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From Defending the Walls to Improving Global Medical Education: Fifty Years of Collaboration between the ECFMG and the NBME

Melnick, Donald E. MD

doi: 10.1097/01.ACM.0000243462.05719.e1
Conference Papers

The author outlines the intertwining roles of the Educational Commission for Foreign Medical Graduates (ECFMG), which is celebrating its 50th anniversary in 2006, and the National Board of Medical Examiners (NBME) in meeting needs for assessment of international medical graduates. Both organizations had early histories focused on a protective role: ensuring that only the most qualified foreign-trained doctors could train or practice in the United States. The two organizations have interacted throughout the ECFMG’s 50-year history to improve the assessment of internationally trained doctors. As both the ECFMG and the NBME have matured, their missions have expanded to include improvement of medical education and assessment around the world. Much of the success of each organization in fulfilling its mission can be attributed to their close collaboration through the past 50 years.

Dr. Melnick is president, National Board of Medical Examiners, Philadelphia, Pennsylvania.

Correspondence should be addressed to Dr. Melnick, NBME, 3750 Market Street, Philadelphia, PA 19104; e-mail: (dmelnick@nbme.org).

As the Educational Commission for Foreign Medical Graduates (ECFMG) celebrates 50 years of outstanding service, the National Board of Medical Examiners (NBME) celebrates its 91st anniversary. The NBME was a child of amazing ferment and internal transformation within medical education. This reform movement had it origins in the 1880s, when the infant American Medical Association (AMA) made its reputation by calling for licensure based on demonstration of competence, as indicated by completion of an effective educational program and by satisfactory performance on examinations.1 By the 1890s, most states had adopted medical practice legislation requiring licensure based on educational achievement and passage of an examination.

A few years later, serious efforts were under way within the young Association of American Medical Colleges (AAMC) to improve American medical education. The association was hindered in these efforts by the large majority of substandard schools in its membership. In 1902, William L. Rodman, MD, in his address as president of the AAMC, asserted that the association needed “not more members, but better ones.”2 In 1904, reformers within the AAMC created an alliance with the AMA leadership to create the AMA Council on Medical Education, destined to become the prime mover in reforming medical education. The council persuaded the Carnegie Foundation to fund an independent study of medical schools, leading to the Flexner Report, which served as a capstone for nearly 25 years of effort to improve medical education.

The same William Rodman who sought reform in the AAMC believed that high standards of assessment would improve both medical practice and medical education. In an unsigned editorial in the Journal of the American Medical Association in 1902, Rodman repeated his earlier message in The Philadelphia Medical Journal: “There is, however, nothing to prevent the creation of a national board of medical examiners whose examinations shall be of such a character and high standard as to command the respect of the several states and cause them to issue a license to anyone who has successfully passed such an examination.”3 Rodman announced the creation of the National Board in his presidential address before the American Medical Association in 1915. The NBME was created as an independent entity by the 15 original members: Rodman, six representatives of the federal services (U.S. Army, Navy, and Public Health Service), representatives of other entities (the AMA, AAMC, Federation of State Medical Boards [FSMB], the Mayo Foundation, and the American College of Surgeons), and three at-large members. Its first certifying examinations were administered in 1916.4, p.4–9

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Early International Engagement by the NBME

The first evidence of internationalism for the fledgling organization grew from the international engagement by the U.S. military during World War I. At the close of the war, military members of the NBME initiated the creation of a commission to study methods of examination for medical licensure in Europe. In July 1919, a committee of NBME members visited Europe, where they were received by leaders in medical education in France and England, including Sir William Osler. A commission consisting of French, English, and Scottish leaders in medical education visited the NBME in April 1920. One outcome of this international collaboration was agreement that the newly formed National Board and its examinations offered a logical basis for reciprocal recognition of the examinations in Great Britain and in the United States; reciprocal agreements were reached between the English and Scottish examination authorities and the NBME that were in place until World War II.4, p.11–12 Early exchanges with European colleagues continued with visits by the NBME Secretary, J. Stuart Rodman (son of the founder), to the General Medical Council in London in 1929 and 1930.

During the 1920s and 1930s, foreign medical graduates could apply to the NBME for examination. The board required comprehensive, authenticated documentation of premedical and medical education. The board also required evidence of licensure in the country where the medical education had been obtained. If these credentials were approved by the NBME’s Examination Committee (which often required personal familiarity with the applicant’s medical school by a member of the committee), the applicant was admitted to the examinations.4, p.49 In the May 1922 Part III examination, for example, six of 230 examinees were graduates of foreign schools; these schools included the University of Beirut, University of London, University of Edinburgh, University of Prague, and University of Zurich.5 These requirements for certification by the NBME were essentially identical to the requirements subsequently established by the ECFMG. On successfully completing all three parts of the examination and documenting an acceptable undergraduate medical education and at least one year of graduate medical education, the applicant was certified by the NBME and designated a Diplomate. State medical boards that accepted NBME certification also accepted certified international graduates.

By the early 1930s, recent economic events influenced the movement of doctors across international boundaries. In this time of worldwide economic depression, medicine continued to provide relatively good compensation: Doctors were the best paid professional class in America in 1920–1925.6 European medical schools were overproducing doctors, including many American nationals not accepted by American medical schools. At the same time, the countries in which those schools were located often imposed citizenship requirements for practice. Hitler’s Germany was producing 15,000–20,000 doctors each year, considerably more than the total American production of doctors7; in 1922, nearly 1,000 American citizens were studying in foreign schools, and many would be unable to practice in the countries where they had studied.

Concerns in the 1930s about medical education outside the United States might well have been voiced today: “It is interesting to note that although they tend to magnify the advantages of study abroad, [former students in Italian medical schools] admit that the opportunities for practical experience fall far short of what is customary in this country. It is this failure to provide for each student the intimate personal contact with patients, which we know as a clinical clerkship, that raises doubt as to whether the graduates of such university should be admitted to our licensing examinations on the same footing as the graduates of our own schools.”8 In 1933, when 5,012 persons were added to the medical profession in the United States,9 500–600 foreign-trained doctors were licensed,10 or about 10% of the total.

These pre–World War II pressures on the U.S. systems of quality assurance, combined with substantial growth in physician immigration in the aftermath of World War II, stimulated the AMA Council on Medical Education and Hospitals to create, in 1947, an advisory committee on foreign medical credentials. In concert with the AAMC, the AMA Council on Medical Education identified international medical schools that warranted recognition by state licensing authorities. Graduates from schools on the AAMC-AMA list were automatically considered eligible for NBME certifying examinations, whereas graduates from other schools continued to be declared eligible only if a member of the NBME committee had personal knowledge of the quality of their schools and only after completion of two to three years of postgraduate training or other experience in the United States deemed equivalent by the National Board.

In addition to foreign-trained doctors seeking qualification to practice in the United States, international medical students sought admission to U.S. medical schools. These students often were allowed to take NBME certifying examinations as “noncandidates” in order to demonstrate their level of knowledge to the medical schools to which they applied. State medical boards were also allowed to “sponsor” a noncandidate for examination with one or more parts of the NBME Certifying Examinations to evaluate fitness for licensure.4, p.50

As the number of international graduates taking NBME Certifying Examinations increased, the performance of these international graduates could be compared with that of U.S. students. Typically, failure rates on the NBME Part I examinations were 14% for U.S. students but 70% to 90% for international graduates. U.S. students failed Part II at a rate of about 4%; international graduates did so at about the same rate as for Part I. The scores of international graduates from the schools listed by the AAMC-AMA as approved and those of other international graduates did not differ significantly.

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Early Collaboration Between the ECFMG and the NBME

Growing numbers of foreign-trained doctors in the United States, difficulties in assessing the quality of medical education, and variability in the manner in which international graduates were evaluated by individual state licensing authorities led to the creation of a committee that ultimately called for the creation of the ECFMG. Based on the committee’s intent to develop a common system of evaluating all international graduates, in 1954 the NBME took formal action to discontinue the admission of all foreign medical graduates, including graduates of the schools on the AMA-AAMC list, to its examinations.

The next year, the committee called for the creation of the ECFMG, and the new organization was born in 1956, with its first home in Evanston, Illinois. The newly created ECFMG moved quickly to establish mechanisms for examining the knowledge and competency of international students. After evaluating several other potential collaborators, including the Educational Testing Service, the ECFMG asked the National Board to develop, from its pools of calibrated test items, examinations that would allow performance of international graduates to be compared with that of students from accredited U.S. medical schools on the same items. The ECFMG asked the NBME to help in developing examinations to assess medical knowledge, in establishing the means to administer those examinations in foreign centers and throughout the United States, in ensuring security of examinations during transit and administration, and in deriving reliable scores based on examination items previously administered to U.S. medical students.

When the National Board debated this request, not all members favored supporting the ECFMG. Records of the debate show that concern existed about examination security, encouragement of “brain drain,” harm to the reputation of the NBME, and potential liability for decisions made based on the examinations. Ultimately, the NBME agreed to the request from the ECFMG because it believed that the proposed system of assessment would contribute to the quality of medical education around the world. Members of the NBME believed that foreign-trained nationals would pursue postgraduate education in the United States and then take their newly acquired skills back to their needy homelands.11,12

The system that resulted called for the ECFMG to assume all responsibility for determining eligibility for the examination, for appointing a committee that would establish the content blueprint and select test items for the new exam, for setting performance standards, and for reporting results. The NBME would provide examination materials, scoring, analysis, and consulting services in evaluation and measurement.

The first examinations were administered in March and September 1958. The examinees had six hours to complete the 360 test items. The content outline developed by the ECFMG examination committee called for 300 items drawn from the NBME Part II (clinical science) examination pool and 60 test items from the NBME Part I (basic medical sciences) examination pool. Because the initial examination committee was concerned that the written examination would not adequately assess the examinees’ ability to understand and respond to spoken English, an additional module was added to the exam. In this additional module, the examination proctor read aloud a narrative describing a patient illness. The examinee was asked to write a summary of the presentation in English. Although this examination component did identify some examinees whose English was deficient, NBME staff and the ECFMG test committee agreed that a more effective test of spoken English proficiency was desirable. Therefore, the ECFMG began to work with the Educational Testing Service to develop such an assessment.

The first test administration, on March 25, 1958, took place at selected U.S. test centers used by the NBME for its certifying examinations. The ECFMG certified 298 graduates of international medical schools as meeting its criteria for eligibility to take the examination; 151 (50%) passed. The second administration, on September 23, 1958, was to occur in international as well as U.S. centers. The ECFMG had negotiated with the U.S. Department of State and had been assured of its support for international test administration. However, at the annual meeting of the NBME on May 4, 1958, the actual letter from the State Department was found to be so disappointing—providing only general support for the examination program but not directing diplomatic posts to cooperate—that the members of the NBME were loathe to allow the test to be administered outside the United States.

During the debate at the 1958 NBME Annual Meeting, the representatives of the Surgeons General of the Army, Navy, and Air Force conferred. Noting that each proposed international test center was near a U.S. military installation, they proposed that the central U.S. military command order these bases to provide the needed support, including space, proctors, and test security. With this commitment, members of the National Board agreed to proceed with the scheduled test and directed that John P. Hubbard, MD, president of the NBME, personally make arrangements for the September 23 administration. See the sidebar for Dr. Hubbard’s account4, p.55–57 of that first ECFMG examination administered outside the United States.

After the institution of the examination program around the world, the NBME’s role became one of support for the ECFMG test committee and processes for delivering the ECFMG examination. The program grew rapidly, with test takers rising from 1,142 in the first year to nearly 15,000 just two years later. In 1970, nearly 30,000 candidates, of whom nearly half were repeaters, took the ECFMG examinations.13 As the number of individuals seeking access to American graduate medical education and practice increased and U.S.-citizen graduates of international medical schools began to use the ECFMG program to gain access to graduate education, concerns increased about the lack of information available on the quality of medical education the examinees had received and about the ECFMG examination process being less comprehensive than that for graduates of U.S. medical schools. These concerns led to a call from the Coordinating Council on Medical Education14 in 1976 that “all foreign medical graduates seeking opportunities for graduate medical education must demonstrate that they have met a standard of professional proficiency equivalent to that required of U.S. medical graduates eligible for the same type or level of graduate education...”

Responding to these concerns, the federal government increased the rigor of prerequisites for foreign medical graduates to obtain visas. Public Law 94–484, enacted in 1976, required that international graduates pass the NBME Part I and Part II examinations or an examination determined by the Secretary of the United States Department of Health, Education, and Welfare to be equivalent. The National Board declined to alter the eligibility requirements for its certification exams but agreed to create a new examination, the Visa Qualifying Examination (VQE), to meet the requirements of Public Law 94–484 for an equivalent exam.15

The VQE was a two-day examination, with a content outline identical to that for the NBME Part I and II examinations, which were two days each. Although the VQE was half the length of the NBME exams, the score scales from the NBME examinations were utilized and the passing standard applied to Part I and Part II was applied to the VQE. Because the VQE was shorter, no subscores were reported; examinees received a separate pass or fail score for the basic science and clinical science components of the exam. Beginning in 1977, foreign graduates requiring a visa to enter the U.S. were required to pass the VQE; foreign graduates not requiring a visa could continue to utilize the ECFMG examination to achieve ECFMG certification.

The increasing numbers of international, primarily Caribbean, medical schools recruiting U.S. citizens in the late 1970s led to a decision by the ECFMG to replace both the ECFMG examination and the VQE with a new exam, the Foreign Medical Graduate Examination in the Medical Sciences, or FMGEMS. The new exam was very much like the VQE, except that numerical scores were provided for each examination component. FMGEMS replaced the ECFMG exam and VQE in July 1984.

As the system of NBME-provided ECFMG examinations evolved, the ECFMG and NBME interconnected in other ways as well. By 1966, the NBME had outgrown its leased office space in west Philadelphia. The ECFMG joined the NBME in a project resulting in construction of facilities that would house the NBME until 1993. The ECFMG’s commitment to lease one floor of the new building made its construction possible. As both organizations continued to grow, the ECFMG relocated to its present headquarters on Market Street in 1971. A few years later, continued growth at the NBME resulted in an NBME expansion into space in the Market Street building, restoring its close physical proximity to the ECFMG, and, in 1993, the NBME headquarters moved to a location just one block from the ECFMG facilities.

By the late 1980s, both organizations were exploring means of more adequately assessing competencies relevant to safe medical practice. Both independently began to work on developing assessments of clinical, interpersonal, and communication skills using standardized patients. Throughout the next decade, the two organizations pursued development in parallel, yet always connected, research endeavors. The director of each organization’s research team served as an important member of the other organization’s research steering committee. This early collaboration created a foundation upon which later integration of efforts would be built.

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The United States Medical Licensing Examination—A New Era of Collaboration

In 1987, political action by U.S.-citizen medical graduates from international medical schools resulted in pressure from several state legislatures to eliminate the dual system of examination then in place. Graduates of accredited U.S. and Canadian medical schools could be licensed either through the NBME certificate or by completing the Federation Licensing Examination (FLEX). International graduates could qualify for licensure only upon completion of FMGEMS and ECFMG certification and completion of FLEX. Although both FMGEMS and FLEX were designed to have content and standards similar to the NBME certifying examinations, U.S. citizen international graduates asserted that the ECFMG/FLEX requirements were made intentionally more difficult in order to limit entry of international graduates into the United States. Legislators in New York and California were sympathetic to this view and were poised to enact legislation requiring a single examination for all licensure applicants.

In response to these concerns, the NBME agreed to allow international medical graduates to take the NBME Part I and Part II Certifying Examinations, and the ECFMG agreed to administer the tests and accept these results in lieu of the FMGEMS. International graduates did not receive the NBME diploma and were not eligible to take Part III or use an NBME certificate as a credential for licensure.

In early 1988, the ECFMG and the FSMB joined the National Board in inviting a coalition of voluntary medical organizations to discuss the desirability of and develop a plan for a single examination for medical licensure. This coalition produced a report, A Proposal for a Single Examination for Medical Licensure,16 published in early 1989. The proposal called for the merger of FMGEMS, FLEX, and the NBME Certifying Exams into a new single examination, which would be required of all those seeking medical licensure in the United States. In the months following the release of the report, negotiations continued among the ECFMG, FSMB, and NBME regarding possible structures for a new examination system.

The United States Medical Licensing Examination (USMLE) emerged from these negotiations. The USMLE was to be jointly sponsored by the FSMB and the NBME. The ECFMG played a critical role as a user of Step 1, an examination of basic medical sciences, and Step 2, an examination of basic clinical sciences, in its certification. In addition to relying on the USMLE in making certification decisions, the ECFMG established USMLE eligibility requirements for international graduates, registered international graduates, and oversaw test delivery at international test sites. Although not a primary sponsor of the USMLE (and avoiding the liabilities inherent in this role), the ECFMG was, from the start, part of the leadership coalition and participated in the USMLE governing committee, the Composite Committee.

The new USMLE Step examinations were phased in beginning in 1992 (Step 1 and Step 2); FMGEMS was phased out, with its last administration in 1993. Although the USMLE did not eliminate concerns about the unknown quality of education of many international medical graduates, it did, for the first time since selected international graduates were certified by the NBME, allow licensure applicants to demonstrate knowledge and skills in identical circumstances against common standards regardless of location of their medical education.

In early 1994, although the final step of the USMLE had not yet been administered, the USMLE Composite Committee adopted a strategic plan for enhancing the USMLE. This plan called for the computer delivery of the USMLE and incorporation of computer-based clinical management simulations in Step 3. The new test delivery model would provide for continuous testing throughout the year (rather than on two annual test dates for each Step), with Steps 1 and 2 to be administered in many more test locations around the world. The plan also called for the continued development of a test of clinical skills for the USMLE, targeted at Step 2.

Computer-based testing became a reality in 1998. This new testing approach drastically changed the role of each organization and required even more daily collaboration. No longer does each organization register its own examinees, administer the test to them on specific dates each year, and report their scores in large batches. Test administration is vested in a commercial vendor, which provides a secure international computer-based testing network. The three organizations must now work together continually rather than episodically to ensure daily smooth transfer of registration data to the NBME for daily transfer to the testing vendor, to troubleshoot when a problem occurs for an examinee on any day of the year in any of hundreds of test centers operating around the clock, and to transfer and report scores continuously.

Meanwhile, the ECFMG’s efforts to develop means of assessing clinical skills came to fruition in the form of the Clinical Skills Assessment (CSA). Although the simpler delivery system required to test only international graduates allowed the ECFMG to implement the CSA as an ECFMG certification requirement in 1998, leaders of the ECFMG and NBME had agreed that the CSA would be supplanted by a similar examination to become part of the USMLE as soon as feasible. In 2001, the USMLE Composite Committee, the FSMB, and the NBME agreed to implement a clinical skills examination as part of USMLE Step 2 in 2004. The NBME Executive Board directed staff to seek a partnership with the ECFMG to develop the infrastructure needed to implement this decision.

During 2002, a negotiating team from governance of the ECFMG and the NBME met to create the structure for this partnership. In late 2002, the Clinical Skills Evaluation Collaboration (CSEC) emerged. This equal partnership between the ECFMG and NBME combined the resources of both organizations to create an integrated structure to support clinical skills assessment. CSEC proceeded to build a network of test delivery sites and conduct preimplementation pilot tests to establish the techniques needed for multisite testing. CSEC delivered the first live USMLE Step 2 Clinical Skills examinations in June 2004, and, by the time of the celebration of ECFMG’s 50th Anniversary, more than 60,000 examinees had been tested in the five CSEC test centers.

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The Past Predicts a Future of Even Closer Collaboration

As summarized in this history of interconnections between the ECFMG and the NBME, the lives of the two organizations have been intertwined for all 50 of the ECFMG’s years, and the NBME was deeply involved with international medical graduates in the years before the ECFMG’s creation. Both organizations were founded as defenders of the gates: the NBME to provide a common high standard of competency for U.S.-trained doctors to enter practice and the ECFMG to provide a common high standard of credentials review and competency assessment for graduates of international medical schools seeking to pursue graduate medical education or practice in the United States.

Although this original objective remains solidly at the core of the missions of both organizations, increasingly both the ECFMG and the NBME recognize the contributions they can make to improving medical education and health care around the world. Their roles as defenders of the gates are now clearly balanced by roles as agents for global improvement of the health of individual patients through contributions to the formation of safe and effective doctors. Although broader roles in global medical education and assessment can be seen as a means to ensure a qualified supply of internationally trained doctors for the United States or to increase the likelihood of high-quality medical care for U.S. citizens when they travel abroad, both organizations transcend these narrow, nationalistic views of international engagement. Both organizations clearly comprehend our shrinking world: There is no artificial barrier between the health of the rest of the world and the health of America or between the education of doctors around the world and at home.

By creating the Foundation for Advancement of International Medical Education and Research (FAIMER), the ECFMG has reinforced its intent to do more than screen qualified applicants for graduate medical education positions in the United States. FAIMER is already making a difference by supporting medical education and faculty development around the world. Similarly, in 2005 the National Board embarked on an expanded mission: to promote high quality, state of the art assessment around the world. Building on their successful partnership in CSEC, the ECFMG and the NBME are committed to extensive collaboration in their international outreach. Each complements the other: the ECFMG focuses on and has expertise in international medical education and faculty development, while the NBME brings expertise in assessment.

Like the interlocked spirals of the DNA double helix, the ECFMG and the NBME pursue their unique missions through an ever-closer interconnected relationship. If the past 50 years are instructive in any way—if “what’s past is prologue”—one can only conclude that this collaboration will draw the two organizations closer and closer together, with a synergy that results in accomplishment that is greater than the sum of its parts. Abraham Flexner is purported to have said, when reflecting on the successful creation of the National Board, that perhaps a credential based on high-quality assessment might be recognized internationally. John R. Ellis, MBE, MA, MD, FRCP, chief medical officer of the U.K. Ministry of Health, speaking at the 50th Anniversary Conference of the NBME in March 1965, opined: “Once [other countries] have something of the same kind [as the U.S. system of assessing all applicants for licensure by a common standard] it will then be possible...to begin to create an international Board of Medical Examiners which will be a necessary prerequisite to the establishment of internationally acceptable standards of medical training.”17 The growing partnership of the ECFMG and the NBME and their commitment to improving global medical education and assessment make them ideal partners to help realize Flexner’s and Ellis’ dream. Even if this lofty goal is not realized, continuing collaboration between the ECFMG and the NBME will improve global medical education and thus improve medical care and the health of patients everywhere.

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References

1 Shryock RH. Medical Licensing in America, 1650-1965. Baltimore, Md: The Johns Hopkins University Press; 1967.
2 Bowles MD, Dawson VP. With One Voice: The Association of American Medical Colleges 1876-2002. Washington, DC: Association of American Medical Colleges; 2003.
3 Rodman WL. Voluntary board of medical examiners. Philadelphia Med J. 1902;9:837.
4 Hubbard JP, Levit EJ. The National Board of Medical Examiners: The First Seventy Years. Philadelphia: National Board of Medical Examiners; 1985.
5 Minutes of the Meeting of the National Board, December 1, 1924. Archives of the National Board of Medical Examiners, Philadelphia.
6 Pinkham CB. Foreign medical students. Federation Bull. 1938;24:132.
7 The surplus of medical students, Berlin letter. JAMA. 1934;103:691.
8 DeGregoris P, D’Isernia R. American students at Italian universities. Federation Bull. 1937;23:106.
9 Lyon EP. Swans sing before they die. In: Proceedings of the 32nd Annual Congress on Medical Education, Medical Licensure, and Hospitals, Feb 18, 1936. Federation Bull. 1936;22:323.
10 Graduates of medical faculties abroad, state board number. JAMA. 1934;102:1393.
11 Minutes of Special Meeting of the National Board of Medical Examiners, October 20, 1957. Archives of the National Board of Medical Examiners, Philadelphia.
12 Minutes of Committee on Coordination of Examinations, May 3, 1958. Archives of the National Board of Medical Examiners, Philadelphia.
13 A Summary for 1970—three categories of National Board services. The National Board Examiner. 1971;18(6):1–2.
14 Physician manpower and distribution: The role of the foreign medical graduate. A report of the Coordinating Council on Medical Education June 1976. [Published as AppendixI in the 76th Annual Report on Medical Education in the United States 1975-1976.] JAMA. 1976;236:3048–3055.
15 Minutes of the Executive Committee, January 24, 1977. Archives of the National Board of Medical Examiners, Philadelphia.
16 The Task Force to Study Pathways to Licensure. A Proposal for a Single Examination for Medical Licensure. Philadelphia: National Board of Medical Examiners, 1989.
17 The NBME viewed from abroad. The National Board Examiner. 1965;12(7):1.
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John P. Hubbard, MD, Describes the First Internationally Administered ECFMG Examination*

The time had come to translate feasibility into action… We were to visit thirty designated centers during the late spring and summer, first to Mexico and South America, then home to change our winged sandals and off again, with stops of about three days each from Tokyo to London.

Only seldom did we meet resistance to the plan of the program. The Cultural Affairs Office (CAO) of the embassy at each stop had already received the letter from Dr. Smiley about the time and the purpose of our visit. But, not surprisingly, the amount of attention that had been paid to the program varied. In Seoul, Korea, one of the early stops, the CAO read … the letter notifying him of my visit and the reason for it. “This looks like a fine program,” he said to me. He then continued, “Whom do you have in mind to administer the program here in Seoul?” “Sir,” I replied, “we are hoping that we may count on the services of your office.” His quick response: “No, my office is already over busy; we would just not be able to give the time.” At that point I replied: “There is no alternative. I have in hand a directive to the officer in charge of the Army post here in Seoul to take charge of the program if your office cannot do so.” “Well,” said the CAO, “let’s have another look at this.” The examination center was set up and supervised by the staff of the CAO.

In India, there was a very different reaction, although also quite negative at first. At a very impressive gathering of high-level medical and governmental officials, I was asked for a description of the program and its objectives. Following my reply, there was a firm response: “We do not approve of the program.” With very carefully chosen words, I explained that this was the route by which their medical graduates could obtain appointments as interns or residents in American hospitals. After a considerable pause, a most interesting question was asked: “Will England be included in the program?” Following a prompt “yes” on my part, the attitude of my hosts changed completely to strong, positive support. Just ten years following the achievement of India’s independence, the Indians were understandably sensitive to the issue of equal treatment in all the English-speaking world.

For the most part, the CAOs, consuls, and other embassy officials were cooperative; they were already deeply involved in the problems of foreign physicians applying for positions in American hospitals and seeking United States visas. In fact, they, in general, welcomed a procedure that would provide a valid reason to refuse a visa to a physician with a medical background of uncertain quality and with little or no knowledge of the English language.

Also, in most of the countries visited, reaction of medical school deans, ministries of health, and other medical authorities was favorable. They, too, had often been dismayed at the ready acceptance of inadequately prepared physicians for appointments in American hospitals. Such individuals not only gave a poor impression of medical education in the area from which they came, they were also unprepared to profit from the experience. I heard plenty in foreign lands about the “exploitation” of foreign physicians by hospitals that seemed to be more interested in acquiring an additional pair of hands than in their responsibilities for graduate education. More attention being paid to the preparation of the incoming physicians fostered the hope that more attention would be given to the medical supervision and training of these physicians. Furthermore, medical educators abroad welcomed the opportunity for their graduates to have a period of training in American hospitals, so that they might benefit their homeland with their learning…

In regions without medical schools on the AMA-AAMC list, especially those in Latin America and Asia, the new plan was welcomed when it was fully explained and understood. The plan was seen as a means by which any graduate of any medical school, anywhere, irrespective of an AMA appraisal, might have equal opportunity to demonstrate individual competence. Since some measure of qualification was deemed imperative, an evaluation of the individual was preferred to an evaluation of the educational institution attended.

* Hubbard JP, Levit EJ. The National Board of Medical Examiners: The First Seventy Years. Philadelphia: NBME, 1985:55-7.

© 2006 Association of American Medical Colleges