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HISTORY OF THE DIVISION OF LICENSING'S PAST APPROVALS AND
DISAPPROVALS OF INTERNATIONAL MEDICAL SCHOOLS |
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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.
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American University of the
Caribbean, St. Maarten (1989)
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Ross University, Dominica (1990)
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St. George’s University (1990)
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Instituto Tecnologico de Santo
Domingo (1996)
Note:
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Approved schools have reporting
requirements.
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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.
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Saba University School of Medicine, Saba, Netherland Antilles (2004)
Medical University of Lublin, Poland (2008)
Medical University of Poznan, Poland (2008)
Medical University of Jagiellonian, Poland (2007)
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.
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Cetec
University, Dominican Republic (1983)
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Cifas
University, Dominican Republic (1984)
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Spartan
Health Sciences University, St. Lucia (1985)
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UTESA SOM,
Dominican Republic (1985) (1997)
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Universidad
Mundial Dominicana (1989)
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Universidad
Eugenio Maria de Hostos (1996)
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Universidad
Federico Henriquez y Carvaial (1998)
D. Schools that applied, were
reviewed, and denied subsequent to the December 2003 regulations.
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St. Matthew's University School of Medicine, Grand Cayman, Cayman Islands
(2005)
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