Offshore Medical Schools Are Buying Clinical Clerkships in U.S. Hospitals: The Problem and Potential Solutions.

U.S. medical education faces a threat from for-profit Caribbean medical schools which purchase clinical rotation slots for their students at U.S. hospitals. These offshore schools are monetizing a system that was previously characterized as a duty-the duty of the current generation of physicians to educate their successors. Offshore schools purchase clinical rotation slots using funds largely derived from federally subsidized student loans. This leads to pressure on U.S. schools to pay for clinical clerkships and is forcing some of them to find new clinical training sites.For-profit Caribbean schools largely escape the type of scrutiny that U.S. schools face from U.S. national accreditation organizations. They also enroll large classes of students with lower undergraduate GPAs and Medical College Admission Test scores than those of students at U.S. medical schools; their students take and pass Step 1 of the United States Medical Licensing Examination at a substantially lower rate than that of U.S. medical students; and their students match for residencies at a fraction of the rate of U.S. medical school graduates.Among the potential solutions proposed by the authors are passing laws to hold for-profit Caribbean schools to standards for board passage rates, placing restrictions on federal student loans, monitoring attrition rates, and denying offshore schools access to U.S. clinical training sites unless they meet accreditation standards equivalent to those of U.S. medical schools.

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska.

PURPOSE: There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. METHODS: A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. FINDINGS: Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. CONCLUSION: The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.

Workplace-based assessment for international medical graduates: at what cost?

OBJECTIVE: To estimate the cost of resources required to deliver a program to assess international medical graduates (IMGs) in Newcastle, Australia, known as the Workplace Based Assessment (WBA) Program. DESIGN AND SETTING: A costing study to identify and evaluate the resources required and the overheads of delivering the program for a cohort of 15 IMGs, based on costs in 2012. MAIN OUTCOME MEASURES: Labour-related costs. RESULTS: The total cost in 2012 for delivering the program to a typical cohort of 15 candidates was $243,384. This equated to an average of $16,226 per IMG. After allowing for the fees paid by IMGs, the WBA Program had a deficit of $153,384, or $10,226 per candidate, which represents the contribution made by the health system. CONCLUSION: The cost per candidate to the health system of this intensive WBA program for IMGs is small.

Private sector contributions and their effect on physician emigration in the developing world.

The contribution made by the private sector to health care in a low- or middle-income country may affect levels of physician emigration from that country. The increasing importance of the private sector in health care in the developing world has resulted in newfound academic interest in that sector's influences on many aspects of national health systems. The growth in physician emigration from the developing world has led to several attempts to identify both the factors that cause physicians to emigrate and the effects of physician emigration on primary care and population health in the countries that the physicians leave. When the relevant data on the emerging economies of Ghana, India and Peru were investigated, it appeared that the proportion of physicians participating in private health-care delivery, the percentage of health-care costs financed publicly and the amount of private health-care financing per capita were each inversely related to the level of physician expatriation. It therefore appears that private health-care delivery and financing may decrease physician emigration. There is clearly a need for similar research in other low- and middle-income countries, and for studies to see if, at the country level, temporal trends in the contribution made to health care by the private sector can be related to the corresponding trends in physician emigration. The ways in which private health care may be associated with access problems for the poor and therefore reduced equity also merit further investigation. The results should be of interest to policy-makers who aim to improve health systems worldwide.

La contribution apportée par le secteur privé aux soins de santé dans les pays à revenu faible ou intermédiaire peut modifier les taux d'émigration des médecins de ces pays. L'importance croissante du secteur privé dans les soins de santé dans les pays en voie de développement a suscité un regain d'intérêt académique dans les influences de ce secteur sur de nombreux aspects des systèmes de santé nationaux. La croissance de l'émigration des médecins des pays en voie de développement a conduit à plusieurs tentatives d'identifier à la fois les facteurs qui incitent les médecins à émigrer et les effets de l'émigration des médecins sur les soins primaires et la santé de la population dans les pays qu'ils quittent. Lorsque les données pertinentes sur les économies émergentes du Ghana, de l'Inde et du Pérou ont été étudiées, il est apparu que la proportion de médecins qui participent à la prestation des soins privés, le pourcentage de dépenses de santé financées publiquement et le montant du financement des soins de santé privés par habitant ont été chacun inversement proportionnels au taux d'expatriation des médecins. Ainsi, la prestation et le financement de soins de santé privés peuvent réduire l'émigration des médecins. Il existe clairement un besoin de recherches similaires dans d'autres pays à revenus faible et intermédiaire, ainsi que d'études pour voir si, au niveau du pays, les tendances temporelles de la contribution aux soins de santé par le secteur privé peuvent être liées aux tendances correspondantes de l'émigration des médecins. Les façons dont les soins de santé privés peuvent être associés à des problèmes d'accès pour les pauvres et, par conséquent l'équité réduite, méritent également une enquête plus approfondie. Les résultats devraient intéresser les décideurs politiques qui visent à améliorer les systèmes de santé à travers le monde.

La aportación del sector privado a la atención sanitaria en un país de ingresos medios o bajos puede repercutir en los índices de emigración de médicos de dicho país. La importancia creciente del sector privado en la atención sanitaria en los países en desarrollo ha suscitado un nuevo interés entre los académicos respecto a las influencias de dicho sector sobre muchos aspectos de los sistemas sanitarios nacionales. El aumento de la emigración de médicos procedentes de países en desarrollo ha conducido a varios intentos de identificar, por un lado, los factores implicados en la emigración de médicos y, por otro lado, los efectos de la emigración de médicos sobre la atención primaria y la salud de la población de los países de donde parten los médicos. Tras investigar la información pertinente sobre las economías emergentes de Ghana, India y Perú, se halló una relación inversa entre el índice de médicos expatriados y cada uno de los siguientes factores: la proporción de médicos que prestan atención sanitaria dentro del sector sanitario privado, el porcentaje de los costes sanitarios financiados con fondos públicos y la cuantía de la financiación per cápita del sector sanitario privado. Por consiguiente, parece ser que la prestación de servicios sanitarios por parte del sector privado y la financiación pueden reducir la emigración de médicos. Resulta evidente la necesidad de realizar investigaciones similares en otros países de renta media y baja, así como estudios que esclarezcan si, a escala nacional, se pueden vincular las tendencias temporales de la contribución por parte del sector privado con las correspondientes tendencias de la emigración de médicos. Cómo la sanidad privada puede relacionarse con los problemas de acceso para los pobres y, por lo tanto, con la reducción de la equidad, merece asimismo mayor investigación. Los resultados podrían ser de interés para los responsables políticos que aspiren a mejorar los sistemas sanitarios a escala mundial.

Cuba's Latin American Medical School: can socially-accountable medical education make a difference?

After graduating more than 12,000 doctors since its founding in 1999, Cuba's Latin American Medical School (ELAM, the Spanish acronym) is tackling one of its greatest challenges to date: how to track graduates from over 65 countries and measure their impact on health outcomes and policy in their local contexts?

Después de graduar a más de 12 000 médicos desde su fundación en 1999, la Escuela Latinoamericana de Medicina de Cuba (ELAM) está enfrentando uno de sus mayores desafíos hasta la fecha: ¿cómo realizar un seguimiento de los egresados, procedentes de más de 65 países, y medir su impacto sobre los resultados en materia de salud y las políticas de salud en sus contextos locales?

A proposal for enhancing the general surgical workforce and access to surgical care.

OBJECTIVE(S): The goals of this focused meeting were to verify and clarify the causes and extent of the general surgery (GS) workforce shortfalls. We also sought to define workable solutions within the existing framework of medical accreditation and certification. BACKGROUND: Numerous peer-reviewed and lay reports describe a current and worsening availability of GS services, affecting rural areas as well as large cities, academia, and the military. METHOD: Primary recommendations were broadly agreed upon by attendee surgeons who were selected from numerous different professional scenarios and included 2 nonmedical observers. RECOMMENDATIONS: (1) enhance the number of GS trainees and the breadth of training, (2) incorporate more flexibility and breadth in residency, (3) minimally invasive surgery should largely return to GS, (4) broader use of community hospitals in these efforts, (5) publicize loan forgiveness and improved visa status for international medical graduates going into GS, and (6) select candidates with a bias toward a general surgical career. CONCLUSION: These methods are promising approaches to this serious deficiency but will require regular reporting and publicity for the recording of actual increases in GS output.

What's wrong with the brain drain (?).

One of the characteristics of the relationship between the developed and developing worlds is the 'brain drain'- the phenomenon by which expertise moves towards richer countries, thereby condemning poorer countries to continued comparative and absolute poverty. It is tempting to see the phenomenon as a moral problem in its own right, such that there is a moral imperative to end it, that is separate from (and additional to) any moral imperative to relieve the burden of poverty. However, it is not clear why this should be so - why, that is, there is a moral reason to stem the flow of expertise in addition to seeking to improve welfare. In this paper, I examine three explanations of the putative moral aspect of the brain drain.

Adding insult to injury: the healthcare brain drain.

Recent reports published by the United Nations and the World Health Organization suggest that the brain drain of healthcare professionals from the developing to the developed world is decimating the provision of healthcare in poor countries. The migration of these key workers is driven by a combination of economic inequalities and the recruitment policies of governments in the rich world. This article assesses the impact of the healthcare brain drain and argues that wealthy countries have a moral obligation to reduce the flow of healthcare workers from the developing to the developed world.