For profit medicine: the good, the bad, and the ugly faces of offshore medical education

Ghebre, Yohannes T.

doi:10.3389/feduc.2025.1647568

PERSPECTIVE article

Front. Educ., 10 September 2025

Sec. Higher Education

Volume 10 - 2025 | https://doi.org/10.3389/feduc.2025.1647568

For profit medicine: the good, the bad, and the ugly faces of offshore medical education

Yohannes T. Ghebre^1,2,3^*

¹Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
²Mays Cancer Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
³Department of Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, United States

In recent decades, a large number of students from the United States, Canada, and, to a lesser extent, other countries have pursued medical education at offshore for-profit medical schools, primarily in the Caribbean. Although these schools offer an alternative path into the medical profession for students who may not be admitted to domestic medical schools, this pathway is confounded by risks and controversies. This article explores the good, the bad, and the ugly faces of the for-profit offshore medical school model, while drawing distinctions between regional and for-profit institutions and highlighting regulatory, legal, and socioeconomic differences across Caribbean jurisdictions.

The good: access, opportunity, and global exposure

One of the primary incentives of offshore medical schools is increased access to medical education. In this regard, Caribbean schools provide a viable option for many academically qualified students including these who are unable to secure admission to medical schools in the United States or Canada. For example, in the United States, less than 50% of the applicants are accepted into allopathic (MD) schools annually (Association of American Medical Colleges, 2023). In addition, osteopathic (DO) schools accept about 30% of the total number of applicants (Schulze, 2025). Historically, students who were unable to gain admission into either of these programs including career changers, older applicants and graduates of foreign schools have considered offshore medical schools as the logical next steps to earn their medical degree.

Importantly, not all Caribbean medical schools operate with the same mission or structure. The University of the West Indies (UWI) Faculty of Medical Sciences, with campuses in Jamaica, Barbados, and Trinidad and Tobago, is a regional public institution that primarily serves Caribbean nationals, although its graduates can pursue licensure in the UK, Canada, and other Commonwealth countries (Eckhert, 2010). In contrast, for-profit schools such as those in Saint Kitts and Nevis, Grenada, Aruba, and Antigua and Barbuda primarily target international students, especially from the United States and Canada, and operate with distinct commercial models (Neilson, 2019).

Another key example is the Latin American School of Medicine (ELAM) in Cuba—a government-funded institution that trains students from Latin America, Africa, and North America to serve in underserved global communities. These models stand in stark contrast to for-profit offshore medical schools, both in mission and operation (Shankar et al., 2017).

Many for-profit Caribbean schools do offer significant opportunities to their students to enrich their clinical experience including exposure to tropical diseases, which are prevalent in the region, and access to underserved patient population. Larger institutions such as St. George's University, and American University of the Caribbean also have strong affiliations with several hospitals in the United States, Canada and the United Kingdom allowing their students to complete clinical rotations and residency in modern healthcare systems (St. George's University, 2024a; AUC Clinical Science Program, 2001). In turn, these and other offshore trained physicians immensely contribute to the healthcare system of the Western countries. In the United States, for example, many of the graduates enter primary care specialties including family medicine, internal medicine, and pediatrics and often practice in medically underserved areas of the country contributing significantly to healthcare access in rural and inner-city communities. According to the National Resident Matching Program (NRMP), there were 3,110 United States citizens who earned their medical degree abroad (referred to as “US International medical Graduates” or “US IMGs”) and successfully matched in the 2025 residency match in the United States (Bell, 2025). Data from the Association of American Medical Colleges (AAMC) also shows that nearly 25% of the United States physician workforce are IMGs (U.S. Physician Workforce Data Dashboard, n.d.).

The aforementioned strengths and additional opportunities such as global health outlook by training in the Caribbean and the United States, Canada and/or the United Kingdom may provide a broader understanding of cross-cultural competency and international health policy.

The bad: lower residency match rate, quality of education, attrition rate, and financial risk

It is safe to assume that the students who join offshore medical schools are not as competitive as the students who train in the United States. This is in part reflected by the low admission standards and difficulty in admission to US residency programs in general and competitive specialties in particular (Goldberg, 2021). For example, the 2025 NRMP residency match data demonstrates that only 67.8% of US IMGs matched into first-year residency positions, compared to 93.5% of US MD seniors (Bell, 2025). Although this gap might partly reflect educational differences, it also raises questions about institutional support, exam preparation, access to competitive specialties, accreditation, and oversight. In the Caribbean, medical schools are generally accredited by recognized bodies such as the Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP) (Caribbean Accreditation Authority for Education in Medicine and Other Health Professions, 2023; Dottin, 2021). However, several medical schools in the region, such as All Saints University School of Medicine in the Dominica and Spartan Health Sciences University in Saint Lucia, have faced criticism for operating without full accreditation from CAAM-HP, despite enrolling international students. Publicly available reports from CAAM-HP have cited deficiencies in faculty qualifications, clinical training facilities, and governance structures at these institutions (Spartan Health Sciences University School of Medicine, 2024). Moreover, schools located in smaller jurisdictions like Sint Eustatius (e.g., the University of Sint Eustatius School of Medicine) or Montserrat (e.g., University of Science, Arts and Technology) may operate under limited or loosely enforced regulatory frameworks. In these areas, ministries of education or health may lack the infrastructure or autonomy to monitor private offshore institutions effectively, resulting in inconsistent implementation of academic and safety standards (Groenewoud, 2024). Below is a summary of schools that were either denied CAAM-HP accreditation or the accreditation status has been voluntarily or involuntarily withdrawn (Caribbean Accreditation Authority for Education in Medicine and Other Health Professions, 2023) (Table 1).

Table 1

Table 1. Summary of CAAM-HP accreditation status of major offshore medical schools by year.

This variability in the regulation of the quality of education delivered is often exacerbated by jurisdictional differences. For instance, Barbados hosts both the UWI Faculty of Medicine and Ross University School of Medicine, highlighting the coexistence of public and for-profit institutions within a single territory. Further complicating the regulatory landscape is that some Caribbean jurisdictions are territories of European nations—such as Aruba and Sint Maarten (Netherlands), Guadeloupe (France), and the Cayman Islands (UK)—and thus operate under distinct legal and administrative frameworks (Groenewoud, 2024).

Taken together, these operational and regulatory deficiencies are likely to culminate into inconsistent clinical training and inadequate supervision of students leading to less competitive graduates who may only be confined to lower-demand specialties and geographic areas.

Another major concern associated with offshore medical education is the high attrition rate. Surprisingly, some Caribbean schools allegedly have attrition rates as high as 40–70% (Trinity School of Medicine, n.d.). By contrast, medical schools in the United States have attrition rates of about 3% and this has been consistent for over 20 years (Graduation Rates and Attrition Rates of U.S. Medical Students, n.d.). Although there might be academic and non-academic reasons for the high attrition rate in the Caribbean schools, the lower admission standards, the inadequate structural and functional support, and the cost of education are strong indicators for the possibility that academic failure, inadequate student support and financial hardship are important contributors of the low graduation rates. For those who persist and graduate, passing the United States Medical Licensing Examination (USMLE) remains a critical challenge. For example, first-time pass rates for the Step 1 exam can range from over 90% at the top schools to below 70% at others. However, some of the schools have a reputation for holding back a large number of their students from sitting for the Step 1 and/or Step 2 exams and therefore the reported pass rates and/or residency placement rates may consequently be inflated to attract more students. The lack of transparency in reporting pass rates for licensing exams further obscures the real outcomes for prospective students (Van Zanten and Boulet, 2010).

Finally, the financial burden from attending offshore medical schools is significant. For example, the 2024/25 basic tuition and fee alone for one of the Caribbean medical schools is shown to be over $360,000 (St. George's University, 2024b). When added to the living expenses and cost of flights the students need to take to visit their home countries, the financial burden could be substantial. To make matters worse, the students at many of these schools are ineligible for federal financial aid unless the school meets stringent requirements such as the United States Title IV eligibility criteria (Title IV Participation Application, n.d.). Practically speaking, high-interest private loans are the mainstream, and perhaps the only option for these students. Taken together, the uncertain prospects of graduating or securing a residency position creates a high-risk investment that requires careful consideration.

The ugly: ethical concerns, mental health issues, and systemic exploitation

The most worrisome aspect of for-profit offshore medical education is the ethical component. Almost all of the for-profit schools operate with a business model that prioritizes revenue over educational outcomes (Goldberg, 2021). This profit-first, corporate mentality is in part reflected by the high acceptance rates, high tuition, and aggressive marketing activities in the United States and Canada. In some cases, students are admitted without adequate evaluation of their academic records, preparedness, and/or support systems. As a result, many of the students are either expelled during the course of their studies, held back from sitting for licensure exams, have trouble landing residencies and/or employment. Nonetheless, misleading claims about graduation rates, USMLE pass rates, and residency placement rates may cause prospective applicants and admitted students to have unrealistic expectations. In this regard, some institutions are alleged to only report data for students who graduate and apply for residency, excluding those who drop out or fail licensing exams (Morgan et al., 2017; Shankar et al., 2015).

Mental health issue among students who attend offshore medical schools is also another prominent concern. Students who leave their families behind in their home countries to attend school in the Caribbean and other islands are expected to experience isolation, anxiety, and depression. These challenges compounded with the heavy debt that they incur, the stigma of being an IMG and the uncertainty of returning home to limited career options may cause or exacerbate mental health disorders. It is also questionable whether many of the offshore medical schools have adequate and sufficiently resourced student support services including student wellness and mental health care (Ngorosha, 2024).

Moreover, there does not appear to be a well-defined and uniform regulatory oversight that governs the offshore medical schools. Schools in different jurisdictions may not adhere to common educational standards. In addition, some schools are known to operate in jurisdictions with minimal monitoring by the governments or educational authorities of the host countries. In the Caribbean, for example, not all schools are accredited by the CAAM-HP; the equivalent of the Liaison Committee on Medical Education (LCME) in the United States and Canada (Spartan Health Sciences University School of Medicine, 2024; Wikipedia Contributors, 2025) (Table 1). In other words, it is conceivable that the schools that do not meet the accreditation criteria fail to meet the functional and structural standards for medical education. When they discover this or when their school loses its accreditation while studying, some students make an expensive and arduous decision to transfer to other offshore medical schools. It is also the case that students who enroll in unaccredited schools may not qualify for federal student loans through the US Department of Education, participate in the USMLE process for licensing and/or cleared by the Accreditation Council for Graduate Medical Education (ACGME) for residency. For example, students who graduated from unaccredited institutions such as the International University of the Health Sciences in Basseterre (Saint Kitts) have reported being ineligible for US residency applications or US federal student loan programs. These limitations severely constrain their ability to practice medicine in North America, despite completing a degree program (Wikipedia Contributors, 2025).

Conclusion

For profit, offshore medical schools occupy a controversial, double-edged sword, reputation in global medical education. They offer an alternate path to aspiring physicians and supplement critical shortage of medical professionals in the United States and Canada. However, their contribution is tampered by the significant academic, financial, ethical, accreditation, and oversight risks described above. This problem is exacerbated by the diverse legal and socioeconomic landscapes of Caribbean jurisdictions and necessitates a nuanced understanding. Importantly, distinguishing between public and for-profit models, recognizing jurisdictional differences, and focusing on specific, understudied challenges such as institutional transparency or regulatory accountability may provide a more constructive path forward.

Although the expansion and increasing popularity of the DO schools in the United States (The Osteopathic Medical Profession, 2023) has created additional opportunities for American students to earn their medical degree within the country, a large number of students still attend offshore medical schools in the hope of returning home to practice medicine. Therefore, it is essential to ensure that this alternative pathway produces competitive and ethically trained professionals. In this regard, future research should be directed toward mapping out the accreditation or regulatory status of offshore medical schools in general and these operating outside the oversight of CAAM-HP or the World Federation for Medical Education. Doing so would allow students, families, and policymakers to make informed decisions that distinguish accredited programs from those that fall below international standards. With more transparency and oversight, these institutions could better fulfill their mission of training competent physicians.

In the meantime, the United States—including accrediting authorities, policymakers and other stakeholders, should seek greater transparency, regulatory oversight, and support mechanisms to protect its citizens and uphold the standards of medical education.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author contributions

YG: Writing – original draft, Writing – review & editing.

Funding

The author declares that no financial support was received for the research and/or publication of this article.

Acknowledgments

The author would like to thank the Department of Radiation Oncology at The University of Texas Health Science Center at San Antonio for overall support.

Conflict of interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

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References

Association of American Medical Colleges (2023). Table A-23: MCAT and GPA Grid for Applicants and Acceptees to U.S. MD-Granting Medical Schools, 2021–2022 through 2023–2024. Washington, DC: Association of American Medical Colleges.