Letters to the Editor  |   August 2008
Dangers of For-Profit Education: More Than Just Words
Author Affiliations
  • George Mychaskiw, II, DO
    Department of Anesthesiology Chief of Anesthesia Blair E. Batson Hospital for Children University of Mississippi School of Medicine Jackson
    Professor and Vice Chairman
Article Information
Medical Education
Letters to the Editor   |   August 2008
Dangers of For-Profit Education: More Than Just Words
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 366-458. doi:10.7556/jaoa.2008.108.8.366
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 366-458. doi:10.7556/jaoa.2008.108.8.366
To the Editor:  
The letters of Peter B. Ajluni, DO,1 and Ronnie B. Martin, DO,2 in the October 2007 issue of JAOA—The Journal of the American Osteopathic Association dismiss the for-profit status of Rocky Vista University College of Osteopathic Medicine (RVUCOM) in Parker, Colo, as a mere difference in “tax status,” compared with nonprofit colleges of osteopathic medicine. The implication of these letters—both of which were responses to an earlier letter of mine3—is that the term “tax status” is just a legalistic technicality that is important only on an obscure line of a corporate 1040 tax form. 
In fact, nothing could be further from the truth. The tax status of a school is critically important in defining the overall philosophy and mission of that school—and it goes to the heart of what is wrong with for-profit education. 
Dr Ajluni1 is quite correct in his assertion that there are many socially minded for-profit corporations, but the comparison of a medical school with such a corporation (eg, Dell Inc), or even with a for-profit hospital, is as invalid as comparing the proverbial apples and oranges. A school's mission should be the education of its students, whereas a for-profit corporation's mission should be the maximization of profit for its investors. 
Socially minded corporations engage in charitable activities because such acts are good business. The general public will always see a responsible corporate member of the community as being more worthy of its business. In the end, such a public perception will boost the corporation's bottom line. No for-profit corporation would engage in charitable activities at the expense of profit—that is, there comes a point at which the goodwill gained by charitable activities is no longer exceeded by the secondary increase in revenue. At that point, charitable activities stop. To do otherwise in a for-profit environment would be irresponsible. 
Both for-profit and nonprofit institutions must produce a high-quality product to stay competitive in the marketplace. However, the difference between these two types of institutions lies in their use of excess revenue. In the case of a nonprofit medical school, all excess revenue is returned to the institution and used to improve its facilities, expand its programs, and engage in research to increase the existing body of medical and scientific knowledge. Frequently, these endeavors realize no short-term reward for the school and would be viewed as fruitless in the for-profit world. Yet, valuable medical discoveries are often built on years of seemingly inconsequential basic science research. 
Thus, it is fair to ask, where will a for-profit medical school draw the line in conducting research? This is a matter of simple economics: to make a profit and generate a return to its investors, a for-profit medical school is likely to divert funds that could otherwise be used to engage in the aforementioned research activities, while at the same time maximizing price (ie, tuition) to competitive market levels. 
For-profit medical education is an anathema to the larger medical community. Most for-profit medical schools exist in impoverished, legally permissive locales, such as the Caribbean region, to exploit the desires of individuals who are willing to pay a premium in tuition—and sacrifice education quality and personal credibility—to become physicians. Certainly, many students who graduate from Caribbean for-profit schools become qualified and respected physicians in the US medical community—but such results happen in spite of, rather than because of, their medical schools. The graduates of foreign for-profit medical schools typically struggle to gain acceptance into US residency training programs, and they frequently must settle for less desirable or unwanted residency slots.4 Considering these realities, I am concerned for the graduates of RVUCOM, the first for-profit medical school in the United States since 1930.5 
Other for-profit medical education ventures have been attempted in the United States in recent years. In 1999, Ross University School of Medicine, a for-profit allopathic institution on the Caribbean island of Dominica, planned to open a branch campus near Casper, Wyo, under the same clarion calls sounded by RVUCOM—meeting the needs of underserved rural communities in the Rocky Mountain West.6 
Through the efforts of the Liaison Committee on Medical Education (LCME), the American Medical Association, and the Natrona County Medical Society, this initiative was vigorously fought and defeated—despite the ostensible support of “many local physicians” and politicians.6 At the time, plans called for the Wyoming campus to be accredited under the auspices of the home campus on Dominica, rather than the LCME.6 
Despite Dr Martin's2 liberal use of the LCME as an example of an accrediting body, the LCME standards state that a medical school should be a nonprofit institution.7 Although this provision in the LCME standards is not an outright prohibition against for-profit medical schools, it still is a long way from the explicit statement by the Commission on Osteopathic College Accreditation (COCA)8 that an osteopathic medical school can be either a for-profit or nonprofit institution. 
Florida-based businessman and real estate investor Yife Tien, BSc, and his wife are the sole owners of RVUCOM.9 There is no reason why, were business to decline, the RVUCOM campus could not be converted overnight into another office park in the rapidly growing Denver metroplex. 
The American University of the Caribbean, which was established by and is owned by Mr Tien's father9 and for which Mr Tien himself has served as chief operating officer, has no traditional connection to osteopathic medicine—aside from the fact that its dean for clinical medical sciences is an osteopathic physician.10 This same individual is also a member of RVUCOM's board of trustees.9 
In a strict business sense, given the popularity of the MD degree, investors would most likely prefer to open allopathic medical schools rather than osteopathic medical schools, if that were possible. 
The LCME is aware of the precedent set by RVUCOM and is currently considering the issue of for-profit educational initiatives in the context of its present standards (B. Barzansky, PhD, written communication, August 2007). 
Nevertheless, there is no evidence to support the concept of for-profit educational institutions as superior to or more efficient than nonprofit educational institutions.11 Furthermore, there is speculation that for-profit medical education will not provide students with an opportunity for a complete experience of humanity, professionalism, and ethics—factors that are ingrained in the nonprofit model of medical education.11 
For osteopathic medicine, the dangers of for-profit education are very real. Regardless of whether RVUCOM provides an education equal in quality to the nonprofit model, there has been no cogent argument put forth as to why the osteopathic medical profession—which has struggled for more than a century to establish its credibility and gain acceptance—needs to take this step. I believe that the individuals who invested in RVUCOM have jeopardized our profession—and, thus, our patients—merely to turn a profit. 
As the “baby boom” generation enters retirement, the United States faces a healthcare challenge heretofore unseen. The “perfect storm” of an aging population, expanding and costly medical technology, and decreasing fiscal resources is looming as a threat to the economy and national security of the United States. 
In the face of these serious problems, it is difficult to justify the establishment of for-profit medical schools in the United States under the guise of osteopathic medicine. When the healthcare funding crisis occurs, as it inevitably will, what is going to get cut first—the large nonprofit medical schools (providing patient care, education, and research) or the smaller for-profit medical schools (generating income for real estate investors)? 
In summary, the “tax status” of a medical school is more than just words. It goes to the very heart and philosophy of a medical school—much more so perhaps than a mission statement, as required by COCA. Although we live in 2008 rather than in 1910, when educational theorist Abraham Flexner5,12 issued his report critical of for-profit medical education, some things do not change and, indeed, should never change. Considering the healthcare challenges facing the United States in the 21st century, the words of Mr Flexner5,12 resonate as strongly today as they did a century ago: 

Such exploitation of medical education is strangely inconsistent with the social aspects of medical practice...the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited.

Dr Martin2 maintains that RVU-COM is “...the right school in the right location at the right time, created for the right reasons.” I respectfully disagree. 
Ajluni PB. Nonprofit and for-profit COMs: investing in the future of osteopathic medicine [letter]. J Am Osteopath Assoc. 2007;107:425-426. Available at: Accessed July 31, 2008.
Martin RB. RVUCOM: striving to meet the needs of the osteopathic medical profession [letter]. J Am Osteopath Assoc. 2007;107:426-428. Available at: Accessed July 31, 2008.
Mychaskiw G. COM accreditation: the Flexner report revisited [letter]. J Am Osteopath Assoc. 2007;107:246-247,277. Available at: Accessed July 31, 2008.
Crosby PJ, Cannon RE. International medical schools for US citizens: considerations for advisors and prospective students; 2004. National Association of Advisors for the Health Professions Web site. Available at: Accessed July 31, 2008.
Beck AH. Student JAMA: the Flexner report and the standardization of American medical education. JAMA. 2004;291:2139-2140. Available at: Accessed July 31, 2008.
Stewart A. The regulated doctor shortage. Consumer Health Journal [serial online]. February 2004. Available at: Accessed July 31, 2008.
Accreditation standards: current standards, latest additions to standards, and standards awaiting approval; June 2007. Liaison Committee on Medical Education Web site. Available at: Accessed July 31, 2008.
Commission on Osteopathic College Accreditation. Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures. Chicago, Ill: American Osteopathic Association. Available at: Accessed July 31, 2008.
Martin RB. Addressing for profit status: a message from the chief academic officer and dean; 2007. Rocky Vista University College of Osteopathic Medicine Web site. Available at: Accessed July 31, 2008.
AUC directory: clinical medical sciences—deans. American University of the Caribbean Web site. Available at: Accessed May 19, 2008.
Croasdale M. First for-profit med school nears approval. American Medical News [serial online]. October 1, 2007. Available at: Accessed July 31, 2008.
Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1910. Available at: Accessed July 31, 2008.