Ross University School of Medicine may be the biggest medical school you've never heard of.
For decades, the school on the Caribbean island of Dominica has been accepting U.S. students whose poor test scores make it impossible for them to get into medical schools in the States.
And though Ross is 1,500 miles from the mainland, U.S. residents who attend the school, and about two dozen other offshore medical schools, qualify for federal student loans.
That has meant more than $150 million a year in government-guaranteed aid for Ross, which has about 3,500 students, double the biggest U.S. medical school.
Ross and other foreign medical schools say they're responding to U.S. demand for new doctors as the population ages.
And there's no question that these schools have produced thousands of practicing physicians. There are more than 80 Ross graduates in the Tampa Bay area alone.
But federal regulators are taking a closer look at evidence suggesting taxpayers and students may be getting shortchanged by foreign medical schools.
• At Ross, fewer than one-third of the students finish in four years, compared to nearly 100 percent at U.S. medical schools.
• Since Ross, like other Caribbean medical schools, doesn't have a teaching hospital, it pays hospitals stateside for students' clinical training, with wide variations in quality.
• Students of foreign medical schools like Ross graduate with higher average debt, $235,000 compared to the average $158,000 owed by graduates of U.S. medical schools, according to an August report to Congress by regulators.
• About 20 percent of Ross graduates fail to land a residency, the key to a license to practice in the United States. If they cannot pay their student debts, taxpayers are left holding the bag.
Steven Moxley, a former Navy corpsman, graduated from Ross in 2005 but can't get a residency due to low test scores. Now 54, with $250,000 in unpaid loans, Moxley is working construction jobs in the Washington, D.C., area and renting a room from his son.
"I'm living hand-to-mouth," he said. "I've got debt out the ying-yang."
Started in a motel
Robert Ross, a commodities trader in New York, opened his medical school in 1978 in a motel in Dominica's capital at the suggestion of an employee whose son couldn't get into medical training in the States. By 2000, Ross had sold majority interest in both the medical school and an affiliated veterinary school in St. Kitts to a group of New York investors. Three years later, both schools were acquired by DeVry for $310 million.
Ross is the only offshore medical school owned by a publicly traded corporation, which must disclose more financial data than privately owned schools.
Last year, DeVry, better known for its tech training schools, reported $165.7 million in net income after taxes. But the company also reported an additional $140 million in tax-free income from the Ross operations.
In order to qualify for federal student loans, schools must report how many students default on their debt over the two years immediately after leaving school.
Ross says less than one percent of its medical students fail to pay their loans during this time frame, but critics question how meaningful that is.
"Lots of schools have developed very sophisticated hand-holding techniques to help their graduates or dropouts get through the two-year window without defaulting," said Barmak Nassirian, spokesman for the American Association of Collegiate Registrars and Admissions Officers. "The student can be making $5 a month payments and the school can come out looking fabulous."
Ross graduate Robb Holley, a pediatrician who is interim director of newborn medicine at Tampa General Hospital, expects to have no problem paying off his $200,000 in school loans but is not in a hurry.
"I could do it earlier, but I just bought a house," the 41-year-old Tampa native said.
The situation is different for Amer Alata, who got his M.D. from Ross in 2007, then quickly washed out of an internal medicine residency — and his prospects of becoming a physician. Now saddled with $470,000 in debt, he's teaching part-time but has never been able to afford a payment, making him one of Ross' official defaults.
"I'm in a state of paralysis," said Alata, 30, who lives outside Detroit. "The worst part is that I know I am not alone."
A spokeswoman for Ross, which has offices in North Brunswick, N.J., declined to discuss Alata's case but defended the institution's "high-quality education and successful student outcomes, comparable with U.S. medical schools."
"At a time when our country is in desperate need of quality physicians, they will help fulfill the unmet need and make important contributions to society," said Ross' Rebekah Herbison.
No one disputes that it's easier to get into Ross than a U.S. medical school. Ross accepts scores on the MCAT, the standardized test all medical school applicants must take, as low as 17, compared to an average of nearly 31 at U.S. medical schools.
Like all medical schools, Ross divides its four-year program into a basic science curriculum followed by hands-on clinical experience. But U.S. medical students usually spend two years in the classroom followed by two years in a teaching hospital on the same campus.
Ross students have 16 straight months of concentrated coursework on Dominica, followed by a fifth semester of intense test preparation in Miami or Saginaw, Mich. Once students pass Step 1 of the U.S. Medical Licensing Exam, they're assigned to two years of clinical rotations in hospitals around the country that have contracts with Ross.
Like U.S. medical students, once Ross enrollees complete their clinicals and pass another standardized exam, they graduate with an M.D. degree, then go on to post-graduate residency training before becoming a licensed physician.
Many Ross students don't make it that far. Even after six years, only 66 percent of entering students graduate.
Some students bail within days of arriving on Dominica, where there is little shopping and few restaurants. Others spend extra time on the remote island, repeating failed courses and running up debt. Ashley Sullivan, who had a 4.0 GPA during her two years at Ross, said one classmate was allowed to repeat three semesters he had failed. "He's a dear friend, but I'm not sure I'd want him taking care of me," she said.
Sullivan lost faith in her physician-educators at Ross after they misdiagnosed her swollen arm as an allergic reaction. When she returned home to Houston, doctors there discovered she had a massive blood clot. Once recovered, Sullivan returned to Dominica only to learn that Ross was reneging on a promise that she could do her clinical rotation in a Houston hospital not officially affiliated with Ross.
"My confidence in Ross had been obliterated and so I left," she said.
Now $100,000 in debt, Sullivan, 29, is working in management consulting for oil and gas companies.
"I realized I wouldn't have been proud of myself if I graduated from Ross," said Sullivan, whose parents are helping with her loan repayments, keeping her out of the default category. "It was a horrible experience."
After finishing their coursework and passing the USMLE Step 1 exam, Ross students vie for clinical rotations at more than 70 locations nationwide that contract with the school.
Michael Rendon, registrar at Ross from 2006 to 2007, said finding suitable clinical training sites was always a challenge.
"Clinicals is the school's Achilles' heel," said Rendon, now registrar at Texas A&M University at Corpus Christi. "There are simply not enough sites, and that problem is not going to go away anytime soon."
Anand Dasrath, 52, says he was forced out of Ross because of the shortage of clinical sites. A pharmacist from New York City, Dasrath finished his studies on Dominica with nearly a 3.0 GPA, but was told he flunked the semester in Miami, though he never received a formal grade.
Back working as a hospital pharmacist, Dasrath, who took on about $60,000 in loans for school, is suing Ross for age discrimination and breach of contract. His lawyer, Salvatore Compaccia, said, "Ross takes your money, then when it's time to place you in a hospital, they create an excuse to get rid of you."
A crisis arose in February when two New York hospitals where Ross had paid for 135 training slots closed, sending students scrambling. Graduates say there are always last-minute scheduling changes that can mean cross-country relocations and sites with widely disparate opportunities.
Students doing clinicals in the States continue paying tuition to Ross, which at more than $30,000 a year is comparable to that at private U.S. medical schools. Yet Ross students say they have virtually no contact with the school's faculty. That means they're on their own if problems arise.
Alata, the Detroit-area graduate, said he had a six-week psychiatry rotation supervised by a surgeon. "He gave me an assignment on cardiovascular disorders," Alata said. "I never had the opportunity to interview a psychiatric patient. There was no clinical experience whatsoever."
During training in Miami, Alata, who speaks no Spanish, was unable to communicate with most of the patients.
"Ross is supposed to monitor those sites, but in two years, I never saw anybody come to visit or ask me about them," he said.
Some students say they thrived despite the loose structure. Holley, the TGH pediatrician, said he sought out the toughest rotations and got valuable experience at his assignments.
"The patients I saw in New York City were from all over the world, and I saw all kinds of diseases I would not see in Tampa," he said. "I'm really glad I did it. It made for a well-rounded experience."
Dr. Mamatha Geddam, who recently joined a family medicine practice in St. Petersburg, also had all her Ross rotations in New York City. She said the students helped each other through.
"It would have been helpful to have an academic adviser because we were quite a big herd," she said. "But we learned from whoever had done it before."
Not ready for residency
Alata said he received "very high evaluations'' from supervisors during his clinical rotations in Miami, New York and Chicago and passed his mandatory USMLE Step 2 exam.
But three weeks into a residency in internal medicine and pediatrics at Virginia Commonwealth University School of Medicine, Alata was suspended from all clinical activities because of poor performance. A few months later he voluntarily withdrew.
"Once you start your residency, you find out how little you know," Alata said. "It was a complete shock when I sat down with the dean and she said I should go back to Ross and tell them how inadequate my training was."
Officials at the Virginia college declined to comment.
Directors of residency programs at the University of Florida College of Medicine in Jacksonville and Bayfront Medical Center in St. Petersburg, both of which have accepted Ross graduates, said they've seen these students succeed.
"Once they're here, we're in training mode and they do fine," said Dr. David Parrish, head of family practice residency at Bayfront, which has three Ross grads.
But Dr. Peter Fabri, former dean of graduate medical education at USF College of Medicine, said his school has had a different experience.
"The quality of clinical education Ross students get is very, very unpredictable," said Fabri, a professor of surgery who retired as dean in September. "We've had some Ross students whom I'm told are superb, but we've also had a number from Ross who ended up being dismissed because they just didn't have it. And it's rare that any residents are dismissed."
More schools coming
Fabri, who has served on national commissions on graduate medical education, said students from foreign medical schools are going to be at a growing disadvantage.
Five new U.S. medical schools, including the University of Central Florida and Florida International University, have begun enrolling students and four more schools are in the permitting process. Those new graduates will make it tougher to get residency slots, which have not increased.
"I have not encouraged our program directors to take students from Caribbean schools," Fabri said. "And now that the competition is greater, I'm telling them to be very, very thoughtful."
In a report to Congress in August, the group that accredits offshore medical colleges recommended that the schools raise standards and improve reporting on everything from test scores to graduation rates to total cost.
Rendon, the former Ross registrar, said he agrees with the need to stiffen entrance requirements.
"We want doctors but we can't give that kind of money to everyone who's chasing a dream of being an M.D.," he said. "We need to be a little bit more discriminating about who those tax dollars go to."
Times researcher Shirl Kennedy contributed to this report. Kris Hundley can be reached at firstname.lastname@example.org or (727) 892-2996.