Examining the WFME Recognition Programme at 10 years

BACKGROUND

In 2012, the World Federation for Medical Education (WFME) evaluated and formally recognized the first agency in its Recognition Programme (RP). The RP was developed to review accrediting authorities in response to a 2010 policy by the Educational Commission for Foreign Medical Graduates (ECFMG) to require international medical graduates (IMGs) seeking to practice in the U.S. to graduate from an appropriately accredited medical school. By the end of 2022, WFME had recognized 33 accrediting bodies and received applications from another 16, which accounted for over three-quarters of the world's medical schools. In 2023, WFME leadership changed hands, and the ECFMG will take its first steps toward implementing its Recognized Accreditation Policy.

APPROACH

In this article, we look back at the genesis of the RP and describe its first decade as informed by the limited existing peer-reviewed literature and the emerging activities of accrediting agencies that could have significant implications for the quality of medical education internationally.

CONCLUSIONS

The rapidly growing influence of WFME on medical education worldwide has largely occurred without significant awareness or scrutiny, and there is a need for the WFME to demonstrate greater transparency, proactively engage its stakeholders, and support research and evaluation.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?

Issue: The World Federation for Medical Education (WFME) was established in 1972 and in the five decades that followed, has been the de facto global agency for medical education. Despite this apparently formidable remit, it has received little analysis in the academic literature. Evidence: In this article, we examine the historical context at the time WFME was established and summarize the key decisions it has taken in its history to date, highlighting particularly how it has adopted positions and programmes that have seemingly given precedence to the values and priorities of countries in the Global North. In doing so, we challenge the inevitability of the path that it has taken and consider other possible avenues that such a global agency in medical education could have taken, including to advocate for, and to develop policies that would support countries in the Global South. Implications: This article proposes a more democratic and equitable means by which a global organization for medical education might choose its priority areas, and a more inclusive method by which it could engage the medical education community worldwide. It concludes by hypothesizing about the future of global representation and priority-setting, and outlines a series of principles that could form the basis for a reimagined agency that would have the potential to become a force for empowerment and global justice in medical education.

Is West Really Best? The Discourse of Modernisation in Global Medical School Regulation Policy

Phenomenon: In 2012, the World Federation for Medical Education (WFME) established a recognition programme to evaluate medical school regulatory agencies across the world, in response to a new U.S. accreditation policy. Given the predominantly Western origins and Eastern impacts of the WFME programme, this article deconstructs tensions in the programme using postcolonial theory. Approach: Critical discourse analysis examines the intersections of language, knowledge, and power relations to highlight what can or cannot be said about a topic. We employed it to delineate the dominant discourse underpinning the WFME recognition programme. We drew on the theoretical devices of Edward Said, whose work is foundational in postcolonial thinking but has not been widely used in medical education scholarship to date. An archive of literature about the WFME recognition programme dating back to 2003, when WFME first released global standards for medical education, was analyzed. Findings: In the globalization of medical school regulation, the discourse of modernization can be conceptualized as a means of holding knowledge and power in the West, and enacting this power on those in the East, playing on fears of marginalization in the event of non-engagement. The discourse allows these practices to be presented in an honorable and heroic way. Insights: By uncovering the representation of the WFME recognition programme as being modern and modernizing, this article explores how such conceptualisations can close off debate and scrutiny, and proposes further examination of this programme through a lens that recognizes the inherent inequities and geopolitical power differentials that it operates within.

Altruism or nationalism? Exploring global discourses of medical school regulation

BACKGROUND

Although medical school regulation is ubiquitous, the extent to which it should be based on global principles is unclear. In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that from 2023, overseas doctors would only be eligible for certification to practise in the United States if they had graduated from a medical school that was accredited by a 'recognised' agency. This policy empowered the World Federation for Medical Education (WFME) to create a recognition programme for regulatory agencies around the world, despite a lack of empirical evidence to support medical school regulation.

METHODS

This study employs critical discourse analysis, drawing on the theoretical perspectives of Michel Foucault and Edward Said, to identify discourses that enabled this 'globalising' policy decision to take place. The dataset includes a series of 250 documents gathered around three key events: the Edinburgh declaration by WFME in 1988, the first set of global standards for medical schools by WFME in 2003 and the ECFMG ruling about medical school accreditation in 2010.

FINDINGS

Two discourses, endorsement and modernisation, were dominant throughout this entire period and framed the move to globalise medical school regulation in terms of altruism and improving medical education worldwide. A discourse of resistance was present in the earlier period of this study but faded away as WFME aligned itself with ECFMG after 2010. Two further discourses, protection and control, emerged in the later period of this study and framed the ECFMG ruling in terms of nationalism and protecting American interests.

DISCUSSION

This study proposes a new conceptualisation of the relationship between ECFMG and WFME in light of the apparently contradictory policy motivations of altruism and nationalism. It goes on to consider the implications of this association for the legitimacy of WFME as an organisation that represents all of the world's medical schools.

Regulatory system to promote the culture of quality at Indian medical schools: Are we doing enough?

The replacement of the Medical Council of India (MCI) with the National Medical Commission (NMC) was an important change in regulatory oversight to bring about transparency in regulatory procedures for improving quality of medical education and meeting the needs of healthcare in India. Similarly, due to globalization of medicine including migration of health workforce and desire to raise standards of medical education and healthcare, efforts have progressed well towards transnational regulation and establishment of an overarching body, which recognizes regulatory agencies for their adherence to good practices. We describe the global collaborative efforts to improve the quality of medical education by the promotion of accreditation through the recognition programme of the World Federation of Medical Education (WFME), the publication of the expert consensus standards across the continuum of medical education and the Guidelines for Accreditation of Basic Medical Education. We also highlight that many medical schools across the world have adopted the WFME standards and many regulatory and accrediting agencies have achieved recognition status. Based on appraisal of the NMC Act and notification on minimum standard requirements (MSRs) for medical colleges, we point out the gaps between the intent stated in the preamble of the NMC Act and the notification on MSRs. We recommend a way forward to develop a regulatory model and approaches that match NMC's stated intent and meet the requirement for medical schools in India to gain international recognition.

Medical School Accreditation Factors Associated With Certification by the Educational Commission for Foreign Medical Graduates (ECFMG): A 10-Year International Study

PURPOSE

In 2024, international medical graduates seeking Educational Commission for Foreign Medical Graduates (ECFMG) certification will be required to graduate from an accredited medical school. This study's goal was to examine relationships between medical school accreditation variables and ECFMG certification for a global sample.

METHOD

Using ECFMG databases, the authors created a 10-year cohort (January 1, 2007-December 31, 2016) of certification applicants, defined as individuals who had attempted at least 2 examinations required for certification. The authors aggregated applicant data at the school level, excluding schools with < 80 applicants. School accreditation statuses were based on agency websites. School region, age, and time of first accreditation were included. Analyses included descriptive and bivariate statistics and multiple linear regressions adjusting for school start year and year of first accreditation.

RESULTS

The cohort included 128,046 applicants from 1,973 medical schools across 162 countries. After excluding low-volume schools, 318 schools across 81 countries remained. These provided 99,598 applicants and 77,919 certificate holders, three-quarters of whom came from the Caribbean, South-Central Asia, and West Asia regions. Two hundred and fifty (78.6%) schools were accredited; 68 (21.4%) were not. Most ECFMG applicants (n = 84,776, 85.1%) and certificate holders (n = 68,444, 87.8%) attended accredited medical schools. Accredited schools had higher rates of ECFMG certification among graduates than nonaccredited schools in comparisons that included all schools (75.0% [standard deviation (SD) = 10.6%] vs 68.3% (SD = 15.9%), P < .001), and for countries that had both accredited and nonaccredited schools (73.9% [SD = 11.4%] vs 67.3% [SD = 16.8%], P = .023). After adjusting for age of school, longer duration of accreditation was associated with higher certification rates (P < .001).

CONCLUSIONS

Accreditation had a positive association with ECFMG certification rates. Future studies should investigate how accreditation processes might account for higher certification rates.

The World Health Organization and the global standardization of medical training, a history

BACKGROUND

This article presents a history of efforts by the World Health Organization and its most important ally, the World Federation for Medical Education, to strengthen and standardize international medical education. This aspect of WHO activity has been largely ignored in recent historical and sociological work on that organization and on global health generally.

METHODS

Historical textual analysis is applied to the digitalized archives and publications of the World Health Organization and the World Federation for Medical Education, as well as to publications in the periodic literature commenting on the standardization of international medical training and the problems associated with it.

RESULTS

Efforts to reform medical training occurred during three distinct chronological periods: the 1950s and 1960s characterized by efforts to disseminate western scientific norms; the 1970s and 1980s dominated by efforts to align medical training with the WHO's Primary Healthcare Policy; and from the late 1980s to the present, the campaign to impose global standards and institutional accreditation on medical schools worldwide. A growing number of publications in the periodic literature comment on the standardization of international medical training and the problems associated with it, notably the difficulty of reconciling global standards with local needs and of demonstrating the effects of curricular change.

What Will It Mean for Me? Perceptions of the ECFMG 2023 Accreditation Requirement from an Online Forum

In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that as of 2023, physicians applying to train and practice in the United States will be required to graduate from a medical school that has been accredited using criteria such as those developed by the World Federation for Medical Education. This study analyzed posts on the Student Doctor Network (SDN) online forum that refer to this accreditation requirement to investigate how it has been perceived and understood by current and prospective medical students. A keyword search of relevant terms was used to identify posts discussing the accreditation requirement on the SDN online forum, which were subjected to thematic analysis. There were a total of 83 posts from 49 distinct user accounts between May 2012 and January 2020. Seven themes were identified in total; four whose overall purpose was to seek or offer advice and three whose overall purpose was commentary. Themes relating to advice included applications and admissions, future career planning, personal circumstances, and countryspecific issues. Themes relating to commentary included the accreditation requirement policy itself, the potential implications of the requirement, and the educational quality of non-U.S. medical schools. Only half of web links on these posts were to the ECFMG website for official information about the requirement. Although a variety of different perspectives about the ECFMG accreditation requirement were expressed on an online forum for student doctors, the overall number of posts was low, which suggests that the requirement has not been a frequent topic of discussion on this platform. The insights gained from posts suggest personal opinions about the requirement and consequences for individual student application and career choices were the main areas of interest. Signposting to official information channels may help to raise awareness about the requirement and tackle areas of uncertainty and confusion about its implementation.

Public availability of information from WFME-recognized accreditation agencies

The World Federation for Medical Education (WFME) Recognition Programme was created to ensure the comparability of medical school accrediting agencies, so that the schools accredited by those agencies would have similar educational quality. WFME explicitly values transparency and has recognition criteria that relate to agencies making information publicly available. Our study examined 20 WFME-recognized agencies' transparency by reviewing agency websites for 27 information elements related to accreditation standards, procedures, and processes. We contacted agencies as needed for information that we could not find on their websites. We were only able to retrieve additional information from 3 of the 12 agencies that we attempted to contact. We found that while 12 agencies had over 90% of expected information elements available, 6 agencies had less than 50%. Our findings illustrate barriers for those who wish to better understand medical school accreditation in some regions and raise questions about how comparable WFME-recognized agencies are.

Reporting a Pass/Fail Outcome for USMLE Step 1: Consequences and Challenges for International Medical Graduates

After extensive stakeholder discussion, the Federation of State Medical Boards and the National Board of Medical Examiners announced in February 2020 that United States Medical Licensing Examination Step 1 will transition to a pass/fail exam. Program directors have historically used Step 1 scores in deciding which residency applicants to interview. The lack of numerical scores will force changes to the residency selection process, which could have both positive and negative consequences for international medical graduates (IMGs). In this Invited Commentary, the authors discuss how some of the issues associated with the transition to Step 1 pass/fail are likely to impact IMGs. The authors also provide insights into how this and other policy changes could help spur the medical education community to improve the process by which medical school graduates transition to graduate medical education.