Setting a global standard for medical education
■ A 2023 rule that all IMGs graduate from appropriately accredited medical schools to practice in the U.S. is fueling global education requirements.
As an international medical graduate, Dr. Saby Karuppiah, MPH, knows the challenges of becoming certified to practice in the United States. He also knows that all medical schools are different. Views on how to prepare students to practice medicine vary by school and by culture.
“Even though a vast majority of IMG physicians are competent and well-trained like myself, a few undertrained IMGs can give a bad rap to all IMGs in general,” said Dr. Karuppiah, who went to medical school at Sri Ramachandra University in India and completed residency training at the Albert Einstein College of Medicine in New York.
Each year, thousands of IMGs seek to practice in the U.S. These doctors make up a quarter of the U.S. physician work force and play an important role in helping to fill shortages nationwide, with many practicing in rural and other medically underserved areas.
But wide variations worldwide in training have caused U.S. medical licensing boards and residency programs to struggle for years to find how best to determine the quality of an IMG's medical education.
Many of those boards and programs rely heavily on the Educational Commission for Foreign Medical Graduates, which certifies IMGs wishing to enter U.S. residency programs — a requirement for them to enter U.S. practice. The ECFMG evaluates physicians' credentials and English proficiency and ensures doctors have passed the first two steps of the United States Medical Licensing Examination.
The ECFMG certified 9,791 IMGs in 2011. Without the certification, IMGs are not considered by U.S. residency programs. Certification also is required for IMGs to take the third and final step of the USMLE and qualify for an unrestricted medical license.
Traditionally, the ECFMG's focus has been on the qualifications of the individual physician. But during the next decade, the commission will expand its scrutiny to international medical schools. Beginning in 2023, any IMG seeking certification by the commission must graduate from a medical school accredited under internationally accepted standards set forth by the World Federation for Medical Education.
With more than 2,500 medical schools worldwide, the initiative is a mammoth undertaking, said ECFMG President and CEO Emmanuel G. Cassimatis, MD. The effort requires global consensus on the fundamentals of medical education and what it means to be a physician. Foreign medical school accrediting agencies must prove that they are in line with WFME standards, and countries without accrediting agencies will have to develop them.
“It's really a complex undertaking,” Dr. Cassimatis said. “In a part of the world with no accreditation system, they would have to set up a system, and schools — if they don't meet the standards — have to be given the time to meet the standards. It would be very hard to do in less than 10 years.”
The new requirements will help protect U.S. patients by providing added assurance about IMGs' credentials, and they will spur improvements in medical education worldwide, he said.
For its part, the WFME has been working to develop international standards in medical education for many years and already has guidelines for medical school accreditation.
The ECFMG initiative helps to underline the importance of those efforts, said WFME President Dr. Stefan Lindgren, professor of medicine at Lund University in Sweden.
“Transparent accreditation processes using internationally recognized and accepted standards is important as part of the global community. However, this does not mean the establishment of international accrediting bodies,” Dr. Lindgren said. “Instead, WFME believes that it is the national or regional legal bodies that should carry out this process.”
There was no way the WFME could set up a process for accrediting all of the thousands of medical schools worldwide, Dr. Cassimatis said. Instead, they are evaluating the accrediting organizations. So for schools to meet the ECFMG requirement, they will have to ensure they are accredited by an agency that has been approved under the WFME standards.
Overall, reaction to the effort has been largely positive, especially from people in the U.S., Dr. Cassimatis said. Outside the U.S., the ECFMG is still working to educate medical schools about the requirement.
The need for global standards
The initiative is a crucial undertaking, said Andrew Jeon, MD, president of DeVry Medical International Inc. The company operates two medical schools: Ross University School of Medicine in Dominica and American University of the Caribbean School of Medicine in Sint Maarten. He said the standards will help to weed out schools that provide an inferior education.
“We do need a single set of standards. It's a challenge facing the world,” Dr. Jeon said.
Many medical boards in the U.S. have struggled for years with how to evaluate the quality of the medical education of IMGs applying for medical licenses, said Humayun Chaudhry, DO, president of the Federation of State Medical Boards. With no such standards in place, some boards try to determine the quality of individual schools. Some, such as the Medical Board of California, have developed lists of approved and disapproved schools.
“The ECFMG's effort is a much needed initiative,” Dr. Chaudhry said.
Officials with the Assn. of American Medical Colleges and the American Academy of Family Physicians say they support the effort.
“There is no question it is a step in the right direction to raise the standard of medical education worldwide in the interest of protecting the public interest,” said AAFP President Glen Stream, MD.
The effort is helping with the move toward a global definition of what medical education should be and a global understanding of what's needed to make a good doctor, said Carol Aschenbrener, MD, AAMC chief medical education officer.
“We would like the processes that are utilized to be comparable to those that the [Liaison Committee on Medical Education] uses in the United States or those that have been established internationally by the WFME,” Dr. Cassimatis said.
Schools that traditionally have sent their graduates to train and practice in the U.S. have a strong incentive to comply. “If they don't meet the requirement, their graduates may not have the opportunity to come to the United States,” Dr. Cassimatis said.
Reaching a consensus
But developing an international standard for medical school accreditation comes with challenges. The ECFMG and WFME will have to allow for some variation in different countries, Dr. Jeon said.
“It's about making sure that we're being fair,” he said. “Just because a curriculum may be different doesn't mean that it's inferior.”
There are diverse perspectives on what it means to be a physician in different cultures and different health care systems, Dr. Stream said. Doctors in different countries may face vastly different health care problems, and countries have different educational systems and methods. For example, medical students in China don't ask questions of their teachers because it is considered disrespectful, he said.
Communicating the requirement to medical schools around the globe also will be difficult, Dr. Karuppiah said.
“Many schools would not be aware of the requirement, and the students might end up being ineligible for U.S. residency [training],” he said. “Communication is the key.”
Even once the new requirement takes effect, Dr. Cassimatis said the ECFMG may need to be flexible.
“We will need to look at the manner of implementing this to facilitate people meeting the goal, rather than causing hardship,” he said. “If a new, recognized accrediting agency has not been able to look at all the schools in its region, the schools that have not yet been reviewed are not necessarily bad schools — the agency just has not had enough time to look at them.”
The pilot project
While the requirement doesn't take effect until 2023, the ECFMG and WFME are laying the groundwork for its implementation. The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions was part of a recently completed pilot project. Headquartered in Kingston, Jamaica, the authority was the first accrediting agency to be reviewed. It was granted international recognition status by the WFME in May, said CAAM-HP Executive Director Lorna Parkins.
CAAM-HP was founded nine years ago to serve as the accrediting agency for a growing number of medical schools in the Caribbean. The region has seen an explosion in schools for several reasons, including the proximity to the U.S., lower operating costs and the fact that English is the spoken language, Parkins said.
CAAM-HP estimates there are 27 medical schools in the English-speaking countries of the Caribbean. Of those, CAAM-HP has accredited five schools. Having international recognition means that graduates will have an easier time being certified to practice in the U.S.
“There has been a great deal of interest in the Caribbean, because a large number of graduates from the Caribbean come to the United States,” Dr. Cassimatis said.
Accrediting agencies in several other countries have since requested evaluation and recognition by WFME, Dr. Cassimatis said. The LCME in the U.S. probably will be the next accrediting body to be evaluated.
Dr. Busharat Ahmad, an ophthalmologist in Monroe, Mich., who came to the U.S. from Pakistan in 1959 to do his residency training at Harvard Medical School, said he hopes the regulation ultimately will make it easier for IMGs to come to the U.S. But he wonders if IMGs from appropriately accredited schools will be treated any differently than they are today. For example, residency positions typically are given first to U.S. medical school graduates, and IMGs are considered for any remaining positions, he said.
“Does that mean that the schools that are certified are equal to the schools in this country?” Dr. Ahmad asked.
The regulation should mean that all IMGs are on par with U.S. medical graduates, said Dr. Karuppiah, clinical assistant professor at Penn State Milton Hershey School of Medicine and at Drexel University College of Medicine. But IMGs will be limited by whether their schools comply with the standards.
“The cons are this might limit the diversity of IMGs,” Dr. Karuppiah said. “Most, if not all IMGs, might come from a few countries. Certainly, not all schools in the world are going to make changes to meet the ECFMG standard simply because they wouldn't have the need.”
Dr. Cassimatis said the new requirement may make it more difficult for some IMGs to come to practice in the U.S. But a lack of growth in funding for graduate medical education positions is a more pressing problem.
“We are going to have a shortage of residency positions at the same time when physician shortages are predicted to develop around the country,” Dr. Cassimatis said, “I think a lot of that will happen long before 2023 rolls around.”