AVMA leaders mull organization's future in international accreditation

Veterinarians lambaste AVMA report that avoids workforce, economy issues

Published: June 04, 2013
By Jennifer Fiala

The American Veterinary Medical Association’s Executive Board will review this week the membership organization's role in accrediting foreign veterinary programs.  

Deliberations will take place as part of the Executive Board’s regularly scheduled meeting June 6-8 in Schaumburg, Ill. On the table is a newly released task force report that explores the impact U.S accreditation has on foreign veterinary schools and whether the AVMA Council on Education’s (COE) accreditation standards are uniformly applied across domestic and foreign programs.  

The report determined that the AVMA’s role in global accreditation benefits the profession and public health by elevating the quality of veterinary education internationally. The 25-page work concludes that providing international accreditation allows the AVMA to shape global veterinary standards and elevate veterinary infrastructures around the globe.  

At the same time, the report states that changes are needed to ensure the COE's 11 accreditation standards are fully met by accredited overseas veterinary programs.  

The task force's acknowledgment that the COE needs improvement, however, has done little to placate a growing number of practitioners who don’t understand why America's largest professional trade group for veterinarians involves itself in global accreditation, which some believe stands to negatively impact many of the AVMA's 80,000-plus members. Some consider claims that the AVMA offers the world's "gold standard" in accreditation to be arrogant.

"Who said the AVMA is the No. 1 authority?" asked Dr. William Folger, a board-certified feline practitioner in Houston. "I must have been in a coma (because) I don't know where I was when the world decided by unanimous vote that the COE had become the Gods of Veterinary Medicine.

"And who actually believes the AVMA is needed to accredit these schools? Did anyone ask the Chinese, Russians, South Africans, Hungarians, the Lebanese if they accepted the fact that the AVMA and the COE are the undisputed kings of veterinary medicine on planet Earth?"

The U.S. Department of Education (USDE) recognizes the COE — a 20-member volunteer body established in 1946 under the AVMA umbrella — as the accrediting agency for colleges and schools of veterinary medicine in the United States. The AVMA’s objective to spread its brand of accreditation internationally, however, is a self-imposed charge with no USDE involvement. To date, 13 veterinary medical programs outside of the United States and Canada are recognized by the COE, and students graduating from those programs are not required to take equivalency examinations that include an English-language assessment as a prerequisite to practicing in the country. Rather, they sit for the same national examination and state licensing tests posed to graduates of U.S.-based veterinary medical programs.

Advantages of AVMA accreditation go beyond testing. While the distinction does not enable a college's veterinary students to participate in Title IV student loan programs such as federal Pell grants or Stafford, PLUS and Perkins loans, it does provide veterinary students access to the U.S. government's Health Professions Student Loans. Such loans are limited only by the amount that eligible students need for tuition and living expenses as opposed to the $138,500 limit for non-medical students.

In other words, AVMA accreditation provides veterinary students access to the upper crust in federal student aid — enough money to cover tuition, no matter the cost — provided their university already has access to Title IV programs. The AVMA's role in student loans at foreign-based programs could change come July 2015, when amendments to the Higher Education Act require the federal government to pick a yet unnamed accrediting agency to evaluate foreign programs before they can offer students access to any kind of federal student aid.

A task force survey conducted of accredited foreign schools and those in the pipeline reveals that the prestige of AVMA accreditation, known as "the highest standard of veterinary education worldwide," motivates overseas programs to seek the COE's seal of approval. The ability to provide American students with access to U.S.-backed student loans was not mentioned.

"Accreditation of foreign schools by the AVMA currently fills a need for accreditation at the world level that recognizes public health, food safety and emergent diseases cross borders," the task force report states. "Increasing the quality of veterinary medicine globally improves veterinary medicine at all levels, and many members believe AVMA leadership in foreign veterinary school accreditation is important."

That might be true, but some negative impacts seemingly tied to AVMA's foray into foreign accreditation were not discussed, critics say. Since the report's release, accounts have surfaced from some of the task force’s 11 members that they were strictly prohibited from debating how foreign accreditation might economically affect private practitioners by increasing competition and pushing down salaries.

Across the country, practitioners report feeling squeezed by what they perceive as an oversupply of veterinarians — a population fed by emerging veterinary programs and ballooning class sizes at many of the 28 veterinary programs in the United States.  

Compounding veterinarians’ angst is the six-figure student loan debt most new graduates accrue as they enter a workforce with declining salaries. Spreading AVMA accreditation to other countries, critics say, eases the way for foreign-educated veterinarians to work in the United States and compete in an already oversaturated job market. What's more, schools overseas are opening their classes to more American students, many of whom pay a premium to attend foreign programs.

A task force member who spoke on condition of anonymity to avoid political backlash from the AVMA's leadership explained that the association’s lawyers instructed the group to not discuss how foreign accreditation might impact the U.S. job market because such talks might be perceived as anti-competitive behavior and run afoul of antitrust laws. It’s not the COE’s responsibility to act as a workforce gatekeeper by considering the impact that foreign-trained veterinarians might have on American’s workforce, AVMA officials contend.

Many critics have questioned the validity of that argument, especially considering that the U.S. accrediting authority for medical education programs does not consider colleges on foreign soil.  

“Truthfully, the AVMA is destroying this profession,” the task force member said. “I firmly believe there is no way that the accreditation standards can be applied evenly, and I don’t understand or comprehend what the push is to accredit foreign schools. It is not our responsibility to ensure that the world is equal to the United States.

He added, “At the rate the AVMA is going, they’re not going to have any members because we’re all going to be out of business. I believe very firmly that this accreditation system is a destructive one.” 

The AVMA notes that just 10 percent of the U.S. veterinary workforce is comprised of foreign graduates, including those coming from Caribbean-based programs catering to American students. On the topic of limiting the task force's talks, AVMA assistant media relations director Sharon Granskog explained by email that the task force's charge — which came in 2011 via a resolution passed by the AVMA House of Delegates — did not include evaluating the impact of foreign school accreditation on the U.S. veterinary workforce. "... The COE cannot consider workforce or economic issues when making accreditation decisions," she said.

Rather, the resolution charged the task force with evaluating whether the COE's standards are being applied consistently overseas compared with domestic programs and to explore how international accreditation serves the needs and interests of the public and AVMA members. The task force was asked to review whether equivalency examinations still are needed to assess the competency, language and skills of graduates of AVMA-accredited foreign programs and if there's pressure on the COE to extend accreditation to them.

Overall, the task force was assigned to consider what consequences the COE's efforts to accredit internationally have on "the veterinary profession in the U.S."

Judging from comments on the AVMA's blog, many believe the AVMA's duty as a trade organization conflicts with its role as an accreditation administrator — a clash exemplified by the task force's order to avoid debating how foreign accreditation might impact the livelihoods of American veterinarians, 90 percent of whom are AVMA members. Since posting the report on May 3, AVMA officials have received negative feedback from members, some of whom threaten to leave the organization.

"I really find it hard to find the words for how disappointed I am in the AVMA," wrote Dr. Mickey Wiltz, a practitioner in Loveland, Colo. "This organization has lost any contact or knowledge of what is going on in this industry, especially private practice. The arrogance, the censorship, the simple immature inability to admit that policies of the past may have had inadvertent negative effects and make honest steps to correct them. The profession is being led over a cliff and the AVMA will not even admit that the cliff exists."  

Dr. Greg Nutt, a practitioner in Canton, Ga., questioned how a not-for-profit trade group that's supposed to represent veterinarians can ignore the impact foreign school accreditation might have on the workforce of its members.  

"How can the AVMA state that their mission is to assist its members, yet you conveniently roll over on this?" Nutt wrote, directing his concern to AVMA CEO Dr. Ron DeHaven. "Shame on you. How can you state that you exist to support your members, yet when a huge issue comes up such as foreign accreditation (an issue that you did not consult with your membership about), you simply state that you cannot study it. That is not entirely true."

Dr. Ruth Beismer concurred, calling the AVMA's antitrust fears "a crock of crap."  

"Yes, COE needs to be fair and balanced in the accreditation practices for U.S. schools," Beismer, of Radcliff, Ky., wrote. "They need not accredit foreign schools at all. We belong to the AMERICAN veterinary medical association. Have you guys forgotten that? If your role is to advocate for your members, shouldn’t your members be consulted about these globalization efforts?"

Inside the task force

Dr. Orlando Garza, a task force member who worked on the report and a private practitioner from El Paso, Texas, explained that the group met once in person and several times by phone, each time with AVMA staff assisting in the talks.  

“We were told it was not the purview of this committee to make policy recommendations to the AVMA and we were told not to talk specifically about workforce issues,” he recounted. Garza is past president of the Texas Veterinary Medical Association (TVMA), a group that twice pushed for a task force to review the merits of foreign accreditation.

During an interview, he commended the task force’s work, given its constraints, and said he’s in agreement with the final report: “Putting these foreign school grads on equal ground with U.S. grads just because a school is accredited — in my view, that’s wrong. But is it absolutely horrible that we’re raising the standard (of veterinary education) around the world? No. It’s not all bad.” 

Trepidation about the COE’s involvement in international accreditation, however, still exists, he said. Concerns peaked among veterinarians in Texas and across the country in 2011, with the accreditation of the National Autonomous University of Mexico (UNAM) in Mexico City.  

UNAM has close ties to Banfield Pet Hospital, the largest corporate chain of veterinary practices in the United States. In 2005, the Portland-based company spent upwards of $10 million to build UNAM a hospital for companion animals so it could pass COE accreditation standards requiring space for the clinical instruction of would-be veterinarians.  

“That was a big elephant in the room,” Garza said of talks during task force meetings. “I don’t know of a single corporation that spends money like that without wanting something in return.” 

Banfield's involvement with AVMA-accredited UNAM did not make it into the task force report, and officials with the company have not publicly acknowledged concerns from veterinarians. With the company’s ever-growing chain of practices — more than 820 in 43 states — some practitioners suspect that Banfield ultimately will turn to Mexico for cheaper veterinary labor. UNAM is one of the largest veterinary schools in the world, and unlike costly U.S. veterinary programs, education at UNAM is nearly free for students.  

Given that veterinarians from UNAM aren’t saddled with student loan debt that weighs on many of their American colleagues, they might be willing to work for less than their U.S.-educated colleagues. To date, however, there's no evidence that the program's 2011 accreditation has caused a surge in UNAM-trained veterinarians seeking work in the United States.

Dr. Eric Bregman, a task force member, worries more that he will be pushed out of business by domestically trained veterinarians who are graduating in increasing numbers due to growing class sizes and new U.S. veterinary schools.

“My dad, brother and I are all veterinarians and have four practices in the New York City area,” he said. “My dad’s selling his practice on its real estate value because three other practices opened within 10 blocks of him. I have a feline-only practice in Long Island. About six months ago, a recent grad opened a practice four blocks down from me.”  

Bregman added: “Most of the task force members I talked to were concerned about this, but it was made clear that we had to have a laser-like focus on the task at hand.”

Bregman refers to the task force's charge to determine whether COE standards are appropriately and uniformly applied overseas. For example, the COE’s Outcomes Assessment Standard requires a minimum 80 percent pass rate for graduates taking the North American Veterinary Licensing Examination, or NAVLE.

The problem, task force members found, was that foreign programs sometimes had just one or two student taking the NAVLE, thereby unfairly skewing their program’s pass-fail rate. (The NAVLE is a requirement for licensure to practice veterinary medicine across the United States and Canada.)

Also in the report:  

  • The task force found no evidence that representatives of the COE are subjected to international pressure to accredit foreign veterinary schools.  
  • The accreditation of foreign schools contributes to networking among institutions and to the collective level of expertise around the world.  
  • The task force believes the COE should clarify the criteria for determining whether a veterinary school is part of an institution of higher learning, which is a requirement of COE standards, or is a free-standing institution and not eligible for accreditation.  
  • Task force members believe that the accreditation standard requiring programs to conduct research should be reviewed and elements of acceptable research programs should be better defined.  

COE owes response to federal government

Officials within USDE’s National Advisory Committee on Institutional Quality and Integrity (NACIQI) also are looking for the AVMA to make changes to its accreditation program, but for slightly different reasons.

NACIQI, an 18-member panel that advises the Secretary of Education on higher education accreditors, ordered the AVMA in December to become more transparent, consistent and create additional firewalls against conflicts of interest after at least a dozen high-profile veterinarians objected to how the COE operates. Some of the complaints were heard in Washington, D.C., during NACIQI's evaluation of COE operations. The review is conducted every five years as a prerequisite to continued USDE recognition.

As a result, NACIQI ordered the AVMA to make changes to how the COE operates. The AVMA has until 2014 to respond to the following NACIQI directives:

  • Ensure that those who are on site-visit teams don't make up the majority of members who vote on a program’s accreditation status.
  • Increase the transparency of its decisions, including by publicizing negative accreditation outcomes.  
  • Rework COE policies and procedures so they are less confusing for both university officials and the COE members who apply the standards to programs.  
  • Publicize COE actions in media outlets that reach the general public, not just AVMA members.   
  • Weed out conflicts of interest within COE ranks by overhauling the way members are elected to the council.    

Foreign accreditation isn't under the USDE's purview, so the panel did not consider the AVMA's efforts to accredit international programs.

Even so, AVMA officials are aware of veterinarians' concerns. In the discussion on the AVMA's blog, CEO DeHaven addressed why protecting the American workforce can't be an objective of an accrediting agency.

"Simply put, if we are going to maintain the integrity and credibility of AVMA COE accreditation, then accreditation decisions need to be based strictly on the quality of the program being evaluated and whether or not it meets the high standards," he wrote. "... We are a free market society, and we have laws to ensure it stays that way. Applied to this situation, any effort by AVMA (or any other entity that accredits programs such as veterinary colleges) to assert economic controls on the workforce through the accreditation process would be illegal."

Folger, the feline practitioner in Houston, believes the AVMA should get out of the foreign accreditation business and focus more on its members.

"Should global accreditation become a necessary consideration, the COE should have reserved for it a single seat at a much larger table joined by other interested sovereign nations and regional veterinary institutions and organizations," he said.

June 11 update: AVMA Executive Board Chairman Dr. Jan Krehbiel today released a statement explaining that the board voted to continue accrediting foreign veterinary medical schools because "the benefits outweigh the risks."

"The world looks to the United States and to the AVMA for leadership in veterinary education," he wrote. "Allowing international schools to seek accreditation and recognition according to established COE standards improves the quality of global veterinary education."

Krehbiel's statement concluded by acknowledging the AVMA's critics: "I know that some of you may never support or agree with this decision. I also know that this explanation may not be acceptable to some of you. However, it is the responsibility of the Executive Board to garner input and advice from its volunteer leaders and its members, to then weigh that advice carefully and discuss it thoroughly, and to ultimately make sound decisions based on fact and on what will have the most positive impact on the veterinary profession as well as individual members. In this case, we felt the best decision was to continue the accreditation process."

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