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From the Hartford Courant

Getting An M.D., The Easy Way

Students at the St. Lucia medical school aren't allowed to train at local hospitals. But they are welcome at U.S. hospitals, including three in this state.

Courant Staff Writers

December 15, 2003

VIEUX FORT, ST. LUCIA -- The road climbing out of this sleepy Caribbean port town is lined with small factories producing the staples of island life: beer, bottled hot sauce, tin roofs and medical doctors.

While the beer and spices have a distinctly local flavor, the doctors who graduate from Spartan Health Sciences University - four classrooms, one lab and three old cadavers in a building near a brewery - are for export only.

For years, government officials and hospital administrators in St. Lucia have refused to license Spartan graduates or allow the school's students to train in local hospitals out of a "deep skepticism" of the school's educational standards.

But Spartan's mostly American-born graduates are allowed to practice in 44 states, including Connecticut. The school's students are also able to come back to the U.S. for the critical hands-on part of their education. Spartan administrators tout three hospitals in Connecticut - St. Mary's in Waterbury, Griffin in Derby and St. Raphael's in New Haven - as prime destinations.

A recent Courant visit to St. Lucia found that the school falls far short of modern standards: The campus consists of one sparsely furnished building, the students acknowledged they sorely lack the academic qualifications to get into U.S. schools, and the faculty includes teachers who do little more than stand in front of the class and read from textbooks.

These conditions have convinced officials in six states, including California and Texas, that licensing its graduates poses an unacceptable risk to patients. Some states won't even allow Spartan students to train in their hospitals.

Those are drastic measures. Only a handful of the 1,642 medical schools located outside the United States and listed by the World Health Organization have been banned by any U.S. medical board.

On St. Lucia, there has long been a sense that the school takes under-qualified Americans and turns them into poorly trained physicians.

"I don't think the foundation of the basic sciences is good at Spartan. I'm not sure the selection criteria are good," said Dr. David Bristol, a surgeon on the committee that reviews applications for medical licenses on St. Lucia. "I don't think you can get more fundamentally deficient than that."

No test? No problem.

Even by the standards of offshore medical schools, Spartan is widely understood to be one of the least selective.

There is no published minimum grade point average and a bachelor's degree is not required. "Academic background is not the main criterion for selection; individual character and motivation to become a physician are essential determinants for admission," according to the school's website.

Most of the students interviewed by The Courant during a weeklong visit in October said that they had never taken the Medical College Admission Test, a standardized exam of scientific knowledge required by medical schools in the United States.

Tracy Mack, 31, a former surgical assistant from Arkansas, said he took the test twice, but both times his scores were too low to get him into an American medical school.

A professor advised him to take some time off and study harder, but Mack was eager to get started on the path to becoming a surgeon, so he ventured offshore, where test scores are not an issue.

"I can't see anything else but putting a blade on somebody," Mack said. "That's been my overwhelming desire."

Another Spartan student, 24-year-old Allen Ameri from Los Angeles, said that his undergraduate degree came from an unaccredited chiropractic school that American medical schools were unlikely to recognize.

"My mom insisted that I start something," said Ameri, recalling his aimlessness after high school. "I just started chiropractic school so she would be satisfied that I was doing something."

But even his chiropractic school offered more individualized access to lab equipment and supplies than Spartan does. There were three students per cadaver in the dissection lab at his old school, but there are 16 students working on each corpse at Spartan, Ameri said.

Ameri and Mack are both in the first of four semesters at Spartan. A more experienced student, who is on the brink of beginning clinical rotations in the U.S. and did not want to be named for fear of retribution from the faculty, summed up the situation this way:

"They allegedly have prerequisites to come here. The reality is that they don't deny anybody entrance. The reality is that most of these people should not be in medical school, period."

An inspection team from California that visited the school in 1985 came to largely the same conclusion. Its report called the Spartan faculty "grossly underqualified." The inspectors were also dismayed by the school's meager facilities, especially the absence of an adequate medical library, and what they referred to as the "lack of an acceptable and uniform" admissions policy.

Little appears to have changed in nearly two decades.

The library at Spartan consists of a single small room with a bookshelf running the length of one wall. There are six computers with Internet access, but two students complained that the Web connection is extremely unreliable.

Spartan administrators refused to answer questions for this story. The night before a scheduled interview, a secretary for the dean - who is listed on the website by the single name Gurumurthy and is known to students and faculty as "Dr. Guru" - left a voice message canceling the meeting due to a sudden scheduling conflict.

Minutes later, the secretary left a second message saying Gurumurthy had subsequently realized that his week was packed with meetings and he would, therefore, be entirely unavailable to comment for this article. A third message said the security guard at the gate to the campus had been instructed to prevent a reporter and a local photographer from returning to the school to talk with students.

Despite its shortcomings, the chief allure of Spartan for Americans aspiring to become doctors is that they don't actually have to spend much time on the island.

In traditional schools, the first two years are devoted to classroom study of the basic medical sciences such as anatomy, physiology and biochemistry. But Spartan accelerates the program, squeezing the standard curriculum into just 16 months.

And unlike schools that have successfully forged relationships with teaching hospitals nearby, Spartan's students fulfill the hands-on part of medical school by cobbling together a patchwork of weekslong rotations in American hospitals: working in emergency rooms, operating rooms, obstetrical units and other hospital departments.

"This is the easy option," said Tarik Mahmood, a 42-year-old chemical researcher from Waterbury, now in his first semester at Spartan. "Time was central for me. I don't want to spend four years."

Mahmood hopes to return home to do at least some of his clinical rotations at St. Mary's sometime next year.

Connecticut Connection

Most large U.S. hospitals rely heavily on medical residents: licensed physicians fresh out of medical school who accept relatively low wages in exchange for advanced training in their chosen specialty.

In order to attract residents, hospitals need a steady supply of medical students on hand for them to teach. That's no problem for places such as St. Raphael's, which has ready access to Yale's medical students. But community hospitals such as St. Mary's and Griffin have to get creative, often relying on students from offshore schools.

Officials at the Connecticut hospitals that train Spartan students seem to have mixed feelings about the place. On the one hand, they admire the determination it takes to become a doctor without the traditional academic qualifications. On the other, they stress how selective they are about which Spartan students to accept onto their wards.

St. Mary's in Waterbury has an open-ended agreement that allows Spartan students to spend 12 weeks in a surgical rotation, taking patient histories, performing physicals and holding retractors during operations, said Dr. V. Timothy Shea, chairman of St. Mary's surgical department.

"A lot of these kids are hard-nosed kids who have done it the hard way," Shea said. "They're not slouches, that's the point I'm trying to make. These are not kids who are in any way inferior to the American students."

That said, the last time St. Mary's accepted Spartan students was 1999. The group of 10 included the daughter of a St. Mary's physician, a hospital spokesman said. Officials did not say why there have been no Spartan students since.

At Griffin Hospital, Spartan students are allowed to rotate through several departments, which means they can do a greater percentage of their hands-on practice there than at the other two Connecticut hospitals.

But Dr. Ramin Ahmadi, head of Griffin's residency program, said the arrangement with Spartan guarantees that Griffin gets the school's best students. And Griffin only takes those who have already passed the first stage of the three-part exam required for all doctors who want to be licensed in the U.S., regardless of where they studied.

"We are one of the most desirable hospitals," said Dr. Howard Quentzel, who heads Griffin's medical education program.

Asked whether the concerns of regulators in California and several other states that refuse to license Spartan graduates give him pause, Griffin's director of public relations, Bill Powanda, said, "We have to go by what our experience has been."

Dr. Charles Riordan, vice president of medical affairs at St. Raphael's, said he was "shocked" to learn that Spartan was touting its relationship with the hospital on its website.

Most of the students who train at St. Raphael's come from Yale, but students from many schools - including Spartan - spend four weeks in advanced electives at the hospital learning to treat patients with conditions such as cancer, heart problems and kidney disease.

But those students must study basics such as internal medicine and general surgery at another hospital first.

"This is not part of their basic clinical training," Riordan said.

He added that only three or four Spartan students have come through St. Raphael's since 2000.

Officials at all three Connecticut hospitals said there have never been any serious safety issues with Spartan graduates learning on their wards. Powanda said Griffin has never had a patient-related problem with a medical student.

Back on St. Lucia, medical regulators are much more reluctant than their peers in Connecticut to put patients in the hands of Spartan students.

The school has spent the last decade trying to get its students into a training program at St. Jude's, which is less than a mile up the road and is the only hospital in Vieux Fort. But St. Jude's officials have refused to accept them, preferring more advanced students from medical schools in England and Ireland, said Dr. Sylvester Francois, the hospital's director of medicine.

Bristol, who is a well-known local critic of the school, was St. Jude's medical director until 2002. During his tenure he would not allow Spartan graduates to perform the hands-on part of the medical education at the hospital, nor would he allow them to pitch in as volunteers, citing fundamental concerns about the competence of the students and faculty.

Those same concerns led St. Lucia's medical council to ban Spartan graduates from practicing on the island when the school was established in 1980. Over the years, that decision has been reaffirmed as committee members watch the students arrive at the school.

"Their entrance requirements are, like, zero," said Dr. Christopher Beaubrun, a Vieux Fort physician and medical council member. "I've seen everything from psychotic Vietnam vets to pathological liars come through there."

When Bristol arrived on the island in 1993 after 13 years of training to become a surgeon in Britain, he was astonished by the brevity of the Spartan program and by the discovery that a single professor taught five or six of the basic science classes.

"This guy had just finished his own M.D. in India about a year before; he had essentially no clinical experience," Bristol said. "How can he be competent to lecture other people?"

Government Help

The current government of St. Lucia, however, is working hard to rehabilitate the school's reputation.

"For years, the overwhelming perception here was that this was another offshore school out for the bucks," said Darrel Montrope, a policy analyst for Prime Minister Kenny D. Anthony.

In fact, Montrope said his first visit to Spartan as a member of the Committee for the Accreditation and Evaluation of Medical Schools was occasioned with a deep sense of skepticism.

But that was in 1997, when the school's reputation and prospects were at an all-time low. A previous administration had claimed no knowledge of the school when asked about it by officials from the World Health Organization.

That awkward act of denial - the government had been accepting dues from the school for years - caused Spartan to be temporarily taken out of the organization's "World Directory of Medical Schools." Even though the directory is little more than a listing of schools acknowledged to exist by local authorities, U.S. regulators have historically refused to consider anyone from a school that isn't included.

So Spartan students were, effectively, cut off from any hope of eventually practicing in the U.S.

Since then, members of the St. Lucian evaluation committee have met repeatedly with the U.S. Department of Education, and American medical licensing authorities, in an effort to develop guidelines for regulating the school.

While conceding that Spartan still has not made most of the improvements to its facilities and curriculum that were recommended by the various bodies, Montrope said that the school's administrators have shown a "willingness to listen to criticism" and have pledged to make "significant changes."

The government told the World Health Organization that Spartan meets local requirements for medical education, and the school was restored to the all-important international list of recognized schools.

"We can't suggest that [Spartan] is an Ivy League school, but we can say that it meets the minimum requirements," Montrope said.

When it comes to licensing graduates of foreign medical schools to practice in Connecticut, state officials rely on the local government to endorse the school.

But in Spartan's case, that policy ignores the concerns of the medical establishment on St. Lucia, which has never allowed a Spartan graduate to practice on the island.

Montrope said it would not be out of the question to license Spartan graduates in the future, presuming they successfully complete residencies in the U.S. or Great Britain and won licensure abroad first.

And lack of adequate staff to supervise the students at the island's hospitals - not distrust of their competence - is the only reason Spartan students can't be invited to do clinical rotations on St. Lucia, Montrope said.

In the end, the hundred or so Americans studying at Spartan today will face a long list of obstacles when they try to come back to the United States to finish their education and pursue careers.

Spartan officials refuse to divulge the percentage of former students who have passed the American medical licensing exam, but experts assume it's pretty low.

And only a handful of the students ever make it to the Connecticut hospitals. Others do rotations at several Chicago-area hospitals, according to the Spartan website. A spokesman for one of those, the John H. Stronger Jr. Hospital of Cook County - made famous as the setting for the TV drama "ER" - could not say how many Spartan students his hospital has trained, but said "they come very infrequently."

Other Spartan graduates do their clinical training in Mexico or try to sell themselves on the basis of test scores to U.S. hospitals that don't have long-established relationships with the school, but might be looking to fill an empty medical student slot.

Their task is made harder by the academic climate on the island. Many of the classes are taught by people who simply read aloud from the textbook because they know little about the subject, several students said.

"If you ask them a question that's not directly answered in the book, you won't get a good answer," said the student who asked not to be named. "Things here are so deficient that you just have to do it on your own."

The school's supporters don't deny that the learning environment forces students to teach themselves, but insist that highly motivated students will always find a way to learn.

"The [Spartan] faculty can be strengthened, we certainly believe that," Montrope said. "But it's like home schooling. It doesn't mean you haven't been taught."

Copyright © 2003, The Hartford Courant