I also agree with that. The LCME could absolutely change the rules - the question is would they and why?
I characterized Puerto Rico as an "exception", and I know you took a little umbrage with that. Naturally, I don't work at the LCME and I have no idea what is going through their collective minds, past or present. But, the reason why I would characterize Puerto Rico (and Canada, for that matter) as being
included (maybe that's a better word) has to do with pragmatism more than anything else.
When the rules were established, as I mentioned before, the goal was to likely limit burdening the regulatory component of the ECFMG for those graduates/doctors who would be more prone to crossing the borders/getting in a plane for training or otherwise to establish a practice. It makes sense for Canada, which has numerous well-established schools, to be
included because it would significantly cut down registration with the ECFMG, giving consideration to the excellent training at those schools and the high bar for admission... and that we share a border. That's very neighborly.
Again, why Mexico - who also shares a border - wasn't included and instead given a "fifth pathway" is beyond me, but probably had to do with concerns about purportedly "sub par" matriculants (and possibly what-was-considered sub par training) at some of those institutions. It was too much work for potential oversight of the 38 Mexican medical schools for the LCME. So, they just wrote the rules to exclude them. There are only 4 in Puerto Rico (one of which has had problems maintaining LCME accreditation), which is much easier manage. Plus, as you astutely point out, it is a part of the U.S. However, they could've very easily made a "fifth pathway" type of arrangement for Puerto Rico, but that might have been a political lightning rod at the time. Just easier to include them and provide proper oversight. Again, remember the rules, and who's
excepted, included, or not included, are
arbitrarily set by the LCME.
Now, consider St. Croix opening a medical school that would likely going to be run in what is tantamount to a similar model for the other already well-established Caribbean medical schools. What would be the
real difference, then, between St. Croix's school and Ross, AUC, or St. George's? The biggest part of why the LCME has never considered including these schools, in my estimation, has to do with the fact that they are perceived as
not really being institutions of higher learning that support research, residency, ongoing training, etc. and instead more as
clinical instruction sites that circumvent requirements of what the LCME considers necessary for the "mission", if you will, of medical education (namely research, clinical stewardship, etc.). If this is the case as it plays out, I don't see how they could approve the U.S. Virgin Islands school if this is the model. The rules wouldn't have to change.
However, let's say they somehow meet the requirements. I don't still believe that the LCME would want to accredit this type of program, notwithstanding the fact that I believe it would be hard for them (in my opinion) to maintain that accreditation. Again, it has to do with resources and opening the door for other such programs in Guam, Marianas Islands... heck, even Samoa. That's why I think they would consider changing the rules, were this to become the case.
I will say this, though. With the infusion of promised cash, I think that there is a real challenge there. I would hate to be at the LCME trying to figure out what to do about this "problem". It is my strong opinion that the AAMC and LCME (and other regulatory bodies) would like nothing more than to see the Caribbean medical schools completely disappear. Discussion of this school in St. Croix just adds a different, and slightly bizarre, challenge to the mix. That's why I'm not holding my breath. The rules have created the current situation, no doubt. But, I don't believe that anything is off the table, including (again) changing the rules to
fit the situation.
-Skip