’s time to leave behind the legacy of “more” and emphasize “better.” Better support, the better quality of life for the students will only mean better doctors.