First of all, I'd like to say that I think the Caribbean is a completely reasonable route for those with less than perfect records.
The Step I passing rate at the Caribbean medical schools is misleading. You might read that the first time pass rate is 95%, but that's a misleading number. Take St. George's for example. The reported 1st time pass rate is probably around 90-95% (it varies by year). However, there is considerable attrition. My understanding is that SGU doesn't have many students who drop out due to poor grades. However, a significant amount of the students decelerate. The same students you start your courses with may not all make it to the boards at the same time. In addition, many of the Caribbean schools require that their students pass shelf exams before sponsoring them for Step I.
It's not super hard to get a residency coming from the more established non-LCME Caribbean schools (e.g., SGU, Ross, AUC, and Saba). Thousands of residency positions are filled by FMGs. However,
you are at a significant disadvantage in getting the residency of your choice. Highly competitive specialties (integrated plastics, ortho surgery, urology, ENT, ophthalmology, dx radiology, rad onc, dermatology, neurosurgery, etc.) are very difficult or nearly impossible to obtain coming from a Caribbean school. Top programs in less competitive specialties (e.g., some Internal Medicine programs) are also very difficult or nearly impossible to obtain coming from the Caribbean.
I'm going to have to disagree with your friend. To state the obvious, highly competitive residencies are highly competitive residencies.
It might be highly competitive to get a certain residency (e.g., dermatology) coming from a US MD school. But coming from a Caribbean med school? Pretty much slim to nil right after graduating. Look, SDN's rad onc moderator, an SGU grad, landed a residency in rad onc at Hopkins. That was quite a few years ago and I believe FMGs match into rad onc much less frequently now. If you ask her point blank whether US MD students and FMGs are on equal footing for that residency, I'll guarantee you that she'll say that FMGs are at a major disadvantage -- and she's been on both side of rad onc residency admissions.
Some of the Caribbean med schools' match lists are misleading (this includes SGU). Last I checked, they didn't even separate preliminary vs. categorical surgery matches. In addition, SGU doesn't specify PGY-1 and PGY-2 years like they should (this could be a plus or a minus depending on how you look at it and what specialty is mentioned).
Take a look at the residency match list for a place considered "less competitive" or "a backup" such as NYMC, Drexel, Rosalind Franklin, etc. I'm willing to bet you'll see that the overall match is generally much better. And check out the residency placement of a supposed "middle tier" school and you'll see a huge difference.
Neurology is really its own residency, not an IM fellowship.
Yes, you can get a good university-based IM program coming from the Carib. SGU and Ross get a bunch of their graduates into those residency programs every year. And if you want to go for a fellowship after that (GI, Cards, Pulmonary, Nephrology, etc.), your medical school isn't going to really matter much. If you know that's what you want to do, then yeah, Caribbean is probably fine and you'd be saving time. This is what my best friend thinks he's going to do -- at the moment anyway.
Other considerations:
Stigma of being a US IMG: It's up to you if this an issue or not, but this does play a role in many residency programs (but much less in practice)
Poor living conditions (except maybe AUC, which I don't think is as strong as SGU or Ross)
Hurricanes
Great variability in education from one Caribbean school to another: It's best to stick with SGU, Ross, AUC, and Saba. Make sure you know the licensure issues of the states you would consider practicing in. The ones to be especially careful about are New York, California, and Texas.
Huge class sizes
Very expensive
Fewer research opportunities- especially in the basic science years
Some Carib schools accept students who should NEVER have been accepted in the first place- There are students with sub-20 MCATs, low GPAs and crappy study habits who think they can suddenly turn their lives around. Some Carib schools accept these applicants, the students aren't prepared and fail out, and the Carib schools take the money to the bank. I think it's great that some Carib schools are willing to give people the opportunity to realize their dreams, but some of the ones they accept have basically no chance of succeeding. In this case, I'd say these low MCAT, low GPA, poor study habits - students *should do a postbac first* to prepare for med school before even
thinking of attending med school anywhere.
Fewer combined degree programs- there are a few and most of them are worthless. The MPH in SGU's MD/MPH program is a HORRIBLE option. It's okay if you're doing their one-year MPH because of the guaranteed admission to SGU and you're at your last resort. But if you actually want an MPH? You're in the wrong place, buddy! It carries no accreditation (state or CEPH or ASPH) in the US and costs as much or more than good one-year MPH programs for professionals in the US. A lot of the most desired MPH programs in the country are comparably priced (sometimes even cheaper) and can be finished in one year if you're a professional (MD, DO, DDS, DMD, and so on).
Less freedom for elective rotations- some hospitals simply do not allow FMGs to rotate. That can pretty much screw you over if you want to audition in certain hospitals.
My best friend screwed up in undergrad, he is currently an MS-3 at SGU, and he's doing GREAT. He went to a top tier university, but had some trouble in the beginning with his grades. At the time he filed his AMCAS, he had ~3.1 GPA, a sub 3.0 bcpm, and a 30 MCAT (all 10s). He got no interviews at any MD school. He didn't apply to DO schools. He didn't have anything against DO schools, but he simply didn't know about them at the time. Around January or so, he realized he wasn't going to be accepted at a US med school. So he applied to some schools in the Caribbean and some SMPs. During his senior year, he pulled a 4.0 average and he *knew* he was ready. He got into the SMPs at BU and G-town, but he wanted to get on with his life. He worked his ass of his first two years and has a 3.9+ GPA (4.0 in science courses, one B came in some legal/healthcare class of some sort). He scored in the 240s on his USMLE Step I this Summer and he's beginning clinical rotations next week at an Ivy League - affiliate medical hospital (part of the Cornell-Columbia New York Presbyterian Hospital System). He's seriously considering doing Internal Medicine w/ a possible fellowship (after doing a summer shadowing experience program that exposed him to multiple medical specialties) and for getting into that, he'll be able to get into a solid program. But he hasn't ruled out something like rads or ortho, and for that, matching is not a sure thing coming from the Caribbean; he'll have his work cut out for him if he pursues that path.
Closing thought:
The more established Caribbean schools are a completely reasonable option. I do think that DO schools offer some significant advantages over Caribbean schools in some respects, but there *are* reasons
other than the initials why people would go to Caribbean schools instead of DO schools even if they may have been accepted to or were competitive for some osteopathic schools (e.g., more international practice rights and not wanting to do OMM). But you should be aware of what you're getting into before you make the decision to matriculate at a Caribbean med school. Caribbean MD schools =/= US MD schools.
On a completely unrelated note, I listened to Radiohead's the Bends today and it's still one of the best damn albums I've ever listened to. 
😛
