This year the Educational Commission for Foreign Medical Graduates (ECFMG) has been celebrating the 50th anniversary of its founding in 1956. In honor of this event and in recognition of the many contributions of international medical graduates (IMGs), the ECFMG was proud to sponsor and host an invitational conference, “Impact of International Medical Graduates on US and Global Health Care,” in Philadelphia on July 21–22, 2006.
The ECFMG Anniversary Planning Committee chose to highlight the role of the ECFMG in certifying and sponsoring IMGs for postgraduate education in the United States and the many accomplishments of IMGs in the United States and globally. International experts were convened to present their knowledge and views and to have an opportunity for more detailed discussion of international medical education. Breakout sessions served as a forum for further discussion of current and future issues relating to IMGs.
In all, 218 persons representing 24 countries attended the conference. These persons included world leaders in medical education and research, including deans of international medical schools; government officials; licensing authorities; and many who are involved in setting standards and assessing medical institutions. It was hoped that the conference would look in detail into current topics of great interest including:
- The global physician workforce
- Establishment and assessment of performance standards for individuals and institutions
- Physician migration
Three main themes emerged from the comments of the speakers and discussion in the workshops.
First, international medical graduates have made critical contributions to health care in the United States and elsewhere.
As of April, 2006, the ECFMG has certified over 292,000 IMGs from more than 200 countries. Currently, in 2006, IMGs constitute 25% of practicing physicians and 25% of residents in training in the United States, clearly a critical mass. As noted in the presentation by Jordan J. Cohen, MD, president emeritus of the Association of American Medical Colleges (AAMC), the need for IMGs will continue and may even increase, given the likelihood that U.S. medical schools may not be able to achieve the required 30% increase in capacity by 2015. There is rising ethical concern, however, about the impact of migration of physicians from poor to rich countries. Speaker Jamsheer Talati, MB, BS, FRCS, of The Aga Khan University, provided a stunning example of the effects of emigration of physicians from Pakistan.
There is growing recognition that health is global, although the practice of medicine is local. In his remarks, Elias A. Zerhouni, MD, director of the National Institutes of Health, emphasized the importance of integrating surveillance and infectious-disease research around the world and noted that globalization offers great opportunity to advance biomedical research. A general sense seemed to exist at the conference that we cannot afford to be anything but committed to advancing the quality of physician education worldwide.
Second, we need and want more data about the quality of international medical schools and the performance of international graduates.
There is no question that the rigor of the ECFMG Certification process is critical in assessing qualifications of international graduates. It was noted in the breakout sessions, however, that the process of medical education matters and that we have little information about most international medical schools. There is consensus that the United States Medical Licensing Examination, including its clinical skills examination, is an essential assessment of minimum medical knowledge and of fundamental communication and physical examination skills. However, we wonder about the need to assess additional elements of individual performance before granting a medical license or accepting applicants for residency training. We rely on the faculty in medical schools accredited by the Liaison Committee on Medical Education to assess other critical dimensions such as core clinical skills, professionalism, ethics, cultural competency, and critical thinking. There seem to be few, if any, comparable measures for students in international schools. In most cases, there is no information about students’ experience in these areas.
Speaker James N. Thompson, MD, president of the Federation of State Medical Boards (FSMB), noted that one element of evaluation for medical licensure is evaluation of medical education. At present, no complete source of information about accrediting bodies outside North America exists, but the Foundation for Advancement of International Medical Education and Research (FAIMER) is building a database. Little information is available about the educational experience of students from the schools that educate most international graduates who enter residencies in the United States. Together FAIMER and the AAMC are gathering data about those schools. A common and compelling question has emerged from this conference: What do we need to know about individuals and their medical education experience in order to have optimal confidence in our decisions about licensure and admission to residency programs?
The third, and most striking, theme is collaboration.
In the presentation opening the conference, the core values of the ECFMG were defined as collaboration, professionalism, and accountability, and it was asserted that “collaboration is a value to move the mission [of the ECFMG] forward.” Indeed, a future direction of the ECFMG was stated as “collaborat[ion] in the global movement to standard setting, assessment of individuals and institutions, and accreditation.”
The theme of collaboration was echoed by the speakers who followed. Dr. Cohen proposed collaboration to develop an appropriate mechanism for assessing medical schools outside North America and collaboration to expand support for medical education in other countries. Dr. Thompson shared the exciting work of the Physician Accountability for Physician Competency summits, in which participants are building collaboration to implement maintenance-of-competence programs for physicians in the United States. Hans Karle, MD, president of the World Federation for Medical Education (WFME), acknowledged the ECFMG as a partner in the standards for medical education proposed by the WFME. He described the partnership between the World Health Organization and the WFME and its growing collaboration with other international organizations to enhance quality assurance and accreditation of medical education around the world. Professor Ronald M. Harden, general secretary, Association for Medical Education in Europe, presented a vision of “transnational medical education,” with faculty and students from a variety of countries collaborating electronically in teaching and learning. Donald E. Melnick, MD, president of the National Board of Medical Examiners (NBME), cited the importance of collaboration with the AAMC, ECFMG, and FSMB in the evolution of the NBME Certification process and the development of a single examination for medical licensure. He shared his anticipation that the NBME and ECFMG and others would collaborate to move toward “internationally accepted standards for medical training.” W. Dale Dauphinee, MD, executive director, Medical Council of Canada, noted the council’s collaboration with the ECFMG on a physician credentials registry and called for collaboration among organizations to provide educational support to medical schools in developing countries.
Clearly, there is a growing recognition of the importance of having widely shared standards for medical education, such as those proposed by the WFME. Discussion in the workshops elicited the tension between the desire for a quality assurance process that would allow the United States and Canada to have confidence in the preparation of IMGs seeking training in their countries and recognition that imposing all of the current standards in North America would be culturally inappropriate and could even undermine some medical schools in developing countries. Dr. Dauphinee challenged us with the question: “What is the right thing to do in a flat world?”
Around their 50th birthdays, people often become acutely aware of the biological cycle: birth, growth and development, maturity (the 50-year mark), followed inevitably by decline and death. Organizations follow a similar life cycle but with a fundamental difference: They can avoid decline by revitalizing themselves through seizing a new opportunity that will set them back on the track of growth and development. In the opening presentation, “Celebrating 50 Years of Experience: An ECFMG Perspective,” there was proposed as a goal for the ECFMG “collaboration in the global movement to standard setting, assessment of individuals and institutions, and accreditation.” This is a bold idea for international collaboration—one that could affect health and medical care worldwide.
The time seems ripe for this bold idea, and the ECFMG 50th anniversary conference brought together a number of the key potential collaborators. If we can realize this goal, the ECFMG’s 75th birthday could be a truly global celebration.
In closing, on behalf of the ECFMG, we gratefully acknowledge the excellent contributions of the ECFMG Anniversary Planning Committee, chaired by John B. Kostis, MD, which led to the theme and content of this conference.
Special acknowledgment goes to Ms. Marianne Shetzline, executive director, Office of the President, who served as the conference administrator responsible for planning and implementing the ECFMG’s 50th anniversary conference events. She was ably assisted by her staff members, Ms. Shannon Walsh and Ms. Maureen Sabo. Their extraordinary dedication and unfailing attention to detail were largely responsible for the highly successful events that occurred.
The editorial expertise and assistance of Barbara Gastel, MD, MPH, allowed the proceedings to be organized and published in a thorough and timely fashion. Much gratitude is also due to Michael E. Whitcomb, MD, editor, and Mr. Albert Bradford, senior deputy editor, Academic Medicine, for their invaluable assistance in bringing these proceedings expeditiously to print. Finally, we appreciate the contributions of the many individuals at the authors’ institutions who aided in preparation of the papers.
James A. Hallock, MD
Carol A. Aschenbrener, MD
Dr. Hallock is president and chief executive officer, Educational Commission for Foreign Medical Graduates, Philadelphia, Pennsylvania.
Dr. Aschenbrener is senior vice president, Division of Medical Education, Association of American Medical Colleges, Washington, DC, and member, Board of Trustees, Educational Commission for Foreign Medical Graduates, Philadelphia, Pennsylvania.