Johnson, David A. MA
In the United States and Canada, all medical school programs are accredited by either the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association's (AOA's) Commission on Osteopathic College Accreditation. These accreditation systems provide assurance to medical students and graduates, the medical profession, state medical boards, health care institutions, and the public that undergraduate medical education programs in the United States leading to the MD or DO degree meet reasonable and appropriate national standards for educational quality and that graduates have a sufficiently complete and valid educational experience.
Whereas graduates of the 126 LCME- and 25 AOA-accredited medical school programs constitute the majority of new physician licensees in this country each year, graduates of medical schools located outside the United States constitute approximately a quarter of all licensed physicians in the United States.1 The contributions of this latter group are significant. IMGs contribute to the overall ethnic, racial, and religious diversity of this country's physician workforce. There is evidence that some hospitals and primary care graduate medical education (GME) programs in the United States are heavily dependent on the IMG population for their workforces. IMGs also serve an important role in underserved areas, as evidence exists that IMGs holding temporary, or J-1, visas are more likely to practice in medically underserved areas than are U.S. graduates.2,3
A Major Challenge
However, questions relative to the licensing of individuals graduated from one of the 1,800-plus medical schools located outside the United States do arise periodically. Articles on this subject appeared in publications of the FSMB as early as 19164 and have continued in recent years in various journals, the most notable of which was an article published in 2000 in the New England Journal of Medicine and written by prominent medical educators.5 The issues described in these articles highlight the challenge facing medical boards today (i.e., assessing the qualifications of physicians who graduated from medical school programs located outside the United States despite limited information—at best—on the specifics of those schools' educational curricula).
Public expectations and statutory language mandate that state medical boards ascertain the qualifications of individuals presenting themselves for initial medical licensure. Assessing the quality of education provided by the licensee's medical school is an inherent part of the licensure process. Complicating the task for state medical boards is the lack of accreditation systems for most international medical schools comparable with that of the LCME or AOA for U.S. medical schools. Absent a comparable accreditation system, state medical boards are left without uniform standards for determining the quality of the medical education provided to its potential licensee graduates of non-LCME- or non-AOA-accredited schools.
Several factors have renewed medical boards' focus on this issue in recent years. First, the number of U.S. citizens attending medical schools outside the United States—presumably with the intention of returning to this country to obtain licensure—seems to be increasing. The number of U.S. citizens obtaining certification from the Educational Commission for Foreign Medical Graduates (ECFMG) annually has tripled during the past decade from 527 in 1995 to 1,932 in 2005. U.S. citizens as a percentage of all individuals certified by the ECFMG rose from 9% in 1998 to approximately 21% for the period covering 1999 to 2006.6
Second, demographic projections suggest that the United States will experience a shortage of physicians within the next 15 years.7,8 It is unclear at this time whether U.S. medical schools will be able to meet the projected shortfall even with a proposed 30% increase in medical school graduates set forth by the Association of American Medical Colleges (AAMC)9 and a projected one-third increase in osteopathic enrollment.10 Because the AAMC proposal calls for removing the cap on GME positions reimbursed by Medicare and rejects a decrease in the number of IMGs, it seems likely that this country will continue to rely on the IMG community to meet a portion of its medical needs.11 Indeed, some would argue that this is already the case, as evidenced by the fact that the two medical schools with currently the largest number of residents in ACGME-accredited programs are both located outside the United States: Ross University in Dominica and St. George's University in Grenada (information derived from unpublished data at the AAMC Center for Workforce Studies).
Third, the number of medical schools worldwide continues to increase, including medical school programs located in the Caribbean region that are heavily dependent on U.S. citizens for much of their enrollment. Estimates for the number of medical schools located in the Caribbean region vary between 45 and 60. The California Medical Board believes 29 new schools have been established in the region within the last six years alone. Many of these medical schools are for-profit endeavors using nontraditional educational practices (e.g., no formal examinations for admission, awarding credit for prior experience in related health care professions, granting credit hours on the basis of limited on-site education).12,13
Finally, with few exceptions, state medical boards lack the resources to conduct a thorough evaluation of the curriculum and operations of individual international medical schools whose educational practices may be in question. This becomes readily apparent when a particular incident or case throws media and public attention on a specific school or its graduates. For example, two cases in recent years involved the University of Health Sciences at St. Johns, Antigua, and advance standing provided to dentists who subsequently earned MD degrees. The resulting media and legal attention focused on the assumptions and inferences the public make when the MD credentials are used professionally, and on the ability of a state medical board to limit the professional use of the MD credential by an unlicensed individual.14
With these factors in mind, state medical boards' questions relative to licensing graduates of international medical schools are understandable. With a fundamental charge that includes protection of the public, state medical boards receive mixed messages on this topic. Whereas some members of the public would call for closer scrutiny of licensees from international medical schools, others urge caution lest heightened scrutiny or added requirements result in delays in licensing physicians or reducing the licensee population, a particularly important public issue for those regions facing a shortage and/or maldistribution of physicians, and one that will only become more critical if the current demographic projections of a physician shortage hold true.15–17
Other pressures can arise in states where specific medical schools have been identified as failing to meet adequate standards for providing medical education and have been added to a list of nonapproved schools whose graduates are not eligible for licensure in that jurisdiction. In response to an FSMB survey, several boards reported pressure from residency programs to either allow the program to accept physicians from nonapproved schools or revise the board's listing of acceptable medical schools whose graduates can be licensed in their jurisdiction.
A National Clearinghouse with Quality Indicators
In response to these concerns, the FSMB formed the Special Committee to Evaluate Undergraduate Medical Education. The committee's final report, issued in spring 2006, offered several recommendations to assist state medical boards in their assessment of licensure candidates from non-LCME or AOA-accredited schools.18 The primary recommendation called on the FSMB, the ECFMG, and state medical boards to collaborate by establishing a national clearinghouse of data and information on international medical schools. The intent is for the clearinghouse to expand on information currently provided through the International Medical Education Directory (IMED), published by the ECFMG's Foundation for the Advancement of International Medical Education and Research and available at (www.faimer.org). The committee identified a number of potential quality indicators for a national clearinghouse of data and information on international medical schools:
* admission requirements, including mandatory tests such as the MCAT;
* the number of years the medical school program has been in operation;
* school policies related to providing advance standing for students entering from related health professions;
* the degree to which distance learning is used in the curriculum;
* the number of weeks of instruction—both classroom and clinical—culminating in a medical degree;
* the status of the school as it appears in other review processes involving licensure (e.g., the California Medical Board's review process), clinical clerkships (New York state's clerkship approval list), and eligibility for federal student loans (National Commission on Foreign Medical Education and Accreditation);
* aggregate United States Medical Licensing Examination performance data for students and/or graduates of the school;
* student progression rates toward successful completion of degree requirements;
* the school's success rate in placing students in ACGME- or AOA-approved residency programs; and
* information on clinical clerkships, such as whether these are performed outside the host country where the school is located, or whether an affiliation agreement exists with the hospital(s) where clerkships are being conducted.
The merits of a national clearinghouse containing substantive information and data on international medical school programs would seem self-evident. One need only compare the limited information on international medical education programs with the extensive, detailed information on LCME- and AOA-accredited medical school programs to recognize that this is an imbalance needing correction and that neither state medical boards, nor the public they represent, are well-served by this situation. Whereas state medical boards are an obvious beneficiary of the proposed clearinghouse, others have an equally strong interest in accessing objective information on international medical schools. Prospective medical students and residency program directors are two of the more obvious groups. In my experience, it has not been unusual for prospective students—and often their parents— to contact the FSMB with questions regarding their ability to be licensed should they obtain a medical degree from an international medical school. Invariably, these conversations involve U.S. citizens inquiring about specific schools in the Caribbean and Latin America.
Turning Concept into Reality
A workgroup with representatives from the FSMB, the ECFMG, and state medical boards began substantive work in late 2007 to turn the concept of a national clearinghouse into reality. At the time this article goes to press, it is still too soon to identify a timetable for the formal establishment of a clearinghouse. Because gathering information and data on 1,800-plus international medical school programs is not feasible, one possibility is that a nascent clearinghouse may focus its energies in data gathering on schools currently providing the largest number of prospective IMG licensees in the United States. For example, ECFMG staff inform me that 10 international schools contributed 67% of the total number of U.S. citizens certified by their organization in 2006. This concentration of a large percentage of U.S.-citizen IMGs from a relatively small cohort of schools is consistent with earlier data published by the ECFMG.19
Another possible approach that the workgroup may embrace involves building on currently available resources. For example, the workgroup may determine that the best means for establishing a national clearinghouse is to work within the preexisting framework of the IMED. Because this directory is a free resource already publicly available via the Internet, incorporating additional information or data elements such as the quality indicators listed in the special committee report might be accomplished quickly as a means for providing a more detailed portrait of those international schools already placing significant numbers of graduates into the U.S. physician workforce.
Even a clearinghouse focused on a narrowed pool of schools will prove challenging. To establish a viable clearinghouse, the workgroup will have to address the critical issue of garnering cooperation from multiple parties, including international medical schools and U.S. governmental entities and organizations already in possession of relevant data. The success or failure of the national clearinghouse will ultimately derive from its ability to obtain desired information from multiple parties, some of whom may be reticent about the subsequent use of the data.
An established clearinghouse presents several potential benefits. First, the clearinghouse would act as a common resource for state medical boards and others with a legitimate need and interest in objective information on international schools. Second, for those medical boards with authority to approve the medical education of their IMG licensees, this common resource may foster greater standardization among states in their decision making relative to licensing international graduates. Currently, decisions by the Medical Board of California to add or remove schools from their listing of “approved” international medical schools carry considerable weight with other jurisdictions that, although possessed of similar authority to approve schools, lack the resources to implement formal review protocols and site visits for international schools.
A Hope for Success
Despite the challenges facing state medical boards in this arena, there is ample reason to hope for success. Potential allies can be found in various quarters, all of whom bring extensive expertise to international medical education: the ECFMG, the Caribbean Accreditation Authority for Medicine, the World Federation of Medical Educators, the U.S. Department of Education's National Commission on Foreign Medical Education and Accreditation, and the California and New York medical boards. Both of those state boards bring considerable experience to vetting international medical school programs for the respective purposes of licensure and participation in clinical clerkships. For inspiration, one need only reflect that nearly a century ago, Abraham Flexner20 identified state medical boards as the key player in his call to arms for strengthening medical education in the United States. Flexner asserted that “state medical boards are the instrument through which the reconstruction of medical education will be largely effected.” Few would argue against the tremendous successes in U.S. medical education stemming subsequently from the establishment of accreditation mechanisms. Perhaps state medical boards—through the mechanism of the national clearinghouse—can duplicate their earlier contributions in educational reform through a similar application in the arena of international medical education.
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