The changing meaning of a health care workforce

In this commentary, the author describes how the meaning of the health care workforce has changed, focusing on the physician workforce. Some questions have been asked consistently over the years: How many should we have? What type? Where should they work? In 1830 there were no licensing laws, and every literate American could be a member of the health care workforce by following detailed instructions in a popular handbook. Subsequent years saw the initiation of state licensing laws and the reform of medical education. Medical specialties and specialty boards were created, although it was not until after World War II that the dominance of the general practitioner gave way to specialists. For over a century, estimates of physician supply have swung between "too many" and "too few." Rural and economically disadvantaged communities have long struggled with access to health care providers. The author also identifies some issues that have only been considered fairly recently, such as the ethnic and gender diversity of the workforce. Wars have played a major role in changing ideas about the workforce, often in ways that long outlast the actual dates of the conflict. The meaning of the health care workforce has always been deeply embedded in a specific social, political, and economic context.

Assessment in the context of licensure and certification

Over the past 25 years, three major forces have had a significant influence on licensure and certification: the shift in focus from educational process to educational outcomes, the increasing recognition of the need for learning and assessment throughout a physician's career, and the changes in technology and psychometrics that have opened new vistas for assessment. These forces have led to significant changes in assessment for licensure and certification. To respond to these forces, licensure and certification programs have improved the ways in which their examinations are constructed, scored, and delivered. In particular, we note the introduction of adaptive testing; automated item creation, scoring, and test assembly; assessment engineering; and data forensics. Licensure and certification programs have also expanded their repertoire of assessments with the rapid development and adoption of simulation and workplace-based assessment. Finally, they have invested in research intended to validate their programs in four ways: (a) the acceptability of the program to stakeholders, (b) the extent to which stakeholders are encouraged to learn and improve, (c) the extent to which there is a relationship between performance in the programs and external measures, and (d) the extent to which there is a relationship between performance as measured by the assessment and performance in practice. Over the past 25 years, changes in licensure and certification have been driven by the educational outcomes movement, the need for lifelong learning, and advances in technology and psychometrics. Over the next 25 years, we expect these forces to continue to exert pressure for change which will lead to additional improvement and expansion in examination processes, methods of assessment, and validation research.

An ERAS-based survey evaluating demographics, United States Medical Licensing Examination Performance, and research experience between American medical graduates and United States citizen international medical graduates: is the bar higher on the continent?

OBJECTIVE

To provide an assessment and comparison of the demographics, medical school academic performance, United States Medical Licensing Examination (USMLE) performance, and research experience between American Medical Graduate (AMG) and United States International Medical Graduate (USIMG) candidates who applied for and successfully matched into categorical general surgery residency programs.

DESIGN

Data were obtained through the Electronic Residency Application Service (ERAS) and a post-match survey distributed to all applicants.

SETTING

The study was conducted at a community-based, university-affiliated hospital.

PARTICIPANTS

All United States citizen graduates of allopathic American medical schools or international medical schools, who were applying for a general surgery residency position at our institution.

RESULTS

A total of 854 candidates applied, including 143 AMGs and 223 USIMGs. Seventy-two AMGs (50.3%) and 41 USIMGs (18.4%) were invited to interview (p < 0.0001). Mean USMLE step 1 scores were higher among USIMG applicants overall (USIMG: 212.1 ± 14.9 vs AMG: 206.9 ± 15.5; p < 0.0005) and among those invited to interview (USIMG: 227.8 ± 16.2 vs AMG: 215.5 ± 16.2; p < 0.0001). Seventy percent of AMGs matched into a categorical surgery residency compared with 31.6% of USIMGs (p < 0.001). Compared with AMGs, USIMGs applied to more programs (USIMG: 90.3 ± 42.8 vs AMG: 52.1 ± 26.4; p < 0.002), were offered fewer interviews (USIMG: 9.0 ± 6.9 vs AMG: 20.9 ± 13.7; p < 0.0001), and subsequently ranked fewer programs (USIMG: 7.5 ± 4.5 vs AMG: 12.5 ± 6.1; p < 0.0008).

CONCLUSIONS

USIMGs require higher USMLE scores than their AMG counterparts to be considered for categorical general surgery residency positions. However, excellence on the USMLE neither ensures an invitation to interview nor categorical match success. A well-rounded application in conjunction with a practical application strategy is critical for USIMGs to achieve success in attaining a general surgery residency position.

Assessment steers learning down the right road: impact of progress testing on licensing examination performance

Although it is generally accepted that assessment steers learning, this is generally viewed as an undesirable side effect. Recent evidence suggests otherwise. Experimental studies have shown that periodic formative assessments can enhance learning over equivalent time spent in study (Roediger & Karpicke 2006). However, positive effects of assessment at a curriculum level have not been demonstrated. Progress tests are a periodic formative assessment designed to enhance learning by providing objective and cumulative feedback, and by identifying a subgroup of students who require additional remediation. McMaster adopted the progress test methods in 1992-1993, as a consequence of poor performance on a national licensing examination. This article shows the positive effect of this innovation, which amounts to an immediate increase of about one-half standard deviation in examination scores, and a consistent upward trend in performance. The immediate effect of introducing objective tests was a reduction in failure rate on the licensing examination from 19% to 4.5%. Various reasons for this improvement in performance are discussed.

The circle game: understanding physician migration patterns within Canada

This report explores the movement of physicians to, from, and within Canada and identifies recurring patterns of migration. The primary position of the report is that physician movement is part of reality both internationally and within Canada, and that movement of Canadian-trained physicians creates a need for international medical graduates (IMGs) in "physician-losing" locations. The report's argument is based on data retrieved from public sources on aggregate physician practice patterns in Canada and analyzed for migration patterns. In addition, literature was reviewed on factors affecting the migration patterns being described.Canadian-educated physicians have tended to move from less prosperous to more prosperous provinces and from rural to urban areas; because of the resulting need, the physician-losing locales generally have the highest proportions of IMGs. Physicians traditionally have tended to emigrate from Canada to the United States, thus increasing Canadian demand for IMGs, but recently this movement has slowed and even reversed. In Canada, liberalized immigration policies for physicians combined with a shortage of postgraduate training positions to create a serious bottleneck early in the current decade. However, this problem is now being resolved. In summary, physician migration within Canada shows specific long-term patterns, and IMGs will be needed in underserved areas for years to come. Well-informed policies for workforce management are essential in Canada to ensure an adequate physician supply consisting mainly of Canadian-educated physicians but also including IMGs. A role for nonadvocacy groups such as the Educational Commission for Foreign Medical Graduates may be to help ensure that recruitment of physicians from developing countries follows accepted ethical principles.

The future of medical licensure in the United States

Medical licensure in the United States is undergoing significant change. With calls for greater accountability and transparency, state medical boards and their membership association, the Federation of State Medical Boards (FSMB), are seeking ways to assure the public that physicians are maintaining their competence throughout the lifetime of their practice of medicine. At present, competence in cognitive, clinical, and communicative skills is regularly measured only at initial licensure. Yet, the public and policy-related organizations are demanding ongoing assessment of physicians' ability to safely and competently practice medicine. The author reports on activities that involve the FSMB and other national organizations, including the Educational Commission for Foreign Medical Graduates, in planning for a future of increased accountability and transparency of the licensing and regulatory communities that oversee the practice of medicine. He notes that topics of discussion include possible nationalization of what has been traditionally state-based licensure. He raises questions about a future that may include specialty-based licensure and greater national and even international license portability.

A multilevel analysis of the relationships between selected examinee characteristics and United States Medical Licensing Examination Step 2 Clinical Knowledge performance: revisiting old findings and asking new questions

BACKGROUND

This study examines: (1) the relationships between examinee characteristics and United States Medical Licensing Examination Step 2 Clinical Knowledge (CK) performance; (2) the effect of gender and examination timing (time per item) on the relationship between Steps 1 and 2 CK; and (3) the effect of school characteristics on the relationships between examinee characteristics and Step 2 CK performance.

METHOD

A series of hierarchical linear models (examinees-nested-in-schools) predicting Step 2 CK scores was fit to the data set. The sample included 54,487 examinees from 114 U.S. Liaison Committee on Medical Education-accredited medical schools.

RESULTS

Consistent with past examinee-level research, women generally outperformed men on Step 2 CK, and examinees who received more time per item generally outperformed examinees who received less time per item. Step 1 score was generally more strongly associated with Step 2 CK performance for men and for examinees who received less time per item. School-level characteristics (size, average Step 1 performance) influenced the relationship between Steps 1 and 2 CK.

CONCLUSION

Both examinee-level and school-level characteristics are important for understanding Step 2 CK performance.

[New licensing regulations for physicians. Main areas of reform and first results of the implementation process]

Since October 2003 medical education in Germany has been given a new more up-to-date basis, the "New Licensing Regulations for Physicians". They represent a reform of both the structure and the content of medical education making great demands on medical faculties and medical students; e.g. elective courses during the first and second cycles of the curriculum, interdisciplinary courses (so-called 'cross-sectional courses'), practical clinical courses of several weeks in five specialties, and family medicine as an option for choice during the last year are central issues of the reform. The number of state-controlled medical examinations has been reduced from four to two. It is now the responsibility of medical faculties to assess the knowledge, clinical skills and professional attitudes of students with respect to the numerous specialties which are part of medical education. This paper presents the essential innovations and describes the current state of the implementation process. It also points out problems that deserve reconsideration. Although the full implementation of the new licensing regulations is still in progress, it might be said that they have already initiated important changes in medical education in Germany.

[The Berlin reformed medical curriculum at the Charité. Experiences with the first cohort]

At the end of the 2004 summer term the first students of the Berlin reformed curriculum finished their education and took their first state examination. With regard to the questions to be answered by the "Berlin Model" the results of the first cohorts were presented and discussed. Overall the Berlin curriculum was successful. The results led to some important considerations concerning adaptation by other faculties, the requirements to start off a problem-based curriculum or an enlargement of the class.

[Abolishment of the AiP. Transformation and further regulations]

Abolishment of the time as a physician in training (intern) in Germany on 1 October 2004 completed the reform of the education of doctors and the total time of education was reduced to 6 years. So the wages of young doctors could be raised and the aim is that these doctors will begin their jobs in hospitals in Germany and not abroad, so that this will be a measure to counteract the regional shortage of doctors. To finance the difference between the wages of the former trainees and now the young doctors in the hospitals, the German law about modernisation of the social health security system ("GKV-Modernisierungsgesetz") ensured that a budget of about 300 million euros would be provided to the hospitals by German health insurance companies. Implementation of this reform in general caused no problems. This can be ascribed to the fact that there are more than 3,000 open jobs for young doctors in German hospitals today.

[Medical education in Germany: past successes and future challenges. An overview]

The reform of the education of doctors with the regulation for licensing of doctors (Approbationsordnung) of 27 June 2002 was a fundamental one. The results of the reform are a better practical training, a better link between theoretical and practical education, a better training in general medicine and a reform of the examinations. As a further result of the reform the additional practical training of 18 months could be abolished with the law from 26 July 2004. Now the universities must transform the regulation into practice and evaluate it. The universities must implement the federal regulation in their university educational regulations and in their day-to-day practice. The further changes in Europe, in the German regulations of specialisation and in the German health security system will create new needs for forthcoming reforms.

Die Bologna-Deklaration

The so-called Bologna process was initiated by the political agreement of ministers of education of different European countries with the objective of creating a common European area of higher education. The content of the agreement was laid down in the declaration of Bologna. Despite lacking legal obligations the implementation of a two-cycle system and the realisation of a general framework for study courses and graduation gained rapid dynamism. Parts of the Declaration of Bologna are without controversy, for example the promotion of mobility by overcoming obstacles to the freedom of movement within the European Union. The structuring of university studies in an undergraduate and a graduate cycle (bachelor/master) may make sense for some study courses but it would be a disaster for medical studies. Not only that the integrative efforts laid down in the new regulation of basic medical studies would be reversed. Much more alarming is the fact that, against the background of a lack of physicians and financial shortages, the two-cycle system would favour the trend to fall back on graduates of paramedical studies in order to ensure medical care. Last but not least the one who has to suffer for it would be the patient.

[Selection of medical students by medical faculties. Problems and advantages for universities]

Due to the amendment of the framework act for higher education in summer 2004, the German universities have to select 60% of the students within all disciplines with limited access (including medicine) by themselves. This requirement fits with the political intention to enhance the achievement of a specific profile and competition among the universities. The first implementation of the legal requirement has shown that the universities were insufficiently prepared to apply selection criteria amending high school grades. Theoretically, a variety of criteria could be considered whose suitability has to be evaluated carefully. Existing evidence related to these criteria is summarized in this article. The implementation of new tools for student selection will raise a variety of problems related to the quality of organisation, but also other aspects of quality assurance. It can be assumed that, in the long run, centrally developed tests will be applied within medicine that might be completed with other selection tools locally.