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.

Examining the Educational Commission for Foreign Medical Graduates Announcement Requiring Medical School Accreditation Beginning in 2023

In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG, Philadelphia, Pennsylvania) announced that, beginning in 2023, graduation from a formally accredited medical school would be necessary for an international medical graduate (IMG) to be eligible for ECFMG certification. The announcement is notable because ECFMG certification is required for graduate medical training and practice in the United States. Graduating from a school accredited by an agency formally recognized by the World Federation for Medical Education (WFME), which has been formally evaluating and recognizing accrediting agencies since 2012, would fulfill the new ECFMG requirement. In 2015, ECFMG applicants came from 1,141 medical schools located in 139 countries or territories. As of December 2018, the WFME had formally recognized 14 accrediting agencies, which would cover only approximately a third of these recent ECFMG-certified IMGs. In this Perspective, the author compares the context of the ECFMG announcement to the beginning of accreditation in the United States so as to provide insight into the challenges the WFME faces as it seeks to evaluate and recognize what could ultimately be over 100 more accrediting authorities. The author then explores the possible effects of the requirement-specifically, its potential to restrict the ECFMG applicant pool-on the quantity and quality of the U.S. physician workforce. The author ends the Perspective by considering the implications of three broad policy options that the ECFMG could consider starting in 2023: implementation as announced, maintenance of the status quo, or a policy modified from the original announcement.

Cuban medical training for South African students: a mixed methods study

BACKGROUND

Achieving universal health care coverage will require greater investment in primary health care, particularly in rural and underserved populations in low and middle-income countries. South Africa has invested in training black students from disadvantaged backgrounds in Cuba and large numbers of these Cuban-trained students are now returning for final year and internship training in South Africa. There is controversy about the scheme, the quality and relevance of training received and the place of Cuban-trained doctors in the health care system. Exploring the experiences of Cuban- and South African-trained students, recent graduates and medical school faculty may help understand and resolve the current controversy.

METHODS

Using a mixed methods approach, in-depth interviews and a focus group discussion were held with deans of medical schools, senior faculty, and Cuban-trained and South African-trained students and recent graduates. An online structured questionnaire, adapted from the USA medical student survey, was developed and administered to Cuban- and South African-trained students and recent graduates.

RESULTS

South African students trained in Cuba have had beneficial experiences which orientate them towards primary health care and prevention. Their subsequent training in South Africa is intended to fill skill gaps related to TB, HIV and major trauma. However this training is ad hoc and variable in duration and demoralizing for some students. Cuban-trained students have stronger aspirations than those trained in South Africa to work in rural and underserved communities from which many of them are drawn.

CONCLUSION

Attempts to assimilate returning Cuban-trained students will require a reframing of the current negative narrative by focusing on positive aspects of their training, orientation towards primary care and public health, and their aspirations to work in rural and under-served urban areas. Cuban-trained doctors could be part of the solution to South Africa's health workforce problems.

'Standardized patients' in teaching the communication skill of history-taking to four-year foreign medical undergraduates in the department of obstetrics and gynaecology

BACKGROUND

Many foreign students have difficulty taking histories from Chinese patients, especially in clinical context of the Department of Obstetrics and Gynaecology. The efficacy of using standardized patients to prepare foreign students for communicating with Chinese patients and taking their histories was evaluated in this study.

METHODS

Ninety-four four-year foreign students were assigned to one of three clinical sub-departments (gynaecology, obstetrics, and reproductive endocrinology) to practice history-taking; after practicing in one sub-department, the students were then crossed over to a different department. The histories were taken from real patients in the sub-departments of obstetrics and reproductive endocrinology and from standardized patients in the sub-department of gynaecology. Prior to contact with real patients in the sub-department of reproductive endocrinology, the students practised with standardized patients. The quality levels of the case reports generated in the three departments were compared by repeated measures ANOVA. The attitudes, satisfaction and suggestions of the students were also investigated through a questionnaire.

RESULTS

The local Chinese language spoken by the patients was thought to be the most common difficulty students (76.7%) encountered while taking patient histories. Two-thirds and one-third of the students were interested in taking histories from standardized and real patients, respectively. Most students (94.2%) thought that working with standardized patients was useful for practising communication skills with Chinese patients. The total scores of the case reports were significantly different among the three groups (P < 0.001), and compared with case reports collected from real patients, case reports collected from standardized patients were of better quality. However, the quality of the case reports taken from real patients was better when the case reports were generated by students who had previous practice with standardized patients than when they were generated by students lacking such experience (P < 0.001).

CONCLUSIONS

Standardized patient training for practising history-taking can be included as part of the clinical training curriculum for foreign medical undergraduates in the Department of Obstetrics and Gynaecology in China.

Language Matters: Development of an Objective Structured Language Test for Foreign Physicians - Results of a Pilot Study in Germany

Objective: To develop a scientifically sound and standardized medical language examination for the State of Bavaria according to the requirements set forth by the 87th Conference of State Health Ministers. This Sprachtest für Ausländische Mediziner (SAM, Language Test for Foreign Physicians) ought to become part of the licensing procedure for foreign physicians in Germany. Using testing stations that are situation-based, it will assess medical language competence and communication skills at the proficiency level of C1. Methods: Case scenarios for four mini-interviews of 10 minutes each were developed. For the written part of the exam, consisting of two separate testing stations with a combined duration of 40 minutes, one video of a physician taking a patient's history and one annotated set of laboratory results were developed. Based on the analysis of existing scientific literature as well as real-life examples, features and characteristics of professional medical language were identified. This served as the basis for the development of itemized rating scales for each of the testing stations. The exam was validated in three simulated trial runs. Each run was video-recorded and subsequently graded by a team of test-raters. Results: 19 participants took part in the three trial runs. A benchmark (gold standard) could be set for 18 of these. A ROC-analysis yielded an AUC-value of .83. This confirmed the predictive quality of the SAM-test. The reliability of the SAM-test could be calculated for only ten participants. The internal consistency, calculated with the use of Cronbach's Alpha, was .85. The pass/fail mark was calculated based on the Youden-Index and yielded a result of >60%. Conclusion: The SAM-test presents a statistically valid medical language examination with a high level of objectivity. As required, it tests language proficiency at the level of C1 and uses authentic communication scenarios within a standardized test setting. Additional studies with larger test samples will help to further validate this test and thus guarantee a higher degree of reliability.

Passing MRCP (UK) PACES: a cross-sectional study examining the performance of doctors by sex and country

BACKGROUND

There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better academically and clinically. It is also known that international medical graduates tend to perform more poorly academically compared to home-trained graduates in the UK, US, and Canada. It is uncertain whether the magnitude and direction of sex differences in doctors' performance is variable by country. We explored the association between doctors' sex and their performance at a large international high-stakes clinical examination: the Membership of the Royal Colleges of Physicians (UK) Practical Assessment of Clinical Examination Skills (PACES). We examined how sex differences varied by the country in which the doctor received their primary medical qualification, the country in which they took the PACES examination, and by the country in which they are registered to practise.

METHODS

Seven thousand six hundred seventy-one doctors attempted PACES between October 2010 and May 2013. We analysed sex differences in first time pass rates, controlling for ethnicity, in three groups: (i) UK medical graduates (N = 3574); (ii) non-UK medical graduates registered with the UK medical regulator, the General Medical Council (GMC), and thus likely to be working in the UK (N = 1067); and (iii) non-UK medical graduates without GMC registration and so legally unable to work or train in the UK (N = 2179).

RESULTS

Female doctors were statistically significantly more likely to pass at their first attempt in all three groups, with the greatest sex effect seen in non-UK medical graduates without GMC registration (OR = 1.99; 95% CI = 1.65-2.39; P < 0.0001) and the smallest in the UK graduates (OR = 1.18; 95% CI = 1.03-1.35; P = 0.02).

CONCLUSIONS

As found in a previous format of this examination and in other clinical examinations, female doctors outperformed male doctors. Further work is required to explore why sex differences were greater in non-UK graduates, especially those without GMC registration, and to consider how examination performance may relate to performance in practice.

Performance of International Medical Students In psychosocial medicine

BACKGROUND

Particularly at the beginning of their studies, international medical students face a number of language-related, social and intercultural challenges. Thus, they perform poorer than their local counterparts in written and oral examinations as well as in Objective Structured Clinical Examinations (OSCEs) in the fields of internal medicine and surgery. It is still unknown how international students perform in an OSCE in the field of psychosocial medicine compared to their local fellow students.

METHODS

All students (N = 1033) taking the OSCE in the field of psychosocial medicine and an accompanying written examination in their eighth or ninth semester between 2012 and 2015 were included in the analysis. The OSCE consisted of four different stations, in which students had to perform and manage a patient encounter with simulated patients suffering from 1) post-traumatic stress disorder, 2) schizophrenia, 3) borderline personality disorder and 4) either suicidal tendency or dementia. Students were evaluated by trained lecturers using global checklists assessing specific professional domains, namely building a relationship with the patient, conversational skills, anamnesis, as well as psychopathological findings and decision-making.

RESULTS

International medical students scored significantly poorer than their local peers (p < .001; η² = .042). Within the specific professional domains assessed, they showed poorer scores, with differences in conversational skills showing the highest effect (p < .001; η² = .053). No differences emerged within the multiple-choice examination (p = .127).

CONCLUSION

International students showed poorer results in clinical-practical exams in the field of psychosocial medicine, with conversational skills yielding the poorest scores. However, regarding factual and practical knowledge examined via a multiple-choice test, no differences emerged between international and local students. These findings have decisive implications for relationship building in the doctor-patient relationship.

Credentialing and retention of visa trainees in post-graduate medical education programs in Canada

BACKGROUND

Visa trainees are international medical graduates (IMG) who come to Canada to train in a post-graduate medical education (PGME) program under a student or employment visa and are expected to return to their country of origin after training. We examined the credentialing and retention of visa trainees who entered PGME programs between 2005 and 2011.

METHODS

Using the Canadian Post-MD Education Registry's National IMG Database linked to Scott's Medical Database, we examined four outcomes: (1) passing the Medical Council of Canada Qualifying Examination Part 2 (MCCQE2), (2) obtaining a specialty designation (CCFP, FRCPC/SC), and (3) working in Canada after training and (4) in 2015. The National IMG Database is the most comprehensive source of information on IMG in Canada; data were provided by physician training and credentialing organizations. Scott's Medical Database provides data on physician locations in Canada.

RESULTS

There were 233 visa trainees in the study; 39.5% passed the MCCQE2, 45.9% obtained a specialty designation, 24.0% worked in Canada after their training, and 53.6% worked in Canada in 2015. Family medicine trainees (OR = 8.33; 95% CI = 1.69-33.33) and residents (OR = 3.45; 95% CI = 1.96-6.25) were more likely than other specialist and fellow trainees, respectively, to pass the MCCQE2. Residents (OR = 7.69; 95% CI = 4.35-14.29) were more likely to obtain a specialty credential than fellows. Visa trainees eligible for a full license were more likely than those not eligible for a full license to work in Canada following training (OR = 3.41; 95% CI = 1.80-6.43) and in 2015 (OR = 3.34; 95% CI = 1.78-6.27).

CONCLUSIONS

Visa training programs represent another route for IMG to qualify for and enter the physician workforce in Canada. The growth in the number of visa trainees and the high retention of these physicians warrant further consideration of the oversight and coordination of visa trainee programs in provincial and in pan-Canadian physician workforce planning.

Supporting international medical graduates' transition to their host-country: realist synthesis

CONTEXT

Many health services and systems rely on the contribution of international medical graduates (IMGs) to the workforce. However, concern has grown around their regulation and professional practice. There is a need, in the absence of strong evidence and a robust theoretical base, for a deeper understanding of the efficacy of interventions used to support IMGs' transition to their host countries. This study seeks to explore and synthesise evidence relating to interventions developed for IMGs. It aims to provide educators and policy makers with an understanding of how interventions should be developed to support IMGs in their transition to the workplace, particularly looking to identify how and why they are effective.

METHODS

The realist synthesis involved an initial systematic search of the literature for the period January 1990 to April 2015. Secondary searches were conducted throughout the review in order to inform and test the developing programme theory. The context, mechanism and outcome data were extracted from all sources meeting the inclusion criteria. Fourteen case studies were included to further aid theory refinement.

RESULTS

Sixty-two articles were identified, describing diverse interventions of varying intensity. A further 26 articles were identified through a secondary search. The findings illustrate that, alongside a developed programme, ongoing support and cultural awareness at organisational and training levels are crucial. Individual differences must also be taken into consideration. This will ensure that IMGs engage in transformative learning, increase their levels of self-efficacy and cultural health capital, and reduce feelings of stress and anxiety. These factors will have an impact on work, interactions and cultural adjustment.

CONCLUSIONS

Organisational, training and individual contexts all play a role in IMGs' adjustment during the transition process. Establishing ongoing support is critical. A list of recommendations for implementation is given.

Exploring cultural and linguistic influences on clinical communication skills: a qualitative study of International Medical Graduates

BACKGROUND

International Medical Graduates (IMGs) are known to perform less well in many postgraduate medical examinations when compared to their UK trained counterparts. This "differential attainment" is observed in both knowledge-based and clinical skills assessments. This study explored the influence of culture and language on IMGs clinical communication skills, in particular, their ability to seek, detect and acknowledge patients' concerns in a high stakes postgraduate clinical skills examination. Hofstede's cultural dimensions framework was used to look at the impact of culture on examination performance.

METHODS

This was a qualitative, interpretative study using thematic content analysis of video-recorded doctor-simulated patient consultations of candidates sitting the MRCP(UK) PACES examination, at a single examination centre in November 2012. The research utilised Hofstede's cultural dimension theory, a framework for comparing cultural factors amongst different nations, to help understand the reasons for failure.

RESULTS

Five key themes accounted for the majority of communication failures in station 2, "history taking" and station 4, "communication skills and ethics" of the MRCP(UK) PACES examination. Two themes, the ability to detect clues and the ability to address concerns, related directly to the overall construct managing patients' concerns. Three other themes were found to impact the whole consultation. These were building relationships, providing structure and explanation and planning.

CONCLUSION

Hofstede's cultural dimensions may help to contextualise some of these observations. In some cultures doctor and patient roles are relatively inflexible: the doctor may convey less information to the patient (higher power distance societies) and give less attention to building rapport (high uncertainty avoidance societies.) This may explain why cues and concerns presented by patients were overlooked in this setting. Understanding cultural differences through Hofstede's cultural dimensions theory can inform the preparation of candidates for high stakes bedside clinical skills examinations and for professional practice.

[Internship-test reveals increased knowledge gaps]

We present the results of the medical knowledge test after fulfilled internship for Swedish medical authorization during the years 2009 to the spring of 2015. A total of 7,613 tests were analyzed. Interns graduated from Swedish universities failed in 2.7% to 3.8% of the test moments. Interns who graduated from countries within the European Union (EU) failed in 21.2% and interns graduated from a non-EU country failed in 41.6%. The results from those who graduated from EU and non-EU countries have worsened compared to an earlier study in 2009. Proper measures have now to be implemented for doctors graduated from a non-Swedish university to improve the outcome and introduction to the Swedish health care system.

Prepared to practice? Perception of career preparation and guidance of recent medical graduates at two campuses of a transnational medical school: a cross-sectional study

BACKGROUND

Graduating medical students enter the workforce with substantial medical knowledge and experience, yet little is known about how well they are prepared for the transition to medical practice in diverse settings. We set out to compare perceptions of medical school graduates' career guidance with their perceptions of preparedness to practice as interns. We also set out to compare perceptions of preparedness for hospital practice between graduates from two transnational medical schools.

METHODS

This was a cross-sectional study. A Preparedness for Hospital Practice (PHPQ) survey and career guidance questionnaire was sent to recent medical graduates, incorporating additional free text responses on career preparation. Data was analyzed using descriptive statistics and tests of association including Chi-square, Mann-Whitney U and Kruskal-Wallis H tests.

RESULTS

Forty three percent (240/555) of graduates responded to the survey: 39 % of respondents were domestic (Dublin, Ireland or Manama, Kingdom of Bahrain) and interning locally; 15 % were overseas students interning locally; 42 % were overseas students interning internationally and 4 % had not started internship. Two variables explained 13 % of the variation in preparedness for hospital practice score: having planned postgraduate education prior to entering medical school and having helpful career guidance in medical school. Overseas graduates interning internationally were more likely to have planned their postgraduate career path prior to entering medical school. Dublin graduates found their career guidance more helpful than Bahrain counterparts. The most cited shortcomings were lack of structured career advice and lack of advice on the Irish and Bahraini postgraduate systems.

CONCLUSIONS

This study has demonstrated that early consideration of postgraduate career preparation and helpful medical school career guidance has a strong association with perceptions of preparedness of medical graduates for hospital practice. In an era of increasing globalization of medical education, these findings can direct ongoing efforts to ensure all medical students receive career guidance and preparation for internship appropriate to their destination.

An international survey of medical licensing requirements for immigrating physicians, focusing on communication evaluation

OBJECTIVE

To identify current entry requirements set by international medical licensing bodies for immigrating physicians, focusing on postgraduate level communication skills, clinical and technical skill assessments.

METHODS

A standardised, author developed survey was administered to a selection of national, state and provincial licensing institutions across 6 continents. Representative institutions were selected from the most populated regions of each continent. Surveys were administered by email and telephone. The information was also searched by website review. Website information alone was used if no response was received by the targeted institution after 2 phone/2 email attempts. Statistical analysis of the non-parametric data was conducted using SPSS (v.21).

RESULTS

Thirty-seven licensing bodies were contacted from 30 countries; verifiable information was available for 29; twenty-six responded to the communication inquiry. Sixty five 65.4% (n=17) surveyed communication skills, 100% involved language proficiency testing; 11.5% tested other forms of communication skills. For clinical and technical skills, 86.2% (n=25) assessed candidates by credential review, 72.4% (n=21) required both credential review and exam and 62.1% (n=18) used country-specific examination. A mentorship period were required by 37.9% (n=11), ranging from 3 months to 1 year. Only 2 countries identified examinations for recertification. No technical/clinical skills nor communication skill evaluation (beyond language proficiency) are routinely assessed at the postgraduate level.

CONCLUSIONS

International assessments of migrating physicians are heterogeneous. Communication skills, beyond language proficiency, are not routinely assessed in foreign trained physicians seeking entry. The majority of clinical and technical skills are assessed by credential review only. This study highlights the lack of standardisation of assessment internationally and the need for steps toward a global agreement on training schemes and summative assessment.

India's foreign medical graduates: an opportunity to correct India's physician shortage

BACKGROUND

India's current estimated doctor-population ratio of 1:1700 against targeted ratio of 1: 1000 shows a clear shortage. A mismatch in number of medical aspirants and available seats, intense competition and unaffordable costs of medical education prompt many Indian students to pursue training opportunities abroad. Many later return to India, and these foreign medical graduates (FMGs) must pass a qualification test which is a required to practice medicine in India. This review undertakes a situational analysis of FMGs in India and suggests a roadmap to better utilize this resource pool of physicians.

METHODS

A thorough literature search was carried out using Google Scholar, PubMed and websites of the Central Board of Secondary Education and Medical Council of India. Foreign Medical Graduate Examination (FMGE) data was obtained from India's National Board of Examinations.

RESULTS

From 2002 to 2014, growth was seen in the number of FMGs who took the FMGE, with more having trained in China than any other country. However, typically only 25% of FMGs pass the FMGE. In 2013, 9,700 FMGs were unable to pass the FMGE to enter practice in India. At least 7,500 FMG physicians are unable to become licensed each year for failure to pass the FMGE, including those who retake and again fail the exam.

DISCUSSION

There are possible solutions. Additional training and hands-on apprenticeships can be introduced to help FMGs build their skills to then be able to pass the FMGE. FMGs can now learn by participating as observers in the established programs. Opportunities also exist for FMGs to work outside of clinical care, including in research, hospital administration and public health. As of now, FMGs are an untapped resource and lost opportunity to a country with shortages of physicians.

OVERVIEW OF EXAMINATION STANDARDS AND EVALUATION PROCESS CONDUCTED BY OUT-SOURCED UNIVERSITIES BY PAKISTAN MEDICAL AND DENTAL COUNCIL FOR FOREIGN QUALIFIED MEDICAL PROFESSIONALS IN PAKISTAN

BACKGROUND

Pakistani nationals that obtained foreign basic/additional medical/dental qualifications need to be registered with Pakistan Medical and Dental Council (PMDC) to serve in health delivery system after qualifying the National Examination Board (NEB) conducted by the outsourced universities. The aim was to analyse the results and the factors that influence the NEB examinations held for accreditation conducted by different universities from the year 2010 to 2015.

METHODS

The register based data was collected from the NEB section of PMDC for examinations conducted in the year 2010, 2013, 2014 and 2015. The format of the examination comprises three parts that include Step I, II based on written assessment composed of both multiple choice and subjective questions. Step III is designed for oral assessment, i.e., viva voce. All these examination were held in Islamabad conducted by the outsourced universities.

RESULTS

The percentage of candidates that has passed all the examinations, Step I, II & III held by various universities varies across the universities. Further, the percentage of passed candidate remains low in Step I & II as compared to candidates passed in Step III. Overall the result of Step III shows a wide gradient that ranges from 50% to 98% among the different universities. Likewise, the lowest percentage of passing candidates in Step I and Step II remains 4% and 9% respectively as compared to 50% in Step III.

CONCLUSION

There is a wide gradient in the results of NEB examination among universities due to lack of uniformity and standardization of assessment process. In addition, with regards to the approach of examination venue, the faced issues include lack of accessibility and cost effectiveness. The PMDC needs to institutionalize a robust and vigorous accreditation system equipped with inbuilt evaluation indicators that should steer to devise strategies to improve the accreditation process.

A longitudinal study of the characteristics and performances of medical students and graduates from the Arab countries

BACKGROUND

While international physician migration has been studied extensively, more focused and regional explorations are not commonplace. In many Arab countries, medical education is conducted in English and students/graduates seek postgraduate opportunities in other countries such as the United States (US). Eligibility for residency training in the US requires certification by the Educational Commission for Foreign Medical Graduates (ECFMG). This study investigates ECFMG application trends, examination performance, and US physician practice data to quantify the abilities and examine the career pathways of Arab-trained physicians.

METHODS

Medical students and graduates from 15 Arab countries where English is the language of medical school instruction were studied. The performances (1(st) attempt pass rates) of individuals on the United States Medical Licensing Examination Step 1, Step 2CK (clinical knowledge), and and a combination of Step 2CS (clinical skills) and ECFMG CSA (clinical skills assessment) were tallied and contrasted by country. Based on physician practice data, the contribution of Arab-trained physicians to the US healthcare workforce was explored. Descriptive statistics (means, frequencies) were used to summarize the collected data.

RESULTS

Between 1998 and 2012, there has been an increase in the number of Arab trained students/graduates seeking ECFMG certification. Examination performance varied considerably across countries, suggesting differences in the quality of medical education programs in the Eastern Mediterranean Region. Based on current US practice data, physicians from some Arab countries who seek postgraduate opportunities in the US are less likely to stay in the US following specialty training.

CONCLUSION

Countries, or regions, with concerns about physician migration, physican performance, or the pedagogical quality of their training programs should conduct longitudinal research studies to help inform medical education policies.

[A standardized practical examination for title revalidation of graduates of foreign medical schools]

BACKGROUND

The University of Chile, backed by its extensive experience in Objective Structured Clinical Examinations (OSCEs), performs the practical exam to graduates of foreign medical school in this format. This test format would give more guarantees of validity and fairness as compared with the previous oral examination that was required for title revalidation.

AIM

To compare the performance of graduates of foreign medical schools and last year medical students of the University of Chile in the same internal medicine OSCE.

MATERIAL AND METHODS

Seventy-seven last year medical students and thirty-three graduates of foreign medical schools participated in the same Internal Medicine OSCE, but in different moments. At the end of the examination, graduates of foreign medical schools answered a questionnaire about their prior experience with OSCEs and about their perception about this type of examination.

RESULTS

The performance of graduates of foreign medical schools was lower than those of our last year medical students in four of the eight stations of the examination. Graduates of foreign medical schools considered the examination objective, fair, and that it assessed skills adequately and that the degree difficulty was homogeneous for all examinees.

CONCLUSIONS

The possibility of obtaining comparable results in a transparent process makes the OSCE the assessment tool of choice for title revalidation of physicians migrating from foreign countries.

"That's your patient. There's your ventilator": exploring induction to work experiences in a group of non-UK EEA trained anaesthetists in a London hospital: a qualitative study

BACKGROUND

European health systems depend increasingly on the services of health professionals who obtained their primary medical qualification from other countries. There has been a significant increase recently in fully qualified specialist doctors arriving from the European Union to provide short term or longer-term solutions to health human resources needs in the UK National Health System. These doctors often take up senior consultant positions. As a result, the NHS has had to learn to deal with both expatriation and repatriation of EU doctors as a constant dynamic characteristic of its own ability to deliver services. We conducted a qualitative study to explore the acclimatisation experience of EU doctors with qualifications in anaesthesia arriving in the United Kingdom to take up clinical employment in the NHS. The question we ask is: how do specialty registered anaesthetists who trained in other European countries experience the process of acclimatisation to practice in the United Kingdom in a large hospital in London?

METHODS

We did individual interviews with non-UK, EU-qualified doctors with Certification of Completion of specialty Training who were registered with the General Medical Council in the UK and could practice in the NHS as specialist anaesthetists. The doctors were all interviewed whilst working in a large NHS teaching hospital in London, UK. We analysed qualitative data from interview transcripts to identity themes and patterns regarding senior doctor's acclimatisation to the British system.

RESULTS

Acclimatisation conceived of as transfer of clinical expertise was problematic for doctors who felt they lacked the right kind of support. Doctors sought different opportunities to share wider perspectives on care deriving from their previous experience.

CONCLUSIONS

Hospital conceptions of acclimatisation as a highly individual process can offer an idealized view of clinical work and learning in the new system. Socio-cultural theories suggest we create regular learning opportunities for international staff to critically reflect on practice with local staff to acclimatise more effectively.

Equal, global, local: discourses in Taiwan's international medical graduate debate

CONTEXT

With the globalisation of medicine, the role of international medical graduates (IMGs) has expanded. Nonetheless, the experiences of native-born IMGs remain under-researched. In Taiwan, public controversy has unfolded around IMGs educated in Poland, calling into question the meaning(s) of equality in policy and medicine. In focusing on the return of IMGs to their countries of origin, this study adds to the growing literature concerning equality and globalisation in medical education.

OBJECTIVES

The primary research aim was to analyse how stakeholders in the IMG debate use equality in their arguments. The authors set out to frame the dispute within the recent history of Taiwanese medical governance. An overarching objective was to contribute a critical, historical view of how discourses of globalisation and equality construct different policy approaches to international medical education.

METHODS

The authors performed a critical discourse analysis of a public policy dispute in Taiwan, assembling an archive from online interactions, government reports and news articles. Coding focused on stakeholders' uses of equality to generate broader discourses.

RESULTS

International and domestic Taiwanese students conceived of equality differently, referencing both 'equality of opportunity' and 'equality of outcome' within localisation and globalisation frameworks, respectively. The dominance of localisation discourse is reflected in hostile online rhetoric towards Poland-educated IMGs.

CONCLUSIONS

Rhetorical disagreements over equality in medical education trace shifting state policies, from earlier attempts to remove barriers for IMGs to the present-day push to regulate IMGs for acculturation and quality assurance. The global Internet had a double-sided influence, facilitating both democratic political mobilization and the spread of hate speech. The policy debate in Taiwan mirrors discourses in Canada, where IMGs are likewise conceived either as globally competent physicians or as lacking in merit and technical competence. Future research could investigate the discursive formation and evidential basis of policies regulating international medical education.

Progress of successful New Zealand Registration Examination (NZREX Clinical) candidates during their first year of supervised clinical practice in New Zealand

AIM

To determine the frequency and nature of clinical difficulties faced in the first year of supervised clinical practice by international medical graduates (IMGs) who have successfully passed NZREX Clinical in order to be able to practise in New Zealand.

METHOD

All doctors who successfully passed NZREX Clinical and who registered with the Medical Council of New Zealand (the Council) from 2005 to 2013 were identified. Supervisor reports for each of the four runs in the first year of practice were obtained and reports where concerns were raised over clinical performance analysed.

RESULTS

Of 353 IMGs successful in NZREX Clinical, 316 (89.6%) completed the subsequent clinical year with no adverse reports. Those requiring more than one attempt to pass NZREX Clinical had an incremental increase in number of unsatisfactory reports, where areas of the IMGs' performance were rated as 'below the expected standard'. Less than 2% of IMGs had more than one unsatisfactory report. The majority of unsatisfactory reports were generated in the first half of the clinical year. Areas of concerns found were Clinical Knowledge and Skills (28%), Clinical Judgment (35%), Patient Communication (28%) and Professional Attitudes and Behaviour (9%).

CONCLUSION

Most IMGs who were successful in NZREX Clinical performed well in the subsequent year of clinical practice. NZREX Clinical would appear to have acceptable criterion validity.

The relationship between licensing examination performance and the outcomes of care by international medical school graduates

PURPOSE

The Step 2 Clinical Knowledge (CK) examination of the United States Medical Licensing Examination sequence is a requirement for the certification of international medical graduates (IMGs) by the Educational Commission for Foreign Medical Graduates. An association between scores on the test and the quality of care later provided by those who take it is central to its use in certification and licensure. The purpose of this study was to determine whether there is a relationship between scores on Step 2 CK and patient outcomes for IMGs.

METHOD

This is a retrospective observational study of the 60,958 hospitalizations from 2003 to 2009 in Pennsylvania where the principal diagnosis was acute myocardial infarction or congestive heart failure and the attending physician (N = 2,525) was an IMG who had taken the Step 2 CK. The main measures were the three-digit scores on Step 2 CK and in-hospital mortality.

RESULTS

After adjustment for severity of illness, physician characteristics, and hospital characteristics, performance on Step 2 CK had a statistically significant inverse relationship with mortality. Each additional point on the examination was associated with a 0.2% (95% CI: 0.1%-0.4%) decrease in mortality. The size of the effect is noteworthy, with each standard deviation (roughly 20 points) equivalent to a 4% change in mortality risk.

CONCLUSIONS

These findings provide evidence for the validity of Step 2 CK scores. Given the magnitude of its relationship with patient outcomes, the results support the use of the examination as an effective screening strategy for licensure.

Two wings and a prayer: should Canada make it easier for Canadian doctors trained abroad to enter practice here?

About 3,600 Canadians are currently studying medicine abroad (CSMAs). Most hope to return to practise in Canada. But the road back is not easy. These graduates must complete postgraduate residency training in Canada and alas, there are less openings than there are aspirants. One might have thought, amid the endless rhetoric of "physician shortages," that an obvious solution would be to increase the number of residency positions. But provincial governments are well aware, even if the media are not, that Canada is in the early stages of a dramatic expansion in physician supply fuelled by increased domestic training capacity. Last time the physician supply outpaced population growth, as it is doing today, governments choked off the entry of international graduates. It could happen again.

Annual Review of Competence Progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: national data linkage study

OBJECTIVE

To determine whether use of the Professional and Linguistic Assessments Board (PLAB) examination system used to grant registration for international medical graduates results in equivalent postgraduate medical performance, as evaluated at Annual Review of Competence Progression (ARCP), between UK based doctors who qualified overseas and those who obtained their primary medical qualification from UK universities.

DESIGN

Observational study linking ARCP outcome data from the UK deaneries with PLAB test performance and demographic data held by the UK General Medical Council (GMC).

SETTING

Doctors in postgraduate training for a medical specialty or general practice in the UK and doctors obtaining GMC registration via the PLAB system.

PARTICIPANTS

53,436 UK based trainee doctors with at least one competency related ARCP outcome reported during the study period, of whom 42,017 were UK medical graduates and 11,419 were international medical graduates who were registered following a pass from the PLAB route.

MAIN OUTCOME MEASURE

Probability of obtaining a poorer versus a more satisfactory category of outcome at ARCP following successful registration as a doctor in the UK.

RESULTS

International medical graduates were more likely to obtain a less satisfactory outcome at ARCP compared with UK graduates. This finding persisted even after adjustment for the potential influence of sex, age, years of UK based practice, and ethnicity and exclusion of outcomes associated with postgraduate examination failure (odds ratio 1.63, 95% confidence interval 1.30 to 2.06). However, international medical graduates who scored in the highest twelfth at part 1 of the PLAB (at least 32 points above the pass mark) had ARCP outcomes that did not differ significantly from those of UK graduates.

CONCLUSIONS

These findings suggest that the PLAB test used for registration of international medical graduates is not generally equivalent to the requirements for UK graduates. The differences in postgraduate performance, as captured at ARCP, following the two routes to registration might be levelled out by raising the standards of English language competency required as well as the pass marks for the two parts of the PLAB test. An alternative might be to introduce a different testing system.

PLAB and UK graduates' performance on MRCP(UK) and MRCGP examinations: data linkage study

OBJECTIVES

To assess whether international medical graduates passing the two examinations set by the Professional and Linguistic Assessments Board (PLAB1 and PLAB2) of the General Medical Council (GMC) are equivalent to UK graduates at the end of the first foundation year of medical training (F1), as the GMC requires, and if not, to assess what changes in the PLAB pass marks might produce equivalence.

DESIGN

Data linkage of GMC PLAB performance data with data from the Royal Colleges of Physicians and the Royal College of General Practitioners on performance of PLAB graduates and UK graduates at the MRCP(UK) and MRCGP examinations.

SETTING

Doctors in training for internal medicine or general practice in the United Kingdom.

PARTICIPANTS

7829, 5135, and 4387 PLAB graduates on their first attempt at MRCP(UK) Part 1, Part 2, and PACES assessments from 2001 to 2012 compared with 18,532, 14,094, and 14,376 UK graduates taking the same assessments; 3160 PLAB1 graduates making their first attempt at the MRCGP AKT during 2007-12 compared with 14,235 UK graduates; and 1411 PLAB2 graduates making their first attempt at the MRCGP CSA during 2010-12 compared with 6935 UK graduates.

MAIN OUTCOME MEASURES

Performance at MRCP(UK) Part 1, Part 2, and PACES assessments, and MRCGP AKT and CSA assessments in relation to performance on PLAB1 and PLAB2 assessments, as well as to International English Language Testing System (IELTS) scores. MRCP(UK), MRCGP, and PLAB results were analysed as marks relative to the pass mark at the first attempt.

RESULTS

PLAB1 marks were a valid predictor of MRCP(UK) Part 1, MRCP(UK) Part 2, and MRCGP AKT (r=0.521, 0.390, and 0.490; all P<0.001). PLAB2 marks correlated with MRCP(UK) PACES and MRCGP CSA (r=0.274, 0.321; both P<0.001). PLAB graduates had significantly lower MRCP(UK) and MRCGP assessments (Glass's Δ=0.94, 0.91, 1.40, 1.01, and 1.82 for MRCP(UK) Part 1, Part 2, and PACES and MRCGP AKT and CSA), and were more likely to fail assessments and to progress more slowly than UK medical graduates. IELTS scores correlated significantly with later performance, multiple regression showing that the effect of PLAB1 (β=0.496) was much stronger than the effect of IELTS (β=0.086). Changes to PLAB pass marks that would result in international medical graduate and UK medical graduate equivalence were assessed in two ways. Method 1 adjusted PLAB pass marks to equate median performance of PLAB and UK graduates. Method 2 divided PLAB graduates into 12 equally spaced groups according to PLAB performance, and compared these with mean performance of graduates from individual UK medical schools, assessing which PLAB groups were equivalent in MRCP(UK) and MRCGP performance to UK graduates. The two methods produced similar results. To produce equivalent performance on the MRCP and MRGP examinations, the pass mark for PLAB1 would require raising by about 27 marks (13%) and for PLAB2 by about 15-16 marks (20%) above the present standard.

CONCLUSIONS

PLAB is a valid assessment of medical knowledge and clinical skills, correlating well with performance at MRCP(UK) and MRCGP. PLAB graduates' knowledge and skills at MRCP(UK) and MRCGP are over one standard deviation below those of UK graduates, although differences in training quality cannot be taken into account. Equivalent performance in MRCGP(UK) and MRCGP would occur if the pass marks of PLAB1 and PLAB2 were raised considerably, but that would also reduce the pass rate, with implications for medical workforce planning. Increasing IELTS requirements would have less impact on equivalence than raising PLAB pass marks.

Workplace-based assessment for vocational registration of international medical graduates

INTRODUCTION

Medical regulatory authorities need efficient and effective methods of ensuring the competence of immigrating international medical graduates (IMGs). Not all IMGs who apply for specialist vocational registration will have directly comparable qualifications to those usually accepted. As general licensure examinations are inappropriate for these doctors, workplace-based assessment (WBA) techniques would appear to provide a solution. However, there is little published data on such outcomes.

METHODS

All cases of WBA (n = 81) used for vocational registration of IMGs in New Zealand between 2008 and 2013 were collated and analyzed.

RESULTS

The successful completion rate of IMGs through the pathway was 87%. The majority (64%) undertook the year of supervised practice and the final assessment in a provincial center. For those unsuccessful in the pathway, inadequate clinical knowledge was the most common deficit found, followed by poor clinical reasoning.

DISCUSSION

A WBA approach for assessing readiness of IMGs for vocational registration is feasible. The constructivist theoretical perspective of WBA has particular advantages in assessing the standard of practice for experienced practitioners working in narrow scopes than traditional methods of assessment. The majority of IMGs undertook both the clinical year and the assessment in provincial hospitals, thus providing a workforce for underserved areas.

Cuba's Latin American Medical School: can socially-accountable medical education make a difference?

After graduating more than 12,000 doctors since its founding in 1999, Cuba's Latin American Medical School (ELAM, the Spanish acronym) is tackling one of its greatest challenges to date: how to track graduates from over 65 countries and measure their impact on health outcomes and policy in their local contexts?

Assessing fitness-to-practice of overseas-trained health practitioners by Australian registration & accreditation bodies

BACKGROUND

Assessment of fitness-to-practice of health professionals trained overseas and who wish to practice in Australia is undertaken by a range of organisations. These organisations conduct assessments using a range of methods. However there is very little published about how these organisations conduct their assessments. The purpose of the current paper is to investigate the methods of assessment used by these organisations and the issues associated with conducting these assessments.

METHODS

A series of semi-structured interviews was undertaken with a variety of organisations who undertake assessments of overseas-trained health professionals who wish to practice in Australia. Content analysis of the interviews was used to identify themes and patterns.

RESULTS

Four themes were generated from the content analysis of the interviews: (1) assessing; (2) process; (3) examiners; and (4) cost-efficiency. The themes were interconnected and each theme also had a number of sub-themes.

CONCLUSIONS

The organisations who participated in the present study used a range of assessment methods to assess overseas trained health professionals. These organisations also highlighted a number of issues, particularly related to examiners and process issues, pre- and post-assessment. Organisations demonstrated an appreciation for ongoing review of their assessment processes and incorporating evidence from the literature to inform their processes and assessment development.

Psychiatric residents' attitudes toward and experiences with the clinical-skills verification process: a pilot study on U.S. and international medical graduates

OBJECTIVE

The authors report on a pilot study of the experiences and perceptions of foreign international medical graduate (F-IMG), United States international medical graduate (US-IMG), and United States medical graduate (USMG) psychiatric residents with the newly mandated Clinical Skills Verification (CSV) process. The goal was to identify and suggest remedies to any problems with the implementation of CSV in order to facilitate its success as an evaluation tool with all the three groups of residents.

METHOD

The authors designed a 51-item survey questionnaire to gather demographic data and information about three principal content areas: 1) views on the effectiveness of the program; 2) the assessment experience; and 3) evaluation and feedback. A link to the survey was e-mailed to the directors of nine general-psychiatry residency programs in the United States with a request to forward it to the residents. The data were collected from February 2010 through March 2010.

RESULTS

Sixty-three general-psychiatry residents (51.2% of 123 eligible residents) from nine selected programs completed the entire survey. Both IMG and USMG residents felt that the CSV was helpful in improving their clinical skills. Both groups of IMG residents, in contrast to their USMG counterparts, wanted more supervised interviews and were more likely to experience feedback as excessively negative and critical. In comparison to USMGs and US-IMGs, F-IMGs were less comfortable conducting an observed interview. They also had had less exposure to and experience with the CSV processes before their residency.

CONCLUSIONS

Most residents reported positive experiences with the CSV. The survey also revealed notable commonalities and differences between IMG and USMG residents in their experiences and perceptions of the CSV process, mostly related to their cultural and medical school backgrounds. Authors recommend that residency programs take definitive steps toward addressing the unique needs of these groups of residents.

Cuba's Latin American Medical School: can socially-accountable medical education make a difference?

After graduating more than 12,000 doctors since its founding in 1999, Cuba's Latin American Medical School (ELAM, the Spanish acronym) is tackling one of its greatest challenges to date: how to track graduates from over 65 countries and measure their impact on health outcomes and policy in their local contexts?

Medical education accreditation in Mexico and the Philippines: impact on student outcomes

CONTEXT

Accreditation of medical education programmes is becoming increasingly prevalent worldwide, but beyond the face validity of these quality assurance methods, data linking accreditation to improved student outcomes are limited. Mexico and the Philippines both have voluntary systems of medical education accreditation and large numbers of students who voluntarily take components of the United States Medical Licensing Examination (USMLE). We investigated the examination performance of Mexican and Philippine citizens who attended medical schools in their home countries by medical school accreditation status.

METHODS

The sample included 5045 individuals (1238 from Mexico, 3807 from the Philippines) who took at least one of the three USMLE components required for Educational Commission for Foreign Medical Graduates (ECFMG) certification. We also separately studied 2702 individuals who took all three examinations (589 from Mexico, 2113 from the Philippines). The chi-squared statistic was used to determine whether the associations between outcomes (first attempt pass rate on USMLE components and rate of ECFMG certification) and medical school accreditation (yes/no) were statistically significant.

RESULTS

For the sample of registrants who took at least one USMLE component, first attempt pass rates on all USMLE components were higher for individuals attending accredited schools, although there were differences in pass rates among the components and between the two countries. The distinction was greatest for USMLE Step 1, for which attending an accredited school was associated with increases in first attempt pass rates of 15.9% for Mexican citizens and 29.2% for Philippine citizens. In registrants from the Philippines who took all three examinations, attending an accredited medical school was also associated with increased success in obtaining ECFMG certification.

CONCLUSIONS

These findings support the value and usefulness of accreditation in Mexico and the Philippines by linking accreditation to improved student outcomes.