Cross-Border Accreditation in the Caribbean: A Potential Threat to the Integrity of the Accreditation Process?

Introduction

As Caribbean schools continue to expand in number, so does the proportion of International Medical Graduates (IMGs) who aspire to enter postgraduate training programs and gain subsequent licensure in the United States (US).¹ According to the World Directory of Medical Schools, approximately 80 medical schools are in the Caribbean.² If we include the Caribbean Community and Common Market (CARICOM) nations not in the Caribbean, the number rises to over 100.² Accreditation bodies recognized by the World Federation for Medical Education (WFME) are a requirement for the recognized accreditation policy by the Educational Commission for Foreign Medical Graduates (ECFMG). This requirement is a crucial factor that significantly influences the educational procedures of Caribbean medical schools.³ Recognized accreditation means an external quality assurance organization has reviewed and recognized the medical school’s accrediting agency. This quality assurance or recognition organization has been reviewed and approved by ECFMG, as outlined in its recognition policy.⁴ Only medical schools accredited by an agency that an organization approved by ECFMG recognizes will satisfy the requirements of the Recognized Accreditation Policy.⁴

Accreditation has been shown to change educational processes at medical schools and improve student performance expectations.^1,3 Besides varying educational levels, different countries, and institutions of higher learning in the Caribbean have different pass rates for the United States Medical Licensing Exam (USMLE) and certification rates for ECFMG.⁵ A 10-year study conducted by Tackett et al observed medical school accreditation factors associated with certification by ECFMG.⁶ Tackett et al study found there to be an association between accreditation and successful ECFMG certification, as well as an increase in performance on the USMLE Step Exams 1, 2 CK, and 2 CS compared to those who attended schools that were not accredited.⁶ When considering medical schools worldwide, including the Caribbean, Tackett et al study showed a constant correlation between graduating from an accredited school and success in receiving ECFMG certification. The year of first accreditation and ECFMG certification rates have raised the possibility that accreditation may have a dose-dependent effect.⁶ The longer commitment to the ongoing process of quality improvement may explain this. This association may be used as a sign for institutions that regard accreditation as a chance to advance their programs, draw in students of higher caliber, or look for support in efforts to raise standards.⁶ Furthermore, there was a strong association between accreditation status and ECFMG certification rates, indicating that program quality, especially regarding the performance of students, may benefit from active participation in quality improvement activities.⁶ Accreditation systems are commonly seen as a technique to guarantee the caliber of medical education and students’ performance afterward. This highlights the need for accreditation because it can harmonize and authenticate educational initiatives.

Van Zanten et al emphasized that the proliferation of medical schools in the Caribbean region is mandating the requirement of an accreditation system in the Caribbean to ensure the quality of medical programs and quality control activities. Four accrediting bodies are recognized by WFME that can conduct accreditation site visits in the Caribbean and CARICOM countries.³ These include the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP), the Accreditation Commission on Colleges of Medicine (ACCM),³ the Accreditation Organization of the Netherlands and Flanders (NVAO), and the Grenadian Medical and Dental Council (GMDC).⁷ NVAO has accredited only one medical school in the Caribbean, Saba University School of Medicine. The literature review for NVAO is limited as its ability to accredit medical schools in the Caribbean is restricted to the islands of Saba and Bonaire.

Medical schools must comply with the pre-publicized standards of the accreditation bodies to attain the accreditation. The importance of advocating to maintain standards when it comes to accreditation should be emphasized as concerns regarding this process arise. A significant concern that has become increasingly apparent is the growing number of WFME “recognized” organizations operating in the Caribbean and the expanding practice of cross-border accreditation by some accreditation bodies such as the Agency for Accreditation of Educational Programs and Organizations (AAEPO) and the Independent Agency for Accreditation and Rating (IAAR). As a result, the Caribbean has been placed in an untenable situation due to the accrediting market. This circumstance seriously threatens the integrity of educational programs in the Caribbean rather than improving the standard of medical education. Due to WFME’s lack of a defined policy for cross-border accreditation, accrediting agencies have been able to take advantage of the situation. This, in turn, has resulted in laxer review procedures and lower standards, which displays a process that is not interested in preserving or enhancing educational quality in the Caribbean.

Immediate attention is needed to address this issue of quality assurance and cross-border accreditation. Clear guidelines should be set for recognizing agencies and strict control systems to avoid conflicts of interest and maintain credibility and education caliber. The rise of “recognized” agencies by WFME and cross-border accreditation are cause for serious concern and subsequent ECFMG intervention. This manuscript aims to address the concerns raised because of cross-border accreditation in the Caribbean region and how to mitigate the risk.

Discussion

Caribbean Graduates Contribution to the United States Workforce

The demand for medical services, particularly primary care, is anticipated to increase because of recent federal healthcare changes, and the US is predicted to experience a shortage of primary care physicians.⁸ The demand for primary care physicians will further be exacerbated by demographic trends such as population expansion, aging populations, and increased diseases linked to modern lifestyles.⁹ Over 50% of individuals who graduated from medical schools in the Caribbean region are actively engaged in primary care roles in the United States.⁹ At least one-third of U.S.-born International Medical Graduates (IMGs) completed their education at offshore Caribbean medical schools.

The number of Caribbean-International Medical Graduates(C-IMGs) who have received certification from ECFMG has steadily increased over time.¹⁰ These universities mostly enroll American citizens and international students who desire to study abroad and become licensed in the US.⁹ According to the available data, the average performance of C-IMGs on the USMLE has also been shown to have improved.¹⁰ These physicians are a potentially useful asset for offering primary care services, but they frequently need to be recognized in the American healthcare system.⁹ According to the 2022 Federation of State Medical Boards Census of Licensed Physicians in the United States, India (21%) is the country with the highest percentage of licensed IMGs in the US, followed by the Caribbean (20%), Pakistan (6%), the Philippines (5%), and Mexico (4%). Notably, the number of credentialed doctors from Caribbean medical schools has increased by 115% since 2010.¹¹ Caribbean doctors who are US citizens have also experienced significant growth in this category, increasing from 48% in 2010 to 67% in 2022.¹¹

Considering their current and potential contributions to the workforce, particularly in high-demand primary care specialties, IMGs have historically played a significant role in the US workforce. Given the consistent number of applicants for ECFMG certification in recent years, they will continue to do so in the future.

Examining the Impact of Accreditation on Academic Performances Among IMGs

Evidence that accreditation improves the quality of medical education is limited. However, a study conducted by van Zanten (2015), as well as a more recent study by Tackett et al, focused on factors associated with the accreditation of medical education programs about students’ performances of graduates from foreign medical schools who voluntarily applied for certification from ECFMG.^1,6 Van Zanten (2015) identified positive associations between the accreditation of medical schools and the performance of International Medical Graduates (IMGs) seeking ECFMG certification. In the Tackett et al study, it was discovered that accreditation had a positive link with performance on board examinations among the self-selected population who took tests during the study period. The presence of an accreditation demonstrated the strongest correlation with performance on Step 1 Basic Science for both the international and Caribbean student populations among the three assessments examined.⁶ Although Step 2 Clinical Skills was later discontinued in January of 2021, all three groups studied (international, Caribbean, and non-Caribbean students and graduates) showed a favorable correlation between accreditation and performance on the Step 2 Clinical Skills.^1,4 This correlation between accreditation and performance on examinations is similarly seen in the study by Roy et al, who investigated the relationship between accreditation cycles and the performance of medical students on a national licensing examination within the Canadian medical education system.¹² The research found that performance on the licensing exam was highest during and shortly after an accreditation site visit, then declined significantly until the midpoint in the accreditation cycle before rising again.¹²

Notably, accreditation had the greatest influence on exam results in the Caribbean, which is especially noteworthy given the significant number of foreign medical graduates from this region who sought ECFMG certification and later provided healthcare to patients in the US. Furthermore, the van Zanten (2015) study discovered that performance in Step 1 Basic Science and Step 2 Clinical Skills was positively influenced by accrediting agency quality, as determined using critical components in their systems. This emphasizes how important a high-quality accreditation system is for improving students’ performance, particularly in the real-world clinical situations assessed by Step 2 Clinical Skills.^1,4 However, this exam does not exist anymore since January 2021.

Challenges in Caribbean Medical School Accreditation and Proliferation of Accreditation Agencies

The accreditation of medical schools in the Caribbean region has become a matter of concern, prompting intervention and reevaluating existing policies. This discussion addresses the pressing issues of deteriorating medical school accreditation in the Caribbean region and asks the ECFMG to intervene urgently. There is no evidence that WFME has the authority to deal with this issue. Specifically, the concerns relate to the rising number of WFME “recognized” agencies working in the Caribbean and the rapidly increasing practice of cross-border accreditation by agencies that have been “recognized” by WFME. This has enabled an untenable position in the Caribbean based on a marketplace of accreditation. Although the intentions of the relevant authorities, WFME and ECFMG, may be good, it is important to advocate for maintaining robust standards.

As van Zanten and Boulet (2008) noted, the Caribbean region hosts many medical schools, each subjected to various accreditation agencies, leading to a need for uniformity in educational standards.¹³ While recognition aims to ensure high standards, it has inadvertently resulted in multiple agencies competing for accreditation in the same region. One of the prominent issues contributing to the accreditation dilemma in the Caribbean is the rapid increase in the number of WFME “recognized” agencies. This proliferation is not unique to the Caribbean but is a global phenomenon, as seen with multiple agencies operating from a single country, such as Kazakhstan.⁷

Threat to Integrity

Rather than enhancing the quality of medical education, the current situation poses a significant threat to the integrity of educational programs in the Caribbean. The accreditation system is deteriorating and rapidly becoming chaotic and uncontrolled due to cross-border accreditation. This deterioration can be traced to the WFME recognition program, which has “recognized”, and therefore legitimized, multiple agencies who are inevitably now competing for customers or are flexing the system in local ways. In turn, this quickly removes all credibility from the accreditation process and has the opposite effect on what was intended to uphold educational standards. As van Zanten et al pointed out, varying external quality assurance mechanisms across Caribbean institutions emphasize the need for a standardized approach.¹⁴ Without ECFMG’s intervention, the situation will continue to worsen and threaten the legitimacy of the entire accreditation landscape. Though this effect is not specific to the Caribbean, its impact in this region is substantially more pronounced.

Uncontrolled Marketplace

The accreditation landscape created by WFME has inadvertently led to the emergence of an uncontrolled marketplace where medical schools can choose among multiple “recognized” agencies. This focus on business interests rather than educational quality compromises the essence of accreditation. Schools can effectively “browse the market” or establish new agencies rather than addressing the root causes of accreditation failures.¹⁵

Challenges in Maintaining Standards

As Norcini et al illustrated, offshore medical schools in the Caribbean play a significant role in the US physicians’ workforce.¹⁶ However, the variation in the number of physicians produced and the performance of their graduates in attaining ECFMG certification highlights the challenges in ensuring consistent standards.¹⁶

There are myriad examples of where the current system is dangerously inadequate, and many in the Caribbean medical education field are already aware of them. A compelling example of the challenges faced in maintaining standards is the case of one of the medical schools in Grenada. When this institution was not accredited to its satisfaction by CAAM-HP in 2020, the accreditation agency GMDC was established, which was ultimately “recognized” by WFME to work with its single medical school.¹⁷ Thereby effectively bypassing the accreditation process’s rigor to become fully accredited when the institution had yet to be fully accredited by CAAM-HP. Similarly, any other island school could follow suit. This case underscores the need for effective policies to prevent deviations from established standards.¹⁶

Problems Associated with Cross-Border Accreditation

The major problem with cross-border/international accreditation is understanding the context. The accreditation bodies from Kyrgyzstan (AAEPO) and Kazakhstan (IAAR) may lack an understanding of the Caribbean context. These accreditation bodies originating from another continent employing their unaltered standards from their respective continents onto the Caribbean could potentially lead to ominous consequences. It is crucial for accreditation bodies not to standardize the standards, emphasizing the need to contextualize standards appropriately. In this process, accreditation bodies such as IAAR and AAEPO may lower their standards or exercise leniency with medical schools as these outgrowths of accreditation bodies from other continents opened the emergence of an uncontrolled marketplace for accreditation bodies in the Caribbean region.

Cross-Border Accreditation Concerns

van Zanten et al found that because of variations in educational programs and accreditation standards, emphasizing the importance of stringent oversight.¹⁵ Unfortunately, another concerning development involves cross-border accreditation attempts, exemplified by the case of one of the medical schools in Curaçao seeking accreditation from the WFME-recognized AAEPO in Kyrgyzstan. At the time of this manuscript submission, AAEPO was not recognized to work in the Caribbean. However, this alone cannot stop the institution from doing so, and WFME recognition may make them attractive to naïve or unscrupulous applicants.⁷ AAEPO visited the college in May 2023 to sign an agreement with the school and the local government. Subsequently, AAEPO led training workshops at the school about filling out self-study documents, which represents a concerning conflict of interest, especially given its WFME recognition status. Furthermore, they have indicated a timeline of just a few weeks to prepare self-study documents and site visits. This must be more credible as a rigorous process in a WFME-recognized agency. It is unclear why it would ever be appropriate for a medical school in the Caribbean to seek accreditation from an agency in Kyrgyzstan other than to gain a more favorable and lenient regulatory process. What is clear is that WFME needs an adequate policy approach to multiple agency recognition and cross-border accreditation. This lack of clear policy from WFME has created a vacuum, which has caused accreditation agencies to profit and drive a marketplace for accreditation. It has led to progressively lower standards, a less rigorous review process, expedited timelines, and ultimately, a clear indication of a predetermined process that is not interested in maintaining or improving educational quality. AAEPO granted accreditation for this school for five years even though the school has very few faculty members in the basic sciences (first two years of the program).

Another example and, more recently, another school opened in Dominica in August 2023 and sought accreditation from the IAAR, which is from Kazakhstan.¹⁸ WFME needs to recognize the IAAR for accreditation in the Caribbean. Furthermore, obtaining recognition from WFME only requires an agreement with the local government. The IAAR has already been recognized by WFME elsewhere, rendering this situation “trivial”, showcasing how far below the standards the Caribbean system is being held at. The more egregious matter lies in the fact that the IAAR granted accreditation to this school for five years even though they had not started their first cohort at the time of obtaining accreditation. These are the dangerous consequences of the cross-border accreditation policies of WFME, necessitating urgent intervention by ECFMG.

A Call for Urgent Intervention

The current state of medical school accreditation in the Caribbean region requires immediate intervention. The importance of this discussion lies in its potential to bring about positive changes in the accreditation landscape, ultimately benefiting the quality of medical education in the Caribbean and similar regions worldwide. The central objectives are the preservation of robust standards and the avoidance of chaos in the accreditation process. While the ECFMG’s recognized accreditation requirement policy and WFME recognition program were well-intentioned, implementing the WFME recognition program, especially with allowing cross-border accreditation, has inadvertently contributed to a chaotic system concerning cross-border accreditation. Urgent attention is needed to address the issues of multiple agencies and cross-border accreditation. Further showing support for the pursuit of intervention, Rashid et al shed light on the broader context of medical education in the Caribbean and emphasized the importance of aligning accreditation practices with local needs and priorities.¹⁹ Recent evidence from literature suggests that the expanding impact of WFME on global medical education has unfolded mainly without considerable attention or examination. WFME must exhibit increased transparency, actively involve its stakeholders, and endorse research and evaluation to address this gap.²⁰

Rather than dismantling the recognition program, a more effective approach would involve refining and enhancing policies. Clear guidelines should be established for recognizing agencies, stringent oversight mechanisms to prevent conflicts of interest, and reviewing accreditation standards and practices to maintain credibility and educational quality. The challenges surrounding medical school accreditation in the Caribbean region may be complex, but they are not insurmountable While the proliferation of “recognized” agencies and cross-border accreditation pose significant concerns, they can be addressed through cooperative efforts, clear policies, and a commitment to maintaining high educational standards. The primary concern can be effectively addressed by making it mandatory for accreditation bodies to undergo the recognition process with WFME when going for accreditation exercise in a different continent or region. Presently, WFME relies on agreement letters between local governments and accreditation bodies, assuming the accreditation entity is already recognized by WFME for another region. This poses a potential risk, as local governments may allow medical schools to choose lenient accreditation entities to ensure the sustainability of medical schools, viewing medical schools as economic contributors. Therefore, the authors suggest that accreditation bodies must undergo the same recognition process by WFME when accrediting medical schools in a different continent or region.

Conclusions

There is a critical need to implement a standardized method for accrediting medical schools in order to uphold educational standards. However, the increasing number of accreditation agencies poses a threat to the integrity of quality education. The rise of these agencies presents challenges in maintaining standards and leads to an uncontrolled marketplace. Furthermore, these developments have culminated in challenges and growing concerns surrounding the accreditation process in the Caribbean. Multiple agency “recognition” and cross-border accreditation bodies, now recognized by the WFME, have led to inconsistent educational standards. Prompt action is required to prevent further decline and safeguard educational standards in the Caribbean. The WFME must establish a framework regarding cross-border accreditation. Intervention by ECFMG directing the WFME on cross-border accreditation is crucial, as this situation compromises the credibility of the entire accreditation system. Without intervention, worldwide implications may ensue as similar issues surface globally.

This discussion suggests an effective approach to enhance, optimize, and strengthen existing policies to address the complexities of the WFME recognition program. Attainment of recognition from the WFME in one region does not inherently guarantee recognition in another, and the WFME must develop a framework for cross-border accreditation. The authors strongly recommend that accreditation bodies undergo the same recognition process by WFME when accrediting medical schools in different regions. A persistent dedication to upholding academic standards within Caribbean medical schools through ECFMG intervention can effectively maintain integrity and assure quality within the system. It is essential to establish clear guidelines for recognizing agencies, implement strict oversight methods to control conflicts of interest, and advocate for a review of accreditation standards to preserve academic excellence.