What's happening with accreditation of foreign health professional schools?

Veterinarians in heated debate; dentists pushed to test water; physicians eye from a distance

July 13, 2010 (published)
By Edie Lau

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When it comes to accrediting schools in foreign countries beyond Canada, veterinary medicine’s accrediting council has been engaged in the work much longer than its counterparts in medicine and dentistry, but the practice may spread.

The Commission on Dental Accreditation (CODA), under pressure from state legislatures interested in foreign-school accreditation, began in 2007 to accept applications from schools abroad. Nine programs from six countries have applied; none has yet been accredited.

In the human medical education realm, the Liaison Committee on Medical Education (LCME), which accredits programs leading to the M.D. degree, judges institutions in the United States and Canada only. Recently the LCME has begun considering whether it, too, should extend its geographic reach and how.

Rising interest in foreign-school involvement comes as the American Veterinary Medical Association Council on Education (AVMA-COE) is under pressure from some AVMA members to reassess its policy of performing accreditation services for institutions outside the United States and Canada.

Concerns include the potential for increased job competition by immigrating professionals; potential effects on wages in this country; and the possibility that accreditation standards might be diminished.

Outside the veterinary community, the COE’s long experience with foreign-school accreditation has made it an example for other programs to follow.

Dr. Anthony Ziebert, director of the dental accreditation commission, said his group studied the veterinary system when it decided to expand offshore. “(Ours) is actually a process modeled very closely on the veterinary-medicine process,” Ziebert said.

The AVMA-COE is the only recognized organization to accredit veterinary education programs in the United States and Canada. It has been accrediting schools in foreign countries beyond Canada for nearly 40 years. The first outside of North America was the State University of Utrecht in the Netherlands in 1973.

“The COE believes that accrediting foreign veterinary colleges supports and encourages the achievement of high standards of veterinary medical education worldwide, thus improving animal and human health,” the group’s document on policies and procedures states.

Today, nine schools outside of the United States and Canada sport COE accreditation. Besides the institution in the Netherlands, they are located in England, Scotland, New Zealand, Australia and Ireland.

The COE recently rejected an application for accreditation by National Autonomous University of Mexico (UNAM) in Mexico City. UNAM appealed the decision; a response is expected by October.

Before its decision, COE consideration of the Mexico City program elicited objections from some in veterinary circles, including a number of members of the Veterinary Information Network (VIN), an online professional community.

Among the worries they raised: The debt load of Mexican veterinary school graduates typically is considerably lower than that of American veterinary school graduates, resulting in the proverbial uneven playing field. Mexican veterinary medicine is very different traditionally from that in the United States, focused on livestock husbandry rather than companion-animal health. Accreditation of UNAM may be influenced by corporate interests.

The last concern stems from the involvement of Banfield, The Pet Hospital, which operates some 750 clinics in this country and built a teaching hospital at UNAM that opened in 2005. Some surmise that Banfield hopes to recruit UNAM graduates to the United States to serve Hispanic pet owners and provide a labor pool for its growing practices in this country.

Banfield executives were not available immediately for comment. In a news article in the May 15 edition of the Journal of the American Veterinary Medical Association (JAVMA), Banfield CEO John Payne is quoted saying that the company, which has veterinary hospitals around the world, wishes to grow throughout North America.

“Obviously our board was very interested in expanding our practice in the United States and also in Canada and Mexico,” Payne told JAVMA. “Canada has very adverse laws that prohibit, in a lot of instances, our type of practice, but Mexico does not, and we wanted to expand in Mexico, so our first natural thought was, ‘Well, let’s help UNAM with a facility.’ ”

Payne also said that his favorable impression of UNAM Dean Dr. Francisco Trigo Travera led him to strongly recommend to Banfield that the company “help UNAM get accredited...”

COE’s foreign-school accreditation has come under scrutiny in the past, for reasons less political and more logistical.

The May 15 JAVMA article recounts: “By the mid-’90s, the growing international demand for COE accreditation required additional staff, volunteer time and expertise. The council recognized that an assessment was needed to address the impact on the domestic accreditation process and educational standards in general.”

For two years, from 1997 to 1999, the COE stopped considering new applications while reappraising the program. Ultimately, a task force recommended that the program continue — with the addition of a policy requiring full cost-recovery of expenses related to the accreditation process — and that the AVMA accept a leadership role in international veterinary medicine.

On the dental education side, the accrediting organization, CODA, had a completely different reason for going international. There, the push to accredit foreign schools came from state governments, according to Ziebert, CODA director.

“There were some state legislatures that were looking at actually requiring their dental boards to accredit, on their own, international schools (in order) to solve some issues with access to care in under-served communities,” Ziebert said. He said the thinking was that dentists from countries that contribute large immigrant populations to the states would have more familiarity with the languages and cultures of those populations.

Notably, California lawmakers in 1997 authorized the California Dental Board to accredit schools on foreign shores, according to Russ Heimerich, a spokesman for the state Department of Consumer Affairs, under which the state dental board operates.

Since then, the California board has accredited the program of only one such school: De La Salle Bajio University in Leon Guanajuato, Mexico. Dental program graduates from De La Salle are allowed to apply for a license to practice dentistry in California under the same process as those who graduate from a CODA-accredited program in the United States.

CODA, meanwhile, concerned that individual state actions would create a hodgepodge of accreditation systems for foreign-school graduates, stepped up to establish an international program. “The commission and the American Dental Association (ADA) felt that it would be better for the commission to accredit schools rather than various dental boards ... that really don’t have the time or expertise or resources to do this,” Ziebert said.

Judging from Heimerich’s response, the states don’t object at all. “I think the states want an overarching authority to do this and not have to do the accreditation themselves,” he said. “I think most states would like to see somebody besides them accredit. In our particular situation, traveling out of state is a major (budget) problem.”

CODA’s expansion of reach was not without critics.

“I think there’s always going to be issues of: You’re going to have a lot of people flooding into the country from international areas and affecting existing practice,” Ziebert said. “There are issues of: How can you monitor something in a foreign country?”

But after stakeholders had their say, Ziebert said, the House of Delegates of the ADA, CODA’s sponsoring organization, approved the program.

Dr. Richard Valachovic, executive director of the American Dental Education Association, is familiar with the debate in veterinary medicine over foreign accreditation, including the situation with UNAM. He said concerns about corporate influence bringing high numbers of competing medical professionals from outside the country aren’t matched in dentistry.

“We don’t have (the) business models that have developed in veterinary medicine — these large practices and businesses — so that hasn’t arisen with us yet,” Valachovic said. He added: “Who knows in the future?”

In undergraduate human medical education, the accrediting body, LCME, has been discussing the possibility of overseas involvement — a discussion prompted in part by the establishment in 2009 of an international division by the Accreditation Council for Graduate Medical Education. The ACGME sets and enforces standards for post-graduate residency programs.

That organization last fall signed an agreement with the Singapore Ministry of Health to accredit residency programs in that country. The impetus behind the expansion abroad is unclear. A spokeswoman for the ACGME declined to provide details and VIN News Service has not yet ascertained the motivation nor the ramifications of ACGME's move.

Dr. Dan Hunt, senior director of accreditation services for the undergraduate medical school accrediting body, the LCME, said ACGME’s foray into the international realm has stirred discussions about whether his group should do the same. However, he was doubtful it would.

“That discussion’s not over, but there’s not a lot of push or interest from members of the LCME to become an accrediting body for other medical schools outside of the U.S.,” Hunt said. “Some of that is related to an awareness of the cultural differences. Some of it is related to, gee, is an organization that’s designed for an American audience really suited to do international accreditation?

“A third (issue) is ... do we want to open that gate for other countries? The brain drain is already pretty substantial,” he continued.

Another issue is the multitude of medical schools in the Caribbean. “We get literally hundreds of students in Caribbean schools wanting to know if their school is LCME-accredited,” Hunt said. “That’s another big can of worms. There are over 60 Caribbean for-profit schools. It’s mind-boggling.”

Moreover, Hunt said, there already exists a World Federation of Medical Education, based in Brussels, Belgium, that has created tools and templates for countries and regions to develop their own accreditation programs.

Hunt said a likelier role for LCME abroad is to act as a consultant or adviser to countries seeking to build their own systems. The LCME Secretariat already has held workshops in places including Egypt, Brazil and Taiwan to help those countries develop their own peer-review system for accreditation, he said.

The decision whether to consider out-of-country schools is entirely up to an accrediting body. The U.S. Department of Education, which oversees accrediting organizations in this country, recognizes those agencies based only on their domestic activities, according to department spokeswoman Jane Glickman. “Some agencies recognized by the Secretary (of Education) do accredit institutions in other countries but the Department of Education does not review those activities,” she said.

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