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Flexner's Global Influence: Medical Education Accreditation in Countries That Train Physicians Who Pursue Residency in the United States

van Zanten, Marta MEd; Boulet, John R. PhD; Simon, Frank A. MD

doi: 10.1097/ACM.0b013e3181c87638
Flexner Centenary: Article

Background Abraham Flexner's report on medical education, published 100 years ago, remains influential in the United States today, although its international impact is unclear. In addition to global variability in content and delivery of medical education programs, systems of quality assurance oversight are not universal, and there are variations in the scope of the reviews, protocols, and standards used.

Method The authors used the process and elements of medical school evaluation that Flexner regarded as important for ensuring quality to create a framework for describing aspects of the accreditation systems used in the 10 countries that supply the greatest numbers of international medical graduates (IMGs) to the United States.

Results Of these 10 countries, most have an accreditation system, although the review in some is voluntary. Globally, there is variability in the use of Flexner's system. Prerequisite entrance requirements vary according to the degree offered. Faculty involvement in research is frequently encouraged but seldom required. Almost all standards mention the need for adequate facilities for experiential learning in the basic sciences. Three accrediting organizations require that clinical facilities be under the direct control of the medical school, and seven indicate that affiliation agreements are acceptable. All accreditation plans use predetermined standards and external evaluation.

Conclusions Data describing accreditation of the medical education programs of IMGs currently seeking to enter graduate training in the United States contribute to a better understanding of medical education practices around the world and can supplement other information available to graduate medical education program directors who select IMGs for their training programs.

Ms. van Zanten is research associate, Research and Data Resources, Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, Pennsylvania, and a PhD candidate, Health Studies Program, Temple University, Philadelphia, Pennsylvania.

Dr. Boulet is associate vice president, Research and Data Resources, FAIMER, Philadelphia, Pennsylvania.

Dr. Simon is senior scholar, FAIMER, Philadelphia, Pennsylvania.

Correspondence should be addressed to Ms. van Zanten, FAIMER, 3624 Market Street, Philadelphia, PA 19104; telephone: (215) 823-2226; fax: (215) 396-3309; e-mail:

Medicine is becoming increasingly globalized, as manifested by the worldwide growth in the number of medical schools1 and the rise in the numbers of physicians who migrate from their native countries to other parts of the world for medical education and graduate training opportunities.2 In the United States, graduates of international medical schools, who are known as international medical graduates (IMGs), constitute approximately 25% of all physicians in graduate training and in practice.3 These physicians are educated in countries with diverse educational systems, including variations in teaching traditions, curricular models, instructional methods, clinical opportunities, assessment principles, and available resources.4 In addition, approximately one-third of countries with medical schools do not have a system of accreditation or other quality assurance oversight of medical education programs that is conducted by an independent or governmental body.5 Where accreditation systems are employed, there is variability in agency governance, responsibilities, level of enforcement, and the specific standards and protocols employed in implementing quality assurance reviews.

In the United States, Abraham Flexner's work describing medical education programs in the early 20th century resembled an accreditation survey.6 The Flexner Report presented conceptual arguments and a model for education and then compared the existing medical schools' characteristics against these standards.7 While Flexner's methodology has been well recognized as a catalyst for change, other initiatives that also facilitated reform were evolving simultaneously.8 For example, in the early part of the 20th century, state licensing boards initiated requirements that a physician graduate from a medical school that was rated as acceptable by the Council of Medical Education of the American Medical Association (AMA) or rated as eligible for licensure by the Association of American Medical Colleges (AAMC). The standards employed by the AMA and AAMC to evaluate medical schools were influenced in part by Flexner's new model of medical education.6 In 1942, the AMA and AAMC consolidated their efforts of evaluation of medical education and formed the Liaison Committee on Medical Education (LCME),9 the organization currently responsible for accrediting medical education programs in the United States and Canada.

Whereas Flexner's efforts in the early 20th century and the current policies of the LCME ensure a level of uniformity in the education offered by U.S. institutions, assessing the quality of medical education has also been recognized as an important need outside North America. Numerous organizations promote accreditation efforts and quality assurance methodology around the world. The World Federation for Medical Education (WFME) is a global association dedicated to enhancing the quality of education and training of medical doctors around the world. The WFME is not an accrediting body, but, through its creation of a tripartite document of global standards (standards for basic medical education, postgraduate medical education, and continuing professional development for medical doctors), it promotes the establishment of accreditation systems ( In the United States, the National Committee on Foreign Medical Education and Accreditation (NCFMEA) voluntarily reviews the accreditation systems used by accrediting bodies around the world to determine whether those systems are comparable to LCME standards. If it is determined that a country has a comparable system, students at accredited medical schools in that country may be eligible to apply to participate in the Federal Family Educational Loan program ( While WFME and NCFMEA and other, regional organizations are involved with accreditation efforts around the world, no unified process or quality assurance standards have been universally adopted.

By using Flexner's methodology and criteria for evaluating medical education as a framework, we conducted this qualitative descriptive study to illustrate and compare the accreditation practices (if present) in the 10 countries outside of the United States and Canada that educate the greatest numbers of physicians who pursue graduate training opportunities in the United States. Our findings can be useful in increasing our understanding of medical education and quality oversight practices around the world. In addition, because many of the physicians seeking to enter graduate training programs in the United States were educated in environments different from the system of medical education in the United States, the results of this study can supplement the information available to program directors who select IMGs for their training programs.

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Before entering graduate training, IMGs must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). Requirements for ECFMG certification include verification of graduation from a medical school listed in the International Medical Education Directory (IMED).1 A medical school is listed in IMED after the Foundation for Advancement of International Medical Education and Research (FAIMER) receives confirmation from the Ministry of Health or another appropriate agency in the country where the medical school is located that the school is recognized by that authority. Recognition in this context refers to the authority of an institution to deliver an educational program and to grant a degree. A designation of accreditation, defined as a quality assessment conducted by an authorized body such as a domestic or international agency, is not an independent requirement for a school to be included in IMED. Although systems of recognition and accreditation are explicitly joined in many countries, a linkage of the authority to grant a degree to mandatory quality assurance review is not universal. FAIMER is not an accrediting body and does not independently verify the quality of the medical education provided at schools listed in IMED.

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Structure of the study

To conduct our comparisons, we obtained copies of the documents detailing the specific standards used to accredit medical schools in the 10 countries educating the greatest numbers of physicians who achieved ECFMG certification in 2007; we describe here the accreditation system extant in each of those countries. In some countries, more than one accreditation body has the authority to review medical education programs. We also include in the comparison the LCME accreditation system for U.S. and Canadian allopathic medical schools, and we provide data on the process of accreditation review and on the governance and scope of authority of the accreditation organizations.

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Flexner's elements

We used Flexner's processes and criteria (here called “elements”) for evaluating medical education as a framework within which to further illustrate similarities and differences among the accreditation systems. For the purposes of the global comparison in this study, we chose five specific aspects of these elements that Flexner emphasized as being especially important for the delivery of effective medical education.

The first of our selected elements that Flexner used to evaluate medical schools was “entrance requirements.” In his report, he presented a case for requiring entering students to have a minimum of two years of college training and for that training to include a strong science background. He specifically emphasized the need for competent knowledge of chemistry, biology, and physics. The second element addressed by Flexner was “teaching staff.” Under this element, he determined the size of the faculty that was needed and evaluated the faculty's qualifications and roles. Flexner argued that, for the curriculum's subject matter and delivery of the content to remain relevant, it was imperative that most of the faculty be engaged in scientific research in addition to teaching. Flexner focused on the third element, “resources available for maintenance,” to obtain information on fiscal matters and school affiliations. Flexner asserted that to ensure the accessibility of adequate resources, it was necessary that schools of medicine be associated with universities. Flexner's fourth element, “laboratory facilities,” had to do with the presence or absence of adequate facilities and resources for experiential student learning in the basic science phase of the curriculum. He felt strongly that an education based on traditional lectures was not sufficient for modern medical instruction and that there needed to be an emphasis not just on learning but on learning how. The fifth element was “clinical facilities,” which was his category for the resources available for the students' clinical teaching opportunities. Because of the importance of this phase of medical education, and the difficulty in ensuring adequate patient contact opportunities for students, Flexner argued that clinical facilities for teaching should be under the direct control of the medical school.

Flexner's process of evaluation of medical education programs was based on predetermined standards and external review. In the first decade of the 20th century, Flexner spent 18 months visiting each of the 155 medical schools in the United States and Canada. During these site visits, he gathered data and reviewed the facilities in relation to the elements he deemed essential for successful medical education. He then created his report on the basis of his evaluation of the medical education programs against these standards. The current study uses Flexner's framework, including both process components and standards, to compare accreditation practices in countries around the world that train large numbers of physicians who pursue residency in the United States.

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In 2007, standard ECFMG certificates were issued to 10,172 IMGs. The countries that provided medical training for the greatest numbers of these certified IMGs were (in descending order) India (2,687 IMGs; 26.4%), Pakistan (617 IMGs; 6.1%), Dominica (563 IMGs; 5.5%), Grenada (491 IMGs; 4.8%), the Philippines (380 IMGs; 3.7%), the Netherlands Antilles (372 IMGs; 3.7%), China (339 IMGs; 3.3%), Nigeria (211 IMGs; 2.1%), Colombia (206 IMGs; 2.0%), and Iran (189 IMGs; 1.9%). The 6,055 IMGs educated in these 10 countries received 59.5% of all certificates issued in 2007.

Table 1 provides information on these 10 countries. Data for each country include the number of medical schools currently open and listed in IMED, the accrediting organization (or organizations, if applicable), and the numbers of schools accredited by the various accrediting bodies. In addition, the table provides data indicating whether the pertinent accreditation standards address the aspects of Flexner's criteria that were chosen as a comparison framework for the current study. For reference, the table also includes LCME information, which is used to evaluate U.S. and Canadian medical schools.10 In addition, an appendix containing the exact language of the specific standards referenced is available from the corresponding author.

Table 1

Table 1

Table 1

Table 1

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Country-level description of standards


The situation in India regarding medical school quality oversight is of great importance because of the large number of medical schools in the country, the recent increase in the number of new schools,11 and the large proportion of graduates who achieve ECFMG certification. There are 267 Indian medical schools currently listed in IMED, of which almost half are private institutions. Mandatory recognition and accreditation are conducted by the Medical Council of India (MCI), a governmental agency. The MCI prescribes minimum standards that are based on the size of the medical school; these standards focus mainly on infrastructure and human resources and less on the quality of education or outcomes.12 The National Assessment and Accreditation Council (NAAC), an autonomous body established by the Indian agency University Grants Commission,13 also accredits higher education institutions in India, although, as of the end of 2008, only seven medical schools had successfully achieved this voluntary marker of quality. The goals of the NAAC review are to make schools aware of their strengths, weaknesses, and opportunities and to encourage innovative methods.11

Medical education in India typically begins immediately after high school and lasts for six years, leading to a bachelor of medicine/bachelor of surgery (MBBS) degree; students are admitted primarily on the basis of entrance exam results. There is, therefore, little emphasis in the MCI or NAAC accreditation standards on entrance requirements or specific prerequisite courses. The involvement of faculty in research activities is encouraged in the NAAC standards but is not emphasized by the MCI. Although a variety of entities are permitted to develop medical schools, each school must be affiliated with a university. The MCI standards speak to the need for experiential learning in the basic science years by indicating, in great detail, the required laboratory facilities and associated equipment. The MCI standards also specify that clinical facilities be under the direct control of a medical school.

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Pakistan's accreditation authority, the Pakistan Medical and Dental Council (PMDC), is a government-run entity that conducts mandatory recognition and accreditation processes.14 The PMDC's authority encompasses the setting of minimum standards for basic qualifications in medicine, including prescribing and enforcing a set of uniform minimum standards for the content and duration of programs leading to medical degrees.

The structure of medical education in Pakistan is the same as in India (six-year duration leading to an MBBS), and the standards and procedures used by the PMDC are similar to those of the MCI. The PMDC requires that all medical schools be affiliated with a chartered Pakistani university.

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Dominica is a small English-speaking island in the Caribbean. The Medical Board of Dominica (MBD) is designated by the Dominican Ministry of Health and Social Security to conduct mandatory reviews of medical schools located in the country.15 Two medical schools are located on Dominica; most of the students are from the United States and Canada. One school has been accredited by the MBD, and the other school is currently under review. The MBD assesses a school in terms of its stated objectives, governance, administration, faculty, educational program, admissions standards, and facilities and other resources.15 The school that MBD has accredited has also received accreditation from the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP).16 The CAAM-HP is a voluntary, independently run organization established in 2004 under the auspices of the Caribbean Community, and it has jurisdiction over numerous countries in the region. CAAM-HP's activities were described in detail in a recently published report.17

The MBD and CAAM-HP standards have many similarities. The CAAM-HP standard regarding entrance requirements specifies an undergraduate degree or “adequate level” (a designation that is not explained in the standards) in the sciences. Both sets of standards indicate that teaching staff should be engaged in research, and both speak to the importance of adequate facilities for experiential learning. In addition, both contain language indicating that affiliation agreements are necessary and acceptable for clinical training sites separate from the medical school.

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There is only one medical school in Grenada, and it primarily educates students from the United States and Canada. The Grenada Ministry of Health and Social Security is responsible for mandatory review of this school, and the ministry works in conjunction with the New York State Education Department (NYSED) to conduct the evaluation. The standards developed for evaluation of international schools seeking clerkship positions for their students in the state of New York were also used to evaluate the school for the purpose of accreditation in Grenada.18 In addition, CAAM-HP has accredited the Grenadian medical school.

The NYSED standards specifically indicate admission requirements of 60 semester hours of college study, including various science courses. Faculty involvement in research is mentioned as desirable but not necessary. Association of the medical school with a university is not required. Experiential learning is not specifically mentioned, although adequate laboratories are deemed to be essential. Affiliation agreements with other institutions for clinical training sites are accepted.

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The Philippines.

The Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU), a private, nonprofit corporation, voluntarily accredits educational institutions or programs in the country, including schools of medicine, that meet its discipline-specific standards of quality education.19 To date, PAASCU has accredited only 3 of the 38 Philippine medical schools listed in IMED, but 3 additional schools are currently undergoing accreditation review.

The accreditation standards used by PAASCU in the Philippines do not specify the courses needed to meet entrance requirements, other than to indicate that those courses must be in harmony with government regulations. The standards indicate that faculty must be involved in research and must provide evidence of their scholarly activities. Affiliation of a medical school with a university is not a requirement. Experiential learning is emphasized, and medical schools must control the clinical teaching sites.

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The Netherlands Antilles.

The Netherlands Antilles is a country comprising five islands in the Caribbean: Bonaire, Curaçao, Saba, Sint Eustatius, and Sint Maarten. Six medical schools in the Netherlands Antilles provide undergraduate medical education, mainly to international students, including a large number of U.S. and Canadian citizens. Currently, there is no nationally mandated accreditation of Antilles medical schools, although two of the schools have pursued accreditation by an outside, independently run organization, the Accreditation Commission on Colleges of Medicine (ACCM).20

The ACCM standards consist of evaluations of 11 elements: educational goals, corporate organization, college management, curriculum, student promotion and evaluation, admissions, resources, faculty, library, student services, and facilities. Entrance specifications indicate that a baccalaureate degree is preferred, and such a degree must include various college-level science courses. Faculty research is not specifically mentioned as an element of consideration, although the standards do indicate that an accredited institution shall foster an atmosphere of scholarly collaboration among the various faculty members. Resources for experiential learning are not specifically required. University affiliation and direct control over clinical teaching sites are also not mandated.

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There are 168 IMED-listed medical schools in China. Currently, no national system of accreditation exists, although numerous pilot studies to develop such a system have been conducted by various groups, including the China Medical Board, the Institute for International Medical Education, and the Association of Medical Universities and Colleges of China. Chinese education and health authorities are considering endorsing a national accreditation process.21

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In Nigeria, the 20 IMED-listed medical schools are accredited by both the Medical and Dental Council of Nigeria (MDCN)22 and the National Universities Commission (NUC).23 Each of these two authorities has its own focus, but they work in tandem. The MDCN concentrates on reviewing the adequacy of a school's infrastructure for clinical services, the quality of student selection, and the pass rates, institutional funding, and other issues. The MDCN grants partial accreditation when a school first opens and full accreditation after students are in clinical training. Both the MDCN and the NUC publish information regarding curriculum content, specifying what should be taught in the various years of medical training. This curriculum content is not mandated, although most medical schools follow the suggestions. The NUC also reviews higher-education administrative issues.

Nigerian medical education has a six-year duration and leads to an MBBS. The MDCN standards indicate the secondary-school-level course prerequisites. Faculty research is not specified as a requirement by either the MDCN or the NUC. In Nigeria, all medical schools, both public and private, are legally required to be associated with universities. Both accrediting bodies require evidence of well-equipped laboratories to ensure adequate experiential learning. A variety of arrangements are possible for clinical training opportunities.

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There are 38 medical schools in Colombia listed in IMED. The government-run National Council of Accreditation (CNA) has established 15 “minimal quality conditions” that a program is required to meet before it can start functioning.24 In addition, the CNA voluntarily accredits educational institutions in the country, including schools of medicine, once they have been in existence for a specified length of time. The law has recently changed and now mandates that all schools undergo this quality review. Currently, 31 medical schools are accredited by CNA, and the remaining 7 schools are undergoing the process. The Association of Colombian Faculties of Medicine supports the accreditation system.25

Students enter medical school in Colombia immediately after high school. Faculty members are not required to engage in research activities for accreditation purposes, although they are emphasized at some medical schools. University affiliation and control of clinical teaching facilities also are not mandated. Opportunities for students to engage in experiential learning and the existence of the appropriate associated laboratories are requirements for accreditation.

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In Iran, the Ministry of Health and Medical Education is currently planning and pilot-testing various changes to medical education at the country's 52 IMED-listed medical schools.26 The standard curriculum is under revision, and medical education accreditation standards and procedures have been developed. A summative national system of accreditation, under the auspices of the Ministry of Health and Medical Education, is expected to be implemented in the near future.

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Comparison of accreditation processes

Flexner's methodology for evaluating medical education programs consisted of the following components: the development of assessment criteria deemed to be critical in evaluating medical school programs, the conducting of a site visit to the schools to observe and compare the facilities and aspects of the program against the criteria, and the creation of a report documenting findings of the evaluation. Of the eight countries discussed in the current study that have summative systems of accreditation of medical programs (or access to outside accreditors), all use processes very similar to the one implemented by Flexner. The accreditation organizations all have published documents detailing the standards used to evaluate medical schools. Some organizations, such as the MCI, PMDC, CAAM-HP, MDCN, CNA, and LCME, make their standards publicly available on their Web sites. All accrediting organizations require a site visit (or multiple site visits) by qualified individuals. Finally, the organizations discussed in the current study create a written report documenting the findings of the site visit (and other methods of inquiry) as part of their accreditation protocols.

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Flexner's work from a century ago has had an important influence on medical education in the United States, yet a large number of physicians currently in graduate training and in practice in the United States attended medical school in other countries. Schools outside of the United States and Canada operate under diverse educational systems and with varied levels of quality oversight. The results of the current study indicate that there is variation among other countries in the governance and scope of authority over medical schools. Most of the accrediting organizations are governmental bodies, although exceptions include the independently run CAAM-HP in the Caribbean and PAASCU in the Philippines. In some instances, governmental ministries allow accreditation activities to be conducted by independent agencies located in other countries, as occurs in the Netherlands Antilles. Accreditation authorities and policies also vary in their levels of enforcement and influence. For example, in the Netherlands Antilles and the Philippines, only a minority of the medical schools have undergone accreditation review. Other countries, such as China and Iran, do not currently have a summative national system of accreditation in place, but both countries are planning for implementation. In contrast, some medical schools have undergone quality assurance reviews conducted by more than one organization, including the small number of schools in India that are accredited by both the MCI and the NAAC and the school in Grenada that is accredited by both the Grenada Ministry of Health and Social Security and CAAM-HP.

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Flexner's elements

The accreditation systems in the 10 countries that educate the greatest numbers of IMGs who achieve ECFMG certification all use processes and elements comparable to those of Flexner. This similarity is evidence of global agreement on the methodology that is considered to be most effective in ensuring the quality of educational programs. Nevertheless, although protocols were similar, accreditation systems varied in their use of standards that were equivalent to the five Flexner elements chosen for the comparison framework in the current study. Many accreditation systems do use some or most of the Flexner elements of focus, a practice that indicates general agreement on the educational fundamentals that are deemed necessary for ensuring quality.

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Entrance requirements.

Medical education in some countries, such as India, Pakistan, Nigeria, and Colombia, incorporates premedical science courses into the general five- or six-year curriculum. The emphasis on science prerequisites by accrediting bodies functioning in countries with a typical four-year curriculum varies, although most do specify a science background. For example, the Grenada Ministry of Health and Social Security, which accredits the single medical school in Grenada, requires 60 semester hours of college study, including courses in general chemistry, organic chemistry, biology or zoology, and physics. The ACCM, which has accredited two of the six schools in the Netherlands Antilles, specifies three years of undergraduate education, including one year each of biology and physics and two years of chemistry. CAAM-HP requires an undergraduate degree or “an adequate level” in the sciences. It is interesting that some accreditation standards, such as those used by the LCME, have recently implied that science may be overemphasized as a prerequisite by stating that students preparing to study medicine should acquire a broad education that also includes the humanities and social sciences.

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Teaching staff.

Flexner argued for the importance of the involvement of the medical school faculty in research activities. The standards used by about half of the accrediting bodies discussed here mention research as an important aspect of faculty qualifications, and some include language suggesting that medical schools should support staff scholarly activities. Standards used by PAASCU in the Philippines go beyond the simple encouragement of faculty research and clearly state that, for a program to receive the highest accreditation grade, faculty must engage in research, and appropriate evidence must be presented detailing these activities.

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Resources available for maintenance.

To ensure the accessibility of adequate resources, Flexner emphasized the importance of the association of a medical school with a university. Although the standards used by most of the accrediting organizations discussed here indicate that a medical school “should” be part of a university, it seems that a wide variety of types of institutions are permitted to provide medical education around the world. In India, a medical school must be associated with a university, although the MCI standards also allow schools to be established by an appropriate state government or union territory, a university, an autonomous body, a society, a public religious or charitable trust, or a company registered under the Company Act.

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Laboratory facilities.

Flexner argued for adequate facilities and resources for experiential student learning in the basic science curriculum, and he operationalized this element of quality by including an evaluation of a medical school's laboratory facilities. This belief seems to be well adopted globally, as almost all accreditation standards documents examined in the current study included either language describing the need for hands-on learning as part of the basic science curriculum, information on the specific laboratories and equipment necessary to facilitate this aspect of instruction, or both. For example, the CAAM-HP standards state that the curriculum must allow students to acquire skills of critical judgment based on evidence and experience and that instruction within the basic sciences should include laboratory or other practical exercises that entail accurate observations of biomedical phenomena. In Nigeria, the MDCN standards mandate that, for every student, there should be at least two square meters of laboratory space, which should include a worktop and equipment cupboard space.

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Clinical facilities.

Flexner's model of medical education included two years of basic science teaching followed by two years of clinical instruction. Because of the importance of the clinical phase in preparing the student to adequately learn to care for a wide variety of patients with an assortment of clinical presentations, Flexner felt strongly that clinical teaching facilities must be under the direct control of the medical school. Otherwise, he argued, because of the competing priorities of hospitals and clinics in providing efficient patient care, and the possibility that clinical instructors who are not affiliated with a medical school may view teaching roles as a low priority, there could be no assurance that medical students would receive adequate clinical training.

Most of the standards used by the several accrediting bodies to evaluate medical schools around the world contain similar language emphasizing this need, although the emphasis varies. Some standards include statements that clinical training facilities must be under the direct control of the medical school, whereas other standards indicate that affiliation agreements with clinical sites are acceptable but that the education of the students must remain under the medical school's control. The standards used by the MDCN in Nigeria seem to be the most lenient in this regard, indicating that a variety of arrangements between health care facilities and the medical school are adequate for clinical training.

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Before Flexner's work a century ago, no systematic process was in place for evaluating the quality of domestic medical education. There currently exists, in many countries around the world, a similar situation, in which medical education functions without a government- or professional-body-endorsed system of review or oversight. Some of the countries that lack a summative quality evaluation process, for example, China and Iran, are poised to implement review systems under the auspices of either governmental or independent agencies. In other countries, such as the Philippines, quality assurance systems are in place, but they lack the authority to mandate review for all medical schools. Much as was the case in Flexner's time, when accreditation of institutions began to be more closely linked to licensure of individuals, many of these voluntary accrediting authorities are making efforts to strengthen incentives for institutions to obtain a positive accreditation status.

Flexner's evaluations sought to improve doctors' knowledge and skills by focusing on ensuring the quality of the education provided at medical schools. Currently, LCME policies continue to provide assurance that institutions meet fundamental standards. For those physicians trained outside of the United States or Canada, the ECFMG certification process ensures the readiness of these individuals to enter graduate medical training, but it does not include an independent review of the quality of certificants' medical schools. In addition, most state medical boards in the United States do not include independent evaluations of institutions as part of their residency or licensure requirements for IMGs. Accreditation of educational programs, conducted by an appropriate body in the country of the applicant's medical school or another suitable agency, in addition to the system of certification of individuals, would augment the process that ensures that those internationally educated individuals who seek training opportunities in the United States are appropriately qualified.

Whereas the current study describes and compares the inclusion of standards used (or not used) by the various accrediting organizations, our analyses have several limitations. We compared only the existence of the element, not the interpretation and application of the standards. It is also possible that various accrediting bodies differ in their conceptualization and implementation of what seems to be the same or a similar accreditation standard. Words or phrases such as “should,” “shall,” or “it is expected that” could be interpreted differently, depending on the exact phrasing of the standard, the various cultural or institutional contexts, or the understanding of particular individuals. For example, in the case of the Philippines element describing faculty involvement in research, the specific standard reads, “Medical school faculty members must have training in research and [must] actively engage in research.” This statement seems to require faculty scholarly activities, but it is possible that it could be interpreted as referring to some but not all faculty members.

Besides being aware of the potential variations in interpretations of written standards, readers of this paper should interpret the results of our study with caution, because our intent was to provide a framework for comparison across countries, not to suggest that particular organizational systems, methodologies, or elements are superior. Despite numerous instances of correspondence, it is also difficult to determine whether these international accrediting bodies intentionally embraced elements of Flexner's methodology or of another methodology, or whether the similarities observed are the result of widespread adoption of generic practices. Further research is necessary to evaluate the importance of these and other accreditation elements in contributing to the quality of medical practice. For example, studies aimed at determining the added value of accreditation fundamentals in relation to educational elements and the quality of graduates are warranted.

Moreover, medical education and quality assurance practices are not static. The LCME's current protocols do not include a strict interpretation of Flexner's original elements in accrediting domestic medical education programs, which indicates that the standards deemed important for ensuring quality in medical education 100 years ago may no longer be fully appropriate or applicable today. Countries continually update and modify their educational programs and quality oversight systems, and new medical schools are under development around the world. Various regions of the world are undergoing political or organizational changes that will affect the education and training of physicians. For example, the Netherlands Antilles is scheduled to be dissolved in 2010, and this event will result in significant changes in the political recognition and subsequent accreditation of the Antillean medical schools.

Flexner's work 100 years ago describing the state of medical education continues to provide relevant insights today. Using elements that he felt were important for ensuring quality, we created a framework for describing quality assurance and accreditation of the medical education of IMG physicians currently seeking to enter graduate training in the United States. All accreditation systems included in this study incorporated Flexner's process components, and many of the accreditation systems embraced the standards and basic tenets of Flexner's report, which provides evidence of the validity of these criteria. The quality assurance data in this report can be useful to program directors who select IMGs for their training programs. Program directors may use the knowledge that a physician's medical school was determined to have met established accreditation standards as additional practical evidence of the quality of its educational program. This additional information is likely of great value in comparisons of candidates with diverse backgrounds, educational attainments, and clinical experiences. Flexner was a proponent of comparing medical education in the United States with that in Europe, and the global data provided here contribute to a better understanding of medical education practices around the world.

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The authors thank the persons from the various accreditation organizations around the world who graciously sent the relevant standards documents to us. Special thanks and acknowledgment go to Professor Muuta Ibrahim, Bayero University, Kano, Nigeria; Dr. Bosede Afolabi, Lagos University, Lagos, Nigeria; and Dr. Ricardo Borda, Pontificia Universidad Javeriana, Bogotá, Colombia, for their valuable assistance in obtaining and interpreting documents.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

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