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HISTORY OF THE DIVISION OF LICENSING'S PAST APPROVALS AND DISAPPROVALS OF INTERNATIONAL MEDICAL SCHOOLS

This memorandum is a complement to the proposed regulations that legal counsel has drafted governing the Division of Licensing's process for reviewing and recognizing international medical schools.

Over the past 20 years, the Division has reviewed 12 medical schools in the Caribbean and Dominican Republic for their compliance with the minimum requirements in Sections 2089 and 2089.5 of the Business and Professions (B&P) Code. The Division followed a fairly standard process in conducting its review of these schools. However, the process has not been adopted in regulations. During recent meetings, the Division members and legal counsel have discussed the wisdom of adopting the Division's review process in regulation. To assist in this process, staff was asked to summarize the historical background to the Division's review of international medical schools. This memo summarizes the Division's activities in this regard over the last 20 years.

BACKGROUND
Section 2084 of the B&P Code authorizes the Division of Licensing to approve medical
schools that comply with the medical education requirements in Sections 2089 and 2089.5 of the Code. Medical schools located in the United States, Canada and Puerto Rico are deemed approved by the Division of Licensing through their accreditation by the Liaison Committee on Medical Education, LCME (pursuant to Section 1314 of Title 16, California Code of Regulations). All other medical schools are subject to the Division's individual review and approval, and must demonstrate that they offer a resident course of professional instruction
that is equivalent, not necessarily identical, to that provided in LCME-accredited medical schools. The law further provides that only students from "approved" medical schools may complete clinical clerkship training in California facilities, and only graduates of "approved" medical schools may qualify for licensure or complete postgraduate training in California.

Prior to 1985, Division staff conducted no reviews of international medical schools. If an applicant graduated from a new medical school that was listed in the World Health Organization's "Directory of Medical Schools," staff issued the school a "school code" and processed the application routinely. WHO listing was not required in statute or regulation. The WHO Directory merely lists the names and addresses of medical schools without conducting any quality review of the schools. In addition, for political reasons, the Directory excludes all Taiwanese medical schools. Therefore, the WHO Directory is not a practical tool for evaluating international medical schools. No other international organization exists that evaluates or accredits the world's 1000+ medical schools for compliance-with some educational standard.

Almost all international medical schools are founded to train physicians to address the medical needs of their country's population. In the late 1970s, entrepreneurs began to develop for-profit, English-language medical schools in the Caribbean and Dominican Republic aimed at attracting Americans who were unable to enter U.S. medical schools. Staff issued school codes to these schools as their graduates began to apply here in the early 1980s.

In the spring of 1983, the U.S. Postal Service uncovered a scandal involving the widespread production of fraudulent medical diplomas and other unethical practices on the part of officials at CETEC and CIFAS Universities in the Dominican Republic and their U.S. agents. During the course of their Investigation, other medical schools in the Dominican Republic and Caribbean were implicated. Thousands of individuals - many of them nurses, physician assistants, pharmacists, chiropractors, podiatrists - bought fraudulent transcripts and diplomas for prices ranging from $8,000 to $50,000. They spent little or no time attending the school listed on their diploma. As a result of the postal investigators' findings, licensing boards across the United States were forced to investigate the backgrounds of thousands of applicants and licensees who had attended the implicated schools. Individuals who were found to have submitted false documentation had their licenses revoked or were dismissed from training programs. Dominican authorities closed two schools, CETEC and CIFAS, and jailed several administrators who were involved in document forgery schemes.

As a result of the above scandal, the Division of Licensing disapproved CETEC on May 19, 1983. With investigators from the Enforcement Division, the Division formed a License Investigation Task Force (LIFT) to investigate the extent of fraudulent documentation among graduates of offshore schools with pending licensure applications in California. In addition to confirming unethical practices involving bogus documents and transfer credit, LIFT investigators uncovered widespread violations of Section 1327 of Title 16, California Code of Regulations; at least 15 hospitals in California were unlawfully training offshore students in clinical clerkships. In many cases, students received little or no supervision or evaluation. In some instances, offshore schools granted students clinical credit for clerkships that had included no hands-on clinical training.

In an emergency session held on October 11, 1984, the Division voted to temporarily disapprove six schools: American University of the Caribbean (AUC), CIFAS University, Ross University, St. George's University,, Spartan Health Sciences University and UTESA School of Medicine. The disapproval order offered each school the opportunity to show cause why the Division should not make the disapproval permanent. On November 16, 1984 following a Show Cause hearing held the previous day, the Division permanently disapproved Ross and CIFAS.

During the summer of 1984, AUC, Ross and St. George's universities sued the Division. The litigation with AUC and St. George's was resolved on November 14, 1984 when both schools signed stipulated agreements with the Division. The litigation with Ross University was resolved on December 14, 1984 when the university signed a stipulated agreement with the Division whereby Ross University received probationary approval for five years. All stipulated agreements imposed terms and conditions on the schools requiring them to bring their educational programs into compliance with California law and included a requirement that the schools were to finance site visits by the Division to the schools' campuses and hospitals where their students receive clinical training,

Specific follow up actions involving AUC, Ross, St. George's and other medical schools are described below.

CETEC & CIFAS Universities                      [Dominican Republic]
These universities opened medical schools in 1979 and 1980, respectively, heavily
targeting U.S. citizens. After launching their own investigation into the U.S. Postal Services' findings and confirming their validity, Dominican Republic government officials closed CETEC and CIFAS in 1984. Therefore, the Division did not conduct site inspections to these two schools. The Division disapproved CETEC on May 19, 1983 and CIFAS on November 16, 1984.

American University of the Caribbean (AUC)

[Montserrat, West Indies; founded in 1978; moved to St. Maarten in 1995]

As a consequence of the stipulated agreement between the Division and AUC, the Division conducted site visits to AUC's campus on Montserrat in April 1985 and April 1986. During the April 1986 follow up visit, the team also inspected St. Croix and St. Thomas Hospitals; the Division approved these two hospitals as core clinical training sites. On June 30-July 1, 1986, separate site visits were conducted to two hospitals in Chicago, Norwegian-American Hospital and Martha Washington Hospital, where AUC students were receiving clinical training. In September 1989, the Division conducted site visits to Rancho Los Amigos Medical Center in Downey and Camarillo State Hospital; these facilities were found to be providing training in compliance with California law. Based on AUC's compliance with the terms of the original stipulation,the Division removed AUC's provisional status on September 15, 1989. In 1995, volcanic eruptions forced AUC to temporarily relocate to Belize and the island of St. Maarten. The Division began reevaluating the school's program. The Division conducted a site inspection of AUC's new, permanent campus on St. Maarten in March 1998. On May 8, 1998, the Division members voted to continue recognizing AUC.

Ross University                                  [Roseau, Dominica; founded in 1979]

The Division conducted site visits to Ross University's campus on Dominica in April 1985 and April 1986. In November 1986, separate site visits were conducted to A.N. France Hospital in St. Kitts and Princess Margaret Hospital on Dominica; the Division approved these hospitals for a limited number of clinical clerkships.

Ross's provisional status was due to expire on December 14, 1989 but was extended until June 30, 1990 to allow the school additional time to submit required documents. In September 1989, the Division conducted site visits to Rancho Los Amigos Medical Center in Downey and Camarillo State Hospital where Ross students were receiving training; these facilities were found to be offering training in compliance with California law. In May of 1990, the Division conducted site visits to three other clinical training sites: Norwegian-American Hospital in Chicago, Horaclo Oduber in Aruba, and. Princess Margaret in Dominica; the Division approved each hospital to provide certain core and elective clerkships. The Division removed Ross University's provisional status effective June 30, 1990, and the school remains in approved status.

St. George's University                                        [Grenada; founded in 1977]

As part of resolving outstanding litigation, the Division conducted site visits to St. George's campus on Grenada in April 1985 and April 1986. A separate site visit was conducted to St. Joseph's Hospital in Orange, California where a St. George's student had trained. The hospital was found acceptable to provide clinical training in compliance with California law. The Division removed St. George's probationary status during their September 15, 1989 meeting, and the school remains in approved status.

Spartan Health Sciences University            [St. Lucia; founded in 1980]

The Division initially recognized this for-profit medical school. After the Division's investigation revealed widespread document fraud and training violations at this school, the Division temporarily disapproved the school on October 11, 1984. A site visit to the school's St. Lucia campus on April 21, 1985 found inadequate facilities and curriculum, and the Division issued a permanent disapproval order on June 13, 1985. Spartan officials responded by suing the Board in Sacramento County Superior Court. The court dismissed the school's lawsuit with prejudice on December 2, 1986. Spartan a the Board entered into a Stipulation that acknowledges Spartan's right to petition the Division to modify or terminate its disapproved status. The school has never petitioned for reconsideration. The Division's June 13, 1985 disapproval order remains in effect.

UTESA School of Medicine [Dominican Republic: founded in 1981)

UTESA is a private for-profit university offering instruction in Spanish or English. The Division temporarily disapproved UTESA on October 11, 1984 based on evidence that UTESA and CIFAS had colluded in fraudulent activities. After conducting a site visit to UTESA School of Medicine on April 12-14, 1985, the Division made its disapproval order permanent effective July 12, 1985. On May 29, 1986 after considering a petition for reconsideration from UTESA officials, the Division adopted a Stipulation and Order whereby UTESA would submit a plan to correct the deficiencies identified by the Division's site team. The plan that the university submitted did not meet the Division's criteria, and at their November 1986 meeting the Division reinstated the July 12, 1985 Order of Disapproval.

While planning the June 1996 site inspection to INTEC and UNIREMHOS, staff invited UTESA officials to participate in the review process. UTESA officials agreed to undergo a new site inspection. Unfortunately, the inspection team found that UTESA had not substantially corrected its previously-identified deficiencies. The Division disapproved UTESA again on February 7, 1997.

Universidad Mundial Dominicana (World University)
[Dominican Republic; founded in 1978]

This private, for-profit school opened in 1980 and offered instruction in English. In 1986, the Division received a few applications from graduates of World University. When staff requested World University officials to complete a detailed questionnaire regarding its facilities and curriculum, school officials declined to provide the requested information and stated that their curriculum did not meet California's requirements. Through other channels, staff learned that various factions within the university were involved in a lawsuit to decide who would control the school. At its meeting on December 1, 1989, the Division disapproved World University. World University closed in February 1991.

Instituto Tecnologico de Santo Domingo (INTEC)
[Dominican Republic; founded in 1972]

This private non-profit university, offering instruction only in Spanish, applied for recognition after three U.S. residents graduated from its program, The Division visited the school in May/June 1996 in conjunction with the inspections of UNIREMHOS and UTESA. The Division approved the medical school on July 26, 1996.

Universidad Eugenio Maria de Hostos (UNIREMHQS) 
[Dominican Republic; founded in 1981]

UNIREMHOS was a private, for-profit university that offered instruction in English. After a few of its graduates applied for licensure in California, the school applied for recognition. The Division visited the school in May/June 1996 in conjunction with the inspections of INTEC and UTESA. The Division disapproved the school on July 26, 1996. School officials requested reconsideration of the disapproval; the Division upheld its disapproval on November 1, 1996. Staff learned later that Dominican government officials at CONES, the Consejo Nacional de Educacion Superior, closed UNIREMHOS on February 13, 1998 citing "grave academic deficiencies and a lack of academic order."

University of Health Sciences Antigua           
[St. John's, Antigua; founded in 1983]

Only one graduate of this private, for-profit school ever applied for licensure in California. After several unsuccessful attempts to have the school complete and submit the Medical School Questionnaire, the Division disapproved the school on July 28, 1995. Since that time, the school has developed an internet-based program that targets healing arts practitioners such as chiropractors, nurses, physician assistants, podiatrists, pharmacists, etc. Students are granted advanced credit for their prior basic sciences education and receive minimal online instruction before commencing clinical clerkships.

Universidad Federico Henriquez y Carvaial (UFHEC)
[Dominican Republic; founded in 1991]

To resolve the lawsuit among principals of World University (see above), the Dominican court allowed World University to close and reopen with new management under the name UFHEC. In late 1994, an UFHEC official contacted staff to inquire about California's licensing requirements. Staff mailed the official a Medical School Questionnaire to complete but had no further contact from UFHEC. Later staff learned that CONES closed UFHEC on February 13, 1998 due to "grave academic deficiencies." The U.S. General Accounting Office also published allegations that an UFHEC administrator was involved in fraudulent diploma issuance practices. To forestall legal complications caused by former UFHEC students and graduates who might apply in California, the Division disapproved UFHEC on July 31, 1998.

Site Inspections to Medical Schools outside the Caribbean

On two occasions, the Division conducted site inspections to non-Caribbean international medical schools for reasons unrelated to approving new medical schools. In 1986, Assembly Bill 1859 mandated the Division to visit medical schools on three continents and review their medical accrediting systems, if such existed., The Legislature authorized funds for the visits. The Division visited schools in England in October 1986, the Philippines in March 1987 and Mexico in November 1987. The Division selected the countries from which the greatest number of graduates apply for California licensure. India was and still is the top country from which California receives applications; however, Indian authorities were cool to the idea of undergoing inspections, and England was substituted for India.

In November 1997, the Division members endorsed the concept of revisiting medical schools in the international countries from which the board receives the largest number of applications. As a result, in January 1999 the Division expended its own funds to conduct site inspections to four Philippine medical schools. All schools were found to satisfy California's minimum statutory requirements. However, no further visits were planned due to the strain on the Board's budget.

Review of Pending Medical Applications

In 2000 and 2001, respectively, the Division received applications from St. Matthew's University located on Ambergris Caye, an island off the coast of Belize, and Saba University located on Saba, an island in the Netherlands, Antilles. Review of their applications is ongoing. These two medical schools are examples of the more desirable process wherein a new medical school applies for the Division's recognition in order to enable its students to train in and become licensed in California. In this way, the Division has a chance to evaluate and approve the schools' educational program before the schools' students and graduates are accepted into clinical clerkship and postgraduate training programs in California.

SUMMARY

In the aftermath of a fraudulent diploma scandal in the Caribbean nearly 20 years ago, the Division realized the need to take proactive steps to protect California's patients from being treated by students and graduates of medical schools that do not meet the minimum requirements of law. The Division's first act was to disapprove the six propriety schools that were either implicated in the scandal or were violating California law. Subsequently, the Division conducted onsite inspections to those medical schools and developed an orderly process for evaluating new proprietary international schools that attract U.S. citizens. Of the 12 schools that the Division reviewed in the Caribbean and Dominican Republic, four were recognized and three were disapproved following a site inspection. The Division disapproved five schools after they either failed to cooperate in the Division's information-gathering process or were closed by their governments for malfeasance. In each instance where a school challenged its disapproval, the courts have affirmed the Division's authority.

While the late 1980s saw dwindling enrollments and school closures in the offshore medical school industry, the 1990s saw an expansion in the development of new proprietary medical schools. In addition to seven Caribbean medical schools that survived into the 1990s, 10 new Caribbean schools have opened or plan to open. In fact, the "offshore school" model has spread beyond the Caribbean. Five new proprietary schools have opened in the South Pacific located in the Cook Islands, Micronesia and Samoa. Three schools opened in Africa, two of which operate from rented facilities in the United Kingdom. Some of these proprietary schools were opened by American entrepreneurs and former students or graduates of other offshore schools. All target U.S. citizens, and almost all promise clinical clerkship training in the United States. 

In a new development, many existing Eastern European medical schools have opened "English-language programs" that promise to prepare students to pass the USMLE and practice medicine in the United States. The countries involved are Hungary, Poland, Czechoslovakia, Slovakia, Russia and Armenia. Like the popular Autonomous University of Guadalajara in Mexico, their approach is that students will receive their basic sciences education in English while simultaneously learning the native language to prepare them to interact with patients during their clinical clerkships. Staff is working with several of these schools in an attempt to ascertain the structure, governance and resources available to U.S. citizens in these new programs. 

As world population expands, many countries have built new medical schools to meet  their citizens expanding health care needs. Legal counsel crafted the attached regulations to exempt these schools from the requirement for the Division’s individual review. This will focus the Division's resources on evaluating free-standing proprietary medical schools whose ability to satisfy minimal quality standards is more likely to be subject to question. 

If you have any questions concerning this memorandum, please telephone me at (916) 263-2367.”

Click here for current, California law.

A. For a detailed history of licensure and clinical training pre dating the December 2003 regulations implementing the California Statutes, see memorandum above. Below are the four schools that applied, were reviewed, and found approved, and eligible to conduct clinical training in California previous to the December 2003 regulations.

  1. American University of the Caribbean, St. Maarten (1989)

  2. Ross University, Dominica (1990)

  3. St. George’s University (1990)

  4. Instituto Tecnologico de Santo Domingo (1996)

Note:

  1. Approved schools have reporting requirements.

  2. Board counsel advised the seven year recertification  requirement commences when the regulation took effect.

B. Subsequent to December 2003 regulations the following schools were approved.  For details click the school name.

  1. Saba University School of Medicine, Saba, Netherland Antilles (2004)

  2. Medical University of Lublin, Poland (2008)

  3. Medical University of Poznan, Poland (2008)

  4. Medical University of Jagiellonian, Poland (2007)

  5. Latin American Medical School, Cuba (2008)
    Staff/Expert Report  |  Database

C. Schools that were reviewed, and denied previous to the 2003 regulations.  For details see Memorandum History above.   

  1. Cetec University, Dominican Republic (1983)

  2. Cifas University, Dominican Republic (1984)

  3. Spartan Health Sciences University, St. Lucia (1985)

  4. UTESA SOM, Dominican Republic (1985) (1997)

  5. Universidad Mundial Dominicana (1989)

  6. Universidad Eugenio Maria de Hostos (1996)

  7. Universidad Federico Henriquez y Carvaial (1998)

D. Schools that applied, were reviewed, and denied subsequent to the December 2003 regulations.   

  1. St. Matthew's University School of Medicine, Grand Cayman, Cayman Islands (2005)


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