Hallock, James A. MD; Kostis, John B. MD
The Educational Commission for Foreign Medical Graduates (ECFMG) is a private, nonprofit, nongovernmental organization that is authorized in federal regulations to serve as the certifying agency for international medical graduates (IMGs) entering the U.S. physician workforce as trainees in postgraduate medical education (GME).
The ECFMG was established in 1956 to meet the need of hospitals to ensure that IMGs—then known as “foreign-alien” physicians—were properly vetted. It was charged with the primary objective of creating a mechanism to evaluate the qualifications of those physicians and certifying their suitability for entry into GME in the United States.
Although the ECFMG was created for these purposes related to health care in the 1950s, it is instructive and important to recognize the contributions that have been made and the evolution that has occurred over the last 50 years.
Many IMGs have entered the United States, participated in GME, and remained in the physician workforce; thus, IMGs now constitute 25% of practicing physicians in the United States. The ECFMG has evolved into a world class certifying entity to serve the needs of IMGs. As data have been collected in these endeavors, the ECFMG has developed databases to become an information-based organization. It strives to continuously improve medical education globally with several domestic and international partners that are active in setting standards, assessing individuals and institutions, and supporting the move toward a common international process of evaluating medical schools.
This article will summarize the contributions that the ECFMG has made to American health care, IMGs, postgraduate medical education in the United States, and international medical education by reviewing mainly the following:
* The origins of the ECFMG
* The values, mission, and purposes of the ECFMG
* The certification process
* The Exchange Visitor Sponsorship Program (EVSP)
* Research programs
* The Foundation for Advancement of International Medical Education and Research (FAIMER)
The Origins of the ECFMG
The ECFMG was established in the mid 1950s to fill the need to evaluate the increasing number of foreign-trained physicians who were migrating to the United States after World War II. The “Information and Educational Exchange Act” of 1948 and the availability of funds from the Fulbright Program gave foreign physicians the opportunity to come to the United States for training. Simultaneously, there was marked growth in the American hospital system, with research-oriented teaching hospitals and medical schools gaining in stature around the world.
Thus, the GME system in the United States developed more than twice as many internships as were necessary to accommodate the then roughly 7,000 U.S. medical school graduates per year. Hospitals began seeking interns to fill the excess slots, and IMG candidates began to fill them. As the system accepted more foreign-trained physicians, it became apparent that a mechanism was needed to evaluate their training, qualifications, and credentials.
In 1954, the American Hospital Association (AHA), the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), and the Federation of State Medical Boards (FSMB) appointed a Cooperating Committee on Graduates of Foreign Medical Schools to devise an effective mechanism to meet these needs. The Cooperating Committee recommended creating a separate organization. The resulting organization was incorporated in May 1956 as the “Evaluation Service for Foreign Medical Graduates”; its name was changed later that year to the “Educational Council for Foreign Medical Graduates.” The stated purposes of the ECFMG were:
* To give graduates of recognized foreign medical schools an opportunity to establish their qualifications for undertaking advanced medical training in United States hospitals, and
* To provide hospitals, state boards of medical examiners, and specialty boards with the means of identifying those foreign medical graduates who were qualified to assume places as interns and residents and those who were not.
These functions proceeded through the 1950s and 1960s, and the Commission on Foreign Medical Graduates (CFMG) was established in 1970 to bring together existing information on foreign medical graduates and to conduct studies to develop new information. The AHA, AMA, and ECFMG each provided financial support to the CFMG for two years, and five additional organizations were represented on the CFMG Board: the American Board of Medical Specialties (ABMS), the AAMC, the Association for Hospital Medical Education (AHME), the FSMB, and the National Medical Association (NMA).
In 1974, the Commission on Foreign Medical Graduates was merged with the Educational Council for Foreign Medical Graduates to resolve the division of authority between the two organizations, thus forming the Educational Commission for Foreign Medical Graduates, as it is known today. The merger broadened the ECFMG’s responsibilities and moved the organization into the international medical education arena, requiring increased expertise in credentials evaluation, international exchange, and data collection, along with formation of a data repository.
The ECFMG has remained intact since 1974, and its operations have evolved to mirror its current values, mission, and purposes. The certification process remains ECFMG’s core mission and provides the assurance to the American public and the GME community that the individual IMG has achieved a level of proficiency sufficient to enter accredited GME.
The Values, Mission, and Purposes of the ECFMG
In 2004, the ECFMG Board of Trustees acted to adopt statements to further define the ECFMG’s values, mission, and purposes. These statements are as follows.
The values of the ECFMG are expressed in its vision statement: Improving world health through excellence in medical education in the context of ECFMG’s core values of collaboration, professionalism and accountability.
The charge of the ECFMG is expressed in its mission statement: The ECFMG promotes quality health care for the public by certifying international medical graduates for entry into U.S. graduate medical education, and by participating in the evaluation and certification of other physicians and health care professionals. In conjunction with FAIMER, and other partners, it actively seeks opportunities to promote international medical education through programmatic and research activities.
The purposes (goals) that actuate and accomplish ECFMG’s mission are to:
* Certify the readiness of IMGs for entry to graduate medical education and health care systems in the United States through an evaluation of their qualifications;
* Provide complete, timely, and accessible information to IMGs regarding entry to graduate medical education in the United States;
* Assess the readiness of IMGs to recognize the diverse social, economic, and cultural needs of U.S. patients upon entry into graduate medical education;
* Identify the needs of IMGs to become acculturated into U.S. health care;
* Provide international access to testing and evaluation programs;
* Expand knowledge about international medical education programs and their graduates by gathering data, conducting research, and disseminating the findings;
* Improve international medical education through consultation and cooperation with medical schools and other institutions relative to program development, standard setting, and evaluation;
* Improve assessment through collaboration with other entities in the United States and abroad;
* Improve the quality of health care by providing research and consultation services to institutions that evaluate IMGs for entry into their country; and
* Enhance effectiveness by delegating appropriate activities in international medical education to FAIMER.
The vision statement and mission statement have broad implications and are meant to guide the ECFMG’s actions, and to ensure that the impact of these actions on the patients being served by physicians and other health care workers is of paramount importance. Although we at the ECFMG are not, and certainly cannot be, responsible for the health of all people, we strive for excellence in international medical education and must be mindful of the interaction of education and health care.
Collaboration stands out as a value that moves our mission forward. We cannot remain insular, and we must share our knowledge and resources. Thus, the ECFMG created FAIMER as a major partner in these endeavors. We have domestic and international collaborations. Our domestic partners include our current six organizational members—the AAMC, ABMS, AHME, AMA, FSMB, and NMA. We also have critically important domestic collaborations with the National Board of Medical Examiners (NBME), the Accreditation Council for Graduate Medical Education (ACGME), and the Commission on Graduates of Foreign Nursing Schools. These partnerships are built on the gathering and sharing of data and help to inform policy discussions.
Collaboration with the NBME deserves special note. The NBME and the ECFMG have been collaborators throughout the 50-year history of the ECFMG. The NBME has provided most of the examination material for the ECFMG and on occasion administered examinations for the ECFMG prior to introduction of the United States Medical Licensing Examination (USMLE) sponsored by the FSMB and the NBME. Upon the creation of the USMLE, the ECFMG became a collaborator with the NBME and the FSMB in the Composite Committee, which has policy oversight of USMLE programs. Since the origin of the USMLE, the NBME has administered the examinations for all examinees, including IMGs, with ECFMG serving as the registration and certification entity. The ECFMG and the NBME have collaborated in research on the performance of IMGs and in a number of projects in international medical education. They also have collaborated significantly in clinical skills assessment and in 2002 created the Clinical Skills Evaluation Collaboration (CSEC). CSEC is a contractual agreement between the ECFMG and the NBME to construct facilities and provide a testing milieu using standardized patients to evaluate clinical skills of medical students and physicians. The first client for this endeavor is the USMLE, for which CSEC has created test centers in Philadelphia, Atlanta, Chicago, Houston, and Los Angeles for administration of the USMLE Step 2 Clinical Skills (CS). This partnership with the NBME will continue and will foster more international collaborations through assessment.
Internationally, we are collaborating with the World Health Organization, the World Federation for Medical Education, the Association for Medical Education in Europe, the Panamerican Federation of Associations of Medical Schools, the International Association of Medical Regulatory Authorities, and others. Each of these collaborations is directed at achieving excellence in international medical education; the emphasis differs depending on the partner.
The Certification Process
Between 1958 and 2005, 656,813 candidates started the ECFMG Certification process by registering for one of the required examinations. Of these first-time applicants, 292,287 (44.5%) were eventually awarded an ECFMG Certificate as of April 2006. Many of the certificate holders went on to secure residency and practice positions in the United States. In 2003, according to the AMA Physician Masterfile, there were 182,737 ECFMG Certificate holders listed as clinically active, including over 25,000 residents. There are also approximately 12,000 IMGs listed in the AMA Physician Masterfile who entered the system before implementation of the requirement of ECFMG Certification.
Time trends of international medical graduates, 1956–2005
The demand for ECFMG Certification, as manifested by the number of new applicants, has varied markedly in the 50 years since the inception of the ECFMG, with a peak in 1975 and a nadir in 1999 (Figure 1). These ebbs and flows have largely reflected world situations, such as postwar events, international alliances, and changes in domestic demand for physicians. They also have reflected changes in the certification process. In the late 1990s, when the USMLE became computer-based and the ECFMG initiated the Clinical Skills Assessment (CSA) for IMGs, IMGs were hesitant to seek certification and the number of new applicants fell. In addition, sudden declines in the number of new applicants occurred in the late 1970s (from 24,076 in 1975 to 8,820 in 1978), in the mid 1980s (from 16,975 in 1982 to 8,634 in 1987), and the late 1990s (from 20,329 in 1997 to 7,424 in 1999). The number of new applicants has rapidly increased continuously since 1999, from 7,424 in 1999 to 12,014 in 2005.
Top countries of origin of ECFMG Certificate holders, based on citizenship at the time of entry to medical school, are provided in Table 1. Over the past 50 years, India has provided the greatest number of certified IMGs, followed by the United States and the Philippines. Interestingly, in the past five years (2001–2005), more than 20% of the ECFMG Certificates were issued to American citizens. Proportions of certificate holders coming from various countries have changed somewhat over the years. For example, comparison of the figures for 1958–2005 and those only for 2001–2005 shows that the Philippines is supplying proportionately fewer doctors. In contrast, Nigeria is supplying proportionately greater numbers, with more than 20% of the certificate holders from Nigeria having been certified in the past five years.
The current ECFMG Certificate is required for entry into accredited GME, for admission to Step 3 of the USMLE, and for licensure in all jurisdictions in the United States.
Steps for IMG certification
The steps for IMG certification are as follows:
* Application to the ECFMG
* Submission of a diploma and medical school transcript for verification
* Successful completion of USMLE Step 1 and Step 2 Clinical Knowledge (may be taken around the world in the Prometric system)
* Successful completion of USMLE Step 2 CS (must be taken in the United States at one of the five centers)
Credentials reference library.
Over the last 50 years, the ECFMG has developed an extensive medical education credentials reference library containing sample medical school diplomas from more than 1,500 medical schools in approximately 150 countries. These holdings include verified credentials from the mid-20th century to the present, as obtained while verifying the credentials of the applicants for ECFMG Certification. The library is a resource containing lists of medical schools’ authorized officials and copies of the officials’ signatures, medical school seals, sample-verified medical diplomas, licenses and certificates of registration, medical school transcripts, and correspondence with government and medical school officials and others. By 2005, much of the credentials reference library had been converted to an electronic format, providing digital images of the library’s extensive holdings.
Introduction of primary source verification requirement.
In July 1986, a major change in the ECFMG’s medical education credential policy took effect. The ECFMG Board of Trustees required that, effective July 1, 1986, the medical diplomas of all graduates applying for ECFMG Certification be primary source verified with the medical school that issued the diploma. (Primary source verification is the process of transmitting a document to the origin and asking that source to attest to the veracity of the individual and the document being proffered.) This change in 1986 began a process to ensure that all diplomas would undergo this scrutiny.
To implement the primary source verification requirement, the ECFMG sent a letter to the applicant’s medical school detailing the primary source verification requirements and included a copy of the applicant’s medical diploma. Attached to the copy of the medical diploma was a verification form for completion by an authorized official of the medical school.
Because of political situations, medical schools in a number of countries—including, but not limited to, the USSR, Bulgaria, Romania, Poland, Vietnam, Yugoslavia, and Cuba—did not respond to the ECFMG’s requests. For these cases, the ECFMG Board of Trustees approved substituting attestations, sworn in the presence of a notary, from three physicians who were fellow students or faculty members at the applicant’s medical school or who had other direct, personal knowledge that the individual attended the specified medical school, graduated, and received the final medical diploma. Physicians submitting such attestations were required to specify that they had personal knowledge of the applicant’s graduation and to specify the basis of that knowledge. The attesting physicians must hold active unrestricted licenses to practice medicine in a state (or states) in the United States or in the District of Columbia and must include their state license numbers in the attestation form. The ECFMG verifies with the physicians’ licensing boards that their licenses are active and unrestricted.
In subsequent years, the ECFMG made considerable efforts to obtain cooperation from officials at the medical schools that did not respond to its verification requests. Additionally, the political situation changed in many countries, most notably those in Central and Eastern Europe in the early 1990s. By the mid-1990s, the ECFMG was routinely receiving responses from medical schools in all but a handful of countries, and it continues to do so today.
Changes to medical education credential policy in 1998.
In 1994, the ECFMG Board of Trustees approved modifications to the ECFMG medical education credential policy, effective July 1, 1998. No longer were applicants required to be licensed or registered in the countries where they received their medical education; rather, they needed only to document that they had completed all requirements for, and received, the final medical diploma. This modification did not alter the requirement that applicants submit their final medical diploma and that ECFMG primary source verify it. Also effective July 1, 1998, applicants for ECFMG Certification were required to pass the ECFMG CSA, in addition to passing the basic medical and clinical science examinations and the ECFMG English test.
Current ECFMG medical education credential policy and process.
The current medical education credential requirements for ECFMG Certification are the following:
* The physician must have had at least four credit years (academic years for which credit was given toward completion of the medical curriculum) in attendance at a medical school listed in the International Medical Education Directory (IMED).
* The physician’s graduation year must be included in the medical school’s IMED listing.
* The physician must provide the required medical education credentials, which include the final medical diploma and final medical school transcript.
Graduates must provide the ECFMG with a photocopy of their final medical diploma. All documents not in English must be accompanied by an English translation prepared and certified to be correct by a government official, medical school official, or recognized translation service. The translation must appear on official stationery and bear the signature of the official or representative of the translation service. If the name on the medical diploma does not exactly match the name in the ECFMG record, the applicant must provide legal documentation that verifies the name on the medical diploma is (or was) the applicant’s name. The applicant must also provide a signed release that authorizes the medical school to verify the medical diploma and the final medical school transcript to the ECFMG, and he or she must provide a current passport-size photograph.
After the ECFMG receives the medical diploma, the release, the photograph, and any other required documents, it compares the diploma with verified sample medical diplomas from the same medical school and year that are contained in the ECFMG credentials reference library. If the diploma is consistent with the verified sample diplomas for the same medical school and year, the ECFMG then sends a primary source verification request to the medical school that issued the diploma.
Thus, the process of ECFMG Certification, with its ever-improving requirements, has helped assure the American public and the medical community of the readiness of individual IMGs to enter GME.
Development of credential initiatives.
Recognizing the unique expertise and resources of the ECFMG, the ECFMG Board of Trustees authorized in 1999 the establishment of ECFMG’s International Credentials Services (EICS). The EICS provides a service to international organizations and authorities involved in medical registration, licensing, and assessment by obtaining primary source verification of the credentials of physicians who completed their medical education outside the authorities’ jurisdiction.
The categories of credentials for which the EICS will obtain primary source verification are medical diplomas and medical school transcripts, certificates confirming completion of postgraduate medical education, and certificates of registration/licensure. The application submitted to the EICS for each physician is typically associated with multiple credentials in these categories. The first EICS application was received in 2000 from a physician applying for registration with the College of Physicians and Surgeons of Nova Scotia, Canada. Since then, a substantial number of international organizations and authorities have made verification of a physician’s credentials by the EICS a requirement for medical registration, licensure, or admission to an examination.
In November 2003, the ECFMG signed an agreement with the Medical Council of Canada (MCC) in which the EICS would provide credentials verification services to the MCC for physicians applying to the MCC for its Evaluating Examination. The EICS and the MCC created a process for providing data and documents to each other electronically. This process includes EICS’s transmitting source verified documents to the MCC electronically. Similar electronic processes are described in the agreements between the ECFMG and the FSMB’s Federation Credentials Verification Service (FCVS), signed in 2004, and between the EICS and the Australian Medical Council, signed in 2005. Through the end of 2005, the EICS had worked with 17 clients in seven countries.*
The ECFMG and the FSMB have agreed that the ECFMG will obtain primary source verification of the medical diplomas and medical school transcripts of IMGs applying to the FSMB’s FCVS. This process will aid many IMGs applying for medical licensure in jurisdictions in the United States by eliminating the duplication of efforts by the ECFMG, the FCVS, and state medical licensing boards.
Gathering these data in such a detailed fashion will allow the ECFMG to generate a database of “migrating” IMGs. Availability of these data will help the IMGs and the countries to which they are migrating, and it will allow the countries from which they are migrating to begin to look at the patterns of migration. The critical role of the ECFMG is to provide and analyze the data in order to inform the discussion.
Medical knowledge testing
The history of the testing of IMGs is quite instructive, revealing the changing approaches and attitudes toward this group. Testing was instituted to measure the knowledge of IMGs as a prerequisite for ECFMG Certification. In early years, more than 50% of the test takers failed. This situation led to the issuance of temporary certificates to allow IMGs to fill vacant slots and have two years to achieve certification by passing the examinations. This approach was stopped in 1964 because both the number and the pass rate of IMGs had increased.
List 1 shows the evolution of the testing process over these 50 years. It is important to note that most of these examinations were provided by the NBME while being administered by the ECFMG.
The examination process—USMLE Steps 1, 2, and 3— is now the same for all physicians seeking licensure in the United States. Thus, IMGs must demonstrate the same level of proficiency as U.S. graduates. They are no longer required to take the Test of English as a Foreign Language.
Clinical skills assessment
As early as 1982, the ECFMG Board of Trustees expressed concern about the clinical skills of IMGs and the methods for assessing hands-on skills. A number of committees were created, and the first pilot examination of clinical skills was administered in 1985 to 117 IMGs and 59 U.S. medical graduates (USMGs). This pilot testing was repeated in 1987 with 635 IMGs and 123 USMGs. The results of these studies, published in 19861 and 1989,2 confirmed that the clinical skills of IMGs were inferior to those of USMGs. Eventually, in July 1998, the ECFMG implemented the CSA, which consisted of 10 scored encounters with standardized patients (SPs). List 2 provides a timeline of major developments leading to the implementation of the CSA examination in July 1998.
From July 1998 through April 2004, all candidates for ECFMG Certification were required to pass the CSA examination as part of the certification process. This requirement addressed the concerns raised by the board in the early 1980s about the clinical skills of IMGs. Whereas the written examinations had long assessed the knowledge base of IMGs, only after the CSA was implemented could we be relatively confident of their clinical skills and spoken English.
In September 2002, as part of collaborative research with the NBME, the CSA was also administered in Atlanta, Georgia. Although the CSA is no longer used, IMGs must still pass a clinical skills examination; the USMLE Step 2 CS is used for this purpose.
During the five and a half years that the CSA was given, there were 43,632 individual CSA examinations (35,548 in Philadelphia; 8,084 in Atlanta) and 436,997 scored SP encounters. Among the 37,930 first-time test-takers, the overall fail rate was 13.6%. This exam served extremely well at screening the clinical skills and spoken English of IMGs. The research of the ECFMG in this area is world renowned and has led to collaborative efforts with the NBME in designing and improving clinical skills assessment. Work on the CSA served as a foundation for CSEC between the ECFMG and the NBME that was noted earlier in this report.
Service to IMGs is a major emphasis of the ECFMG. To this end, in the past few years we have moved from a paper-based communication system to one that is almost paper-free. We have markedly improved services to IMGs by facilitating completion of transactions via the World Wide Web. Thus, IMGs can electronically submit applications, register for and schedule examinations, receive score results, and query the system about their status in any regard. The ECFMG Web site has become very user-friendly and includes all links needed to ensure smooth access by users. The Web-based actions are password protected and thus protect the privacy and identity of the user. Questions are answered rapidly via an e-mail system. The ECFMG’s several Web-based publications, which currently have a combined total of approximately 80,000 subscribers, provide rapid, accurate information and facilitate exchange of information with IMG applicants and certificants. All of these improvements in technology and communications have improved services to IMGs.
The Exchange Visa Sponsorship Program
The ECFMG has played a major role in facilitating the entry of foreign national physicians to the United States under the government’s diplomatic initiative known as the J-1 Exchange Visitor Program. For more than 35 years, the ECFMG has collaborated with various government agencies in the management and oversight of physicians who pursue graduate medical education and training on J-1 visas. These agencies have included the Departments of State, Health and Human Services, and Homeland Security, as well as the now-defunct United States Information Agency and the now-defunct Immigration and Naturalization Service.
The legislation and federal regulations that established the Exchange Visitor Program date back to the U.S. Information and Exchange Act of 1948 and the Immigration and Nationality Act of 1952. The Exchange Visitor Program was designed to improve and strengthen the international relations of the United States by enhancing mutual understanding through educational and cultural exchange. From the beginning, participants in the Exchange Visitor Program have been admitted to the United States as temporary nonimmigrants on J-1 visas. From 1952 through 1978, the ECFMG, along with some 225 select educational and scientific institutions, served as visa sponsors for J-1 exchange visitor physicians (“alien physicians”) who came to the United States.
In 1979, the ECFMG was designated the sole visa sponsor for J-1 alien physicians enrolled in clinical training programs. Program administration was centralized through the ECFMG in order to provide assurance regarding the academic and medical qualifications of foreign-trained physicians. The ECFMG continues to administer its EVSP in accordance with provisions set forth in a Memorandum of Understanding with the International Communication Agency, now Department of State, and the J-1 regulations promulgated to implement the Mutual Education and Cultural Exchange Act (22CFR§62).† The ECFMG continues to be responsible for ensuring that J-1 alien physicians and their host institutions meet the federal requirements for participation. However, the ECFMG does not issue the visa; it is issued by the U.S. Department of State in the home country of the applicant.
In order to participate in clinical training in the United States, J-1 physician applicants must (1) hold a valid ECFMG Certificate (foreign nationals who graduated from U.S. or Canadian medical schools are exempt from this requirement), (2) provide a Statement of Need from the Ministry of Health of the country of most recent legal permanent residence evidencing support for the proposed U.S. training, and (3) hold a contract for an approved program of GME. ECFMG sponsorship is restricted to GME programs accredited by the ACGME and nonstandard fellowships associated with these programs. By regulation, J-1 clinical training is limited to a maximum of seven years. The ECFMG is also authorized to sponsor physicians as J-1 “research scholars” for nonclinical activities. These activities are limited to three years in duration.
Internal medicine has traditionally been the most common specialty for J-1 sponsored physicians. In the mid-1980s, more than 33% of all J-1 physicians were enrolled in internal medicine residencies or in fellowships in subspecialties of internal medicine. That proportion climbed to about 50% in the late 1990s but declined to 43% in the 2003–04 academic year. Pediatrics has remained the second most popular specialty, representing another 10–15% of sponsored physicians, although this percentage has declined in recent years. Anesthesiology, psychiatry, and general surgery have also maintained high percentages of J-1 physicians. J-1 physicians have been overwhelmingly citizens of India, Pakistan, and the Philippines. However, Canadian and Lebanese physicians have outnumbered those from the Philippines for the past three academic years (2002–03, 2003–04, and 2004–05).
Between 1979 and 1996, foreign national physicians entering or progressing through U.S. GME were presumed to be J-1 visa holders. Over the past 10 years, however, immigration options for foreign national physicians have expanded considerably. The most common alternative to the J-1 visa for physicians is the H-1B for “Temporary Workers in a Specialty Occupations.” The H-1B requires visa sponsorship by the employing hospital. The ECFMG continues to sponsor about 25% of all IMGs in GME through the J-1 program.
Beyond its administrative responsibilities as a J-1 visa sponsor, ECFMG’s EVSP remains a critical resource on a broad range of immigration and workforce-related issues regarding IMGs. Through continued collaboration with the Departments of State, Health and Human Services, and Homeland Security, the ECFMG plays an important role in the collection, dissemination, and analysis of data on IMGs. Therefore, the ECFMG is uniquely qualified to respond to the changing immigration environment and to continue to carry out the U.S. diplomatic mission of educational and cultural exchange.
Historically, ECFMG research has focused primarily on establishing the relevance of required certification examinations, assessing their impact on IMGs, and developing international aid programs. Research has been carried out primarily by ECFMG staff, at times in collaboration with outside researchers. Today, with the existence of FAIMER, a nonprofit foundation established by the ECFMG in 2000, the research agenda has expanded considerably and includes many areas relevant to international medical education.
Between 1996 and 2004, ECFMG research was devoted mainly to the validation of the CSA, which was designed to assess the clinical readiness of graduates of international medical schools to enter graduate training programs in the United States. During this period, more than 200 presentations relating to the CSA were made at national and international conferences. Reports of more than 30 peer-reviewed studies on the subject were published in academic journals. These reports provided details on the CSA; aspects that were addressed included the recruitment and training of standardized patients, scoring systems, score-equating strategies, content justification, standard-setting protocols, psychometrics, and evidence to counter a host of challenges to the validity of the examination.
From the mid 1980s until the implementation of the CSA in July 1998, most ECFMG research activities concentrated on the operational aspects of providing a high-volume, high-stakes clinical skills assessment for IMGs.3,4 Several pilot studies were conducted, both in the United States and internationally. In 1996–1997, the ECFMG conducted a large-scale Norming and Validity (NAV) study at a large medical school consortium in the United States. To help determine protocols for administering and scoring the test, a prototype version of the CSA was administered to more than 900 U.S. medical students. The NAV study was followed in 1997–1998 by a Calibration and Validity (CAV) study. This investigation, involving nearly 400 IMGs, was designed to provide information on the utility of specific CSA cases and to gather performance data to use in setting realistic assessment standards. Between 1989 and 1995, before the NAV and CAV studies, pilot studies of the CSA were conducted in the United States (in Chicago) and internationally (for example, in Israel, Brazil, Spain, and the Ukraine). These investigations were done to evaluate the readiness of IMGs to enter U.S. residency programs, to validate national medical examinations in other countries, and to introduce other countries to new methods of evaluating medical students.
Before the fieldwork for the implementation of the CSA, ECFMG research efforts were directed primarily at describing examination performance of select cohorts (for example, U.S. citizens who studied medicine abroad) and establishing the overall utility of the certification process with regard to medical competence. From 1959 to 1989, there were several published reports outlining the ECFMG Certification process, summarizing examination results by country, and describing the experiences of internationally-trained physician groups during the process of obtaining medical licenses in the United States. In addition, some work was done to investigate the graduate specialty training experience and work experience of IMGs in the United States.
With the establishment of FAIMER and the discontinuation of the ECFMG Clinical Skills Assessment, the responsibility for many of ECFMG’s academic research activities moved from the ECFMG to FAIMER. From 2003 to 2005, the FAIMER Research Committee developed a broad research agenda focused on studies to help advance international medical education. Both short- and long-term research goals were formulated to direct research efforts toward projects to help identify, track, and assess the educational experiences and migration patterns of IMGs. It was concluded that targeting certain key areas would help to disentangle the complex issues related to the supply of, and need for, physicians in various regions around the world. FAIMER research endeavors, therefore, are now categorized into three broad domains: international migration of physicians, U.S. physician workforce issues, and international medical education programs. Within these broad areas, studies focusing on international medical education, including the quality of medical schools and their graduates, and international accreditation, licensure, and certification processes, are being conducted. Consistent with previous ECFMG efforts, these investigations are being carried out, often in collaboration with other institutions, to help inform policymakers in government, academia, and other interested entities.
The idea of establishing a separate foundation developed from the ECFMG’s long-standing commitment to promoting excellence in international medical education. This commitment began with the ECFMG’s first faculty exchange program in 1983. In the years that followed, the ECFMG increased resources for exchange programs, introduced consultation services for medical schools outside the United States, and considered a number of research initiatives related to international medical schools and their graduates. However, the ECFMG’s Board of Trustees believed that more could be accomplished by a separate organization with dedicated resources focused on the international medical community. Discussions began in early 2000, and in July of that year, the ECFMG Board of Trustees approved a resolution to establish an ECFMG foundation.
FAIMER was incorporated as a nonprofit foundation of the ECFMG in September 2000, and FAIMER’s Board of Directors held its first organizational meeting in December 2000. An executive search initiated at the end of 2001 resulted in recruitment of the foundation’s first president and chief executive officer, John J. Norcini, PhD, who joined FAIMER in May 2002. Throughout the period from 2001 through 2003, the membership of the foundation’s board expanded with the election of directors-at-large. By the end of 2003, all board positions had been filled, and, in April 2004, the board held its first meeting with full membership.
According to its strategic plan, FAIMER concentrates its efforts in three thematic areas: creating educational opportunities for medical educators, discovering patterns and disseminating knowledge with regard to medical education, and developing data resources on medical education. In approaching these activities, FAIMER maximizes its impact by concentrating its efforts and resources in specific geographical areas based on need as well as in countries that have supplied substantial numbers of IMGs to the United States. South Asia has been identified as FAIMER’s primary focus, and Sub-Saharan Africa and South America as additional areas of concentration. The strategic plan also calls for FAIMER to identify and collaborate with appropriate partners to leverage resources and maximize impact.
Creating educational opportunities for medical educators
In 2001, the ECFMG began to move its fellowship program, the International Fellowship in Medical Education (IFME), to FAIMER. This transition was completed in 2003.
The IFME program allows faculty from schools of medicine abroad to access educational opportunities in the United States that suit specific home-country needs. From 1997 to 2004, the IFME program provided individual mentorships. In the individual mentorship program, up to 20 fellowships were awarded annually for programs of 6 to 12 months’ duration. Mentorship was provided by preceptors in basic medical science, clinical science, and medical education departments in U.S. medical schools. Programs included such topics as medical school governance, teaching and assessment methods, and curricular design. More than 280 fellows from 75 countries participated. Mentoring was provided by more than 200 mentors from more than 100 institutions. The program boasted a return-home rate of more than 90%.
In addition to initiating the migration of the IFME program to FAIMER in 2001, the foundation established a new fellowship program, the FAIMER Institute, which has now replaced the individual mentorships. The Institute is a two-year part-time fellowship program designed for international medical school faculty with the potential to play key roles in improving medical education at their schools. The first year consists of two residential sessions of three weeks each in the United States and, between the two sessions, a curriculum innovation project at the participant’s home institution. The second year, completed from the fellow’s home country, involves mentoring an entering fellow and participating in the institute’s Internet discussion group. The program is uniquely designed to teach education methods and leadership skills, as well as to develop strong professional bonds with other medical educators around the world. As of 2005, 56 fellows had been accepted to the institute.
In 2005, the IFME program began its transition from an individual mentorship program to a program that supports the acquisition of advanced academic degrees by FAIMER Institute alumni.
Summary and Future Perspective
Thus, for 50 years, the ECFMG has served the intent of its origins very well. It has established processes and mechanisms to ensure the qualifications of applicants and the veracity of their credentials. It has modified testing to measure the ability of IMGs to enter GME in the United States. The process has certified 44.5% of all who have applied during this period. Although the certification rate has increased to 50% in the past 10 years, ECFMG Certification remains a formidable challenge to those desiring GME in the United States. The ECFMG will continue to serve as the certifying and sponsoring entity for IMGs. We will continuously seek ways to facilitate these processes and apply technological advances where and when useful to the global community.
We will continue to collect data and build our databases with the hope of sharing data to inform policy regarding health care, medical manpower, and physician migration.
The ECFMG is a ready partner and collaborator as the global movement to standard setting, assessment of individuals and institutions, and accreditation seeks to help improve health care for all.