The Foreign Route

With only a B average at the State University of New York at Buffalo, Ronald Koval of Dover, N.J., knew that he faced tough competition when he applied for admission to medical school back in 1965. So he was not surprised when each of his eight applications was rejected, one with a curt note wishing him success in another field. But Koval refused to abandon his ambition to become a doctor. For the past seven years, he has been studying at Belgium's Free University of Brussels, and next month he will finally receive his M.D. degree.

Koval is one of some 4,000 Americans now studying for their M.D.s abroad. Many of them were well qualified to enter overburdened U.S. medical schools but were rejected simply because there was no room for them. Last year, for example, only some 13,000 of 35,000 would-be physicians who applied for admission to U.S. schools were accepted. Of those who were turned down, well over 600 are trying the foreign route, further swelling the ranks of U.S. medical students overseas.

For those who take that route, gaining admittance to a good school may be a problem. For a start, many foreign schools simply will not accept Americans. In fact, laws in The Netherlands and Switzerland restrict or deny admission to most foreign students. British medical schools give priority to Britons, and Canada's world-renowned McGill University School of Medicine takes only a handful of well-qualified Americans annually. But there are several schools that do welcome U.S. medical students--if they can master the local language. The Belgian universities at Brussels and Louvain have a total of more than 500 Americans. Some 800 attend the Italian university at Bologna; the medical school at Rome has 175 more, many of whom make their presence known every Thanksgiving Day by playing in a football game that has become known as the Pasta Bowl. Mexico's Autonomous University of Guadalajara has the largest contingent; it numbers 1,300 gringos among its 4,000 students.

The four-year course at Guadalajara resembles an American medical school curriculum, but education at European medical schools is considerably different. Because European students often enter medical training directly from high school, most schools on the Continent require six or seven years for an M.D. compared with only three or four in the U.S. Before they get their diplomas, graduates of Louvain must take a one-year internship, while Mexican schools require a year of social service, usually in rural areas. Furthermore, American schools increasingly emphasize clinical experience and put students into contact with patients early in their training; European schools --which have limited teaching-hospital facilities--rely heavily on lectures and classroom work.

Despite these differences and difficulties, most Americans complete their educations abroad, and manage to win the respect of their professors and classmates. "American students are either exceptionally good or exceptionally bad," says Dr. Antoine Dhem, a professor of anatomy at Louvain, "and the vast majority are exceptionally good." Lynette Goodstine, 26, of Manchester, Conn., a second-year student at Louvain, has a simple explanation for the Americans' success. "Anyone who comes here has to be motivated," she says. "You have to learn a new language, the school is constant hard work, and it's difficult to get back into the States to practice."

Before they can intern or practice in the U.S., American graduates of foreign schools must pass a special examination administered by the Educational Council for Foreign Medical Graduates. Some American students feel that the tests, required by the American Medical Association and the American Hospital Association, discriminate against those who fail to gain admission to U.S. medical schools. Others, noting the shortage of physicians in the U.S., see an A.M.A. plot to protect the practices--and incomes--of American-trained physicians. Actually, the test is not insurmountable for most U.S. students trained in good foreign schools; it is primarily designed to weed out students who are unable to speak English or whose medical education is not up to U.S. standards. Many of those who pass go on to gain good positions in the U.S. on hospital staffs or as instructors in medical schools.

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