By Anemona Hartocollis From New York Times

For a generation, medical schools in the Caribbean have attracted thousands of American students to their tiny island havens by promising that during their third and fourth years, the students would get crucial training in United States hospitals, especially in New York State.

But in a fierce turf battle rooted in the growing pressures on the medical profession and academia, New York State’s 16 medical schools are attacking their foreign competitors. They have begun an aggressive campaign to persuade the State Board of Regents to make it harder, if not impossible, for foreign schools to use New York hospitals as extensions of their own campuses.

The changes, if approved, could put at least some of the Caribbean schools in jeopardy, their deans said, because their small islands lack the hospitals to provide the hands-on training that a doctor needs to be licensed in the United States.

The dispute also has far-reaching implications for medical education and the licensing of physicians across the country. More than 42,000 students apply to medical schools in the United States every year, and only about 18,600 matriculate, leaving some of those who are rejected to look to foreign schools. Graduates of foreign medical schools in the Caribbean and elsewhere constitute more than a quarter of the residents in United States hospitals.

With experts predicting a shortage of 90,000 doctors in the United States by 2020, the defenders of these schools say that they fill a need because their graduates are more likely than their American-trained peers to go into primary and family care, rather than into higher-paying specialties like surgery.

New York has been particularly affected by the influx because it trains more medical students and residents — fledgling doctors who have just graduated from medical school — than any other state. The New York medical school deans say that they want to expand their own enrollment to fill the looming shortage, but that their ability to do so is impeded by competition with the Caribbean schools for clinical training slots in New York hospitals.

Their argument is one that has been lobbed at Caribbean schools for decades: that those schools turn out poorly trained students who undercut the quality of training for their New York peers learning alongside them at the same hospitals.

And they complain that the biggest Caribbean schools, which are profit-making institutions, are essentially bribing New York hospitals by paying them millions of dollars to take their students. The American medical schools traditionally pay nothing, because hospitals like the prestige of being associated with universities.

“These are designed to be for-profit education mills to train students to pass the boards, which is all they need to get a license,” said Dr. Michael J. Reichgott, a professor at the Albert Einstein College of Medicine in the Bronx.

Charles Modica, chancellor of St. George’s University in Grenada, whose first class started studying in 1977, making it one of the oldest in the Caribbean, said the New York deans were simply afraid of competition.

“It’s basically a situation where the New York State deans just can’t hold their noses high enough up in the air, and I think it’s disgraceful,” said Mr. Modica, who founded St. George’s after he was rejected from medical school and went on to law school. Most Americans had never heard of the school until 1983, when President Reagan sent troops into Grenada, partly, he said, to rescue St. George’s American students from unrest.

The debate is so fraught that officials of Ross University, on the island of Dominica, were at first reluctant to talk about it, fearing students would be scared away from offshore schools.

“If the domestic schools felt we were taking opportunities away from their students, if they can specifically tell us what location we were taking them away from — that question was never answered,” said Dr. Nancy Perri, Ross’s chief academic officer.

The New York schools want the state to adopt the position of the American Medical Association, that “the core clinical curriculum of a foreign medical school should be provided by that school and that U.S. hospitals should not provide substitute core clinical experience.”

Under their proposal, the foreign schools could send students to New York only for electives, in their fourth year, not for core training, in their third. Short of that, the domestic schools want to stop any more foreign schools from sending students to New York for long-term clinical training while the state studies how it approves the schools.

The foreign schools do not go through the same accreditation process as the United States schools. So the state has its own process for approving foreign schools, but the New York schools contend it is not as thorough as the national accreditation process, and it should be.

The Regents are struggling to compare the academic and professional performance of students from the domestic and foreign schools. The Government Accountability Office, a federal agency, tried to do so in a report aimed at determining whether the foreign schools should continue to qualify for federal loans.

The report, issued in June, found that on average, foreign-trained students lagged behind their American-trained peers in passing the medical licensing exams. But over the last decade, they had narrowed the gap, especially in the clinical knowledge portion of the exams, which 75 percent of foreign-educated Americans passed on the first try in 2008, up from 57 percent in 1998. For students in American and Canadian schools, which are subject to the same accreditation process, the rate was 94 percent in 2008, about the same as 10 years earlier.

The report found few differences in the rates of disciplinary actions or malpractice payments between physicians educated abroad and in the United States.

A memorandum submitted to the Regents this month by Frank Muñoz, a deputy state education commissioner, suggested that the top Caribbean schools, like St. George’s, American University of the Caribbean and Ross, have been successful at establishing their academic merit.

“There is evidence,” Mr. Muñoz said, that the more mature Caribbean schools “admit students with very competitive backgrounds. It appears that many of these students were not granted admission to domestic schools because of the limited number of available seats.”

The New York schools say they now send about 4,400 of their students to New York hospitals for clinical training in their third and fourth years, and would need to expand that by 15 to 30 percent to help solve the doctor shortage.

Foreign schools send about 2,200 students, more than 90 percent of them from the Caribbean, according to the state. St. George’s alone sends about 1,000 students, many through a 10-year, $100 million contract with the New York City Health and Hospitals Corporation, which runs public hospitals. (A high-ranking St. George’s official, who also sat on the board of the city hospitals corporation, was fined for a conflict of interest for his role in soliciting clinical training slots for the school.)

City hospital officials have defended the contract with St. George’s as a way of getting students into hospitals in poor neighborhoods that have been shunned by New York schools. Once they have done their clinical training in those hospitals, the students often return as residents and then as full-fledged attending physicians, officials said.

But New York deans say the hospitals are taking too many students. “There are realistic limits to the number of students that can be placed in any one clinical environment and have a high-quality education take place,” said Dr. Lawrence G. Smith, dean of the Hofstra North Shore-LIJ School of Medicine, which will accept its first class of 40 students next fall.

The issue, which was reported this month in the Chronicle of Higher Education, is so charged that the city’s hospital trade group, the Greater New York Hospital Association, has declined to take a position. State officials say it is unclear just how many clinical trainees New York hospitals could reasonably accommodate, and they are surveying the hospitals to try to determine that.

Meanwhile, St. George’s continues to turn out doctors like Janine Reinhardt, 27, who grew up in Massapequa, N.Y., had a 3.97 grade-point average as a biology major at Cornell, but scored 27 on the MCAT. She said she probably needed a score of 30 to get into an American school.

Dr. Reinhardt graduated from St. George’s this year, and is now a resident in emergency medicine at Stony Brook University Medical Center, which was her first choice. She said her underdog status as a St. George’s student had made her work harder.

“At St. George’s, we’re rejected from the U.S. schools and then we feel we have something to prove, as opposed to the sense of entitlement that some U.S. medical students might feel,” Dr. Reinhardt said.

IMAGE: By Maxine Hicks for The New York Times. Dr. Janine Reinhardt, a graduate of a Caribbean medical school, is a resident at Stony Brook University Medical Center.

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