Prospects for a National Clearinghouse on International Medical Schools

All medical school programs in the United States and Canada are accredited by one of two national accrediting bodies: the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association's (AOA) Commission on Osteopathic College Accreditation (COCA). These accreditation systems are critical to the high quality of this country's system of medical education. They provide assurance to medical students/graduates, the medical profession, licensing authorities, healthcare institutions and the public that this country's undergraduate medical education programs leading to the M.D. or D.O. degree meet reasonable and appropriate national standards for educational quality and that graduates have a sufficiently complete and valid educational experience.

Graduates of this country's 129 LCME- and 25 AOA-accredited medical school programs constitute the majority of new physicians licensed in this country. However, graduates of medical schools located outside the United States comprise roughly one quarter of all licensed physicians in the United States.¹ The contributions of international medical graduates (IMGs) are significant. Not only do they contribute to the overall ethnic, racial and religious diversity of this country's physician workforce but some hospitals and primary care graduate medical education (GME) programs in the United States rely heavily upon IMGs for their workforce. IMGs also serve an important role in providing health care to underserved areas. There is considerable evidence demonstrating that IMGs holding temporary or J-1 visas are more likely to practice in a medically underserved area than U.S. graduates.^2,3

Despite these strong contributions, questions arise periodically relative to the licensing of individuals graduated from one of the more than 1,800 medical schools located outside the United States. Articles on this subject appeared in some of the earliest publications of the FSMB in 1916. They continued in recent years through a variety of journals, the most notable of which was an editorial in the New England Journal of Medicine one of whose co-authors was the former president of the Association of American Medical Colleges (AAMC).^4,5 The issues described in these articles describe a fundamental quandary facing medical licensing boards today, i.e., how to assess the qualifications of physicians graduated from non-U.S. medical schools despite possessing limited information (at best) on the educational curriculum of these schools.

Public expectations and statutory language require medical licensing boards to assess the qualifications of individuals presenting themselves for licensure. Assessing the quality of education provided by the licensee's medical school is an inherent, if not always explicit, part of the licensure process. Complicating this task for medical licensing boards is the absence accreditation systems for most international medical schools. In those instances, where accreditation systems are in place it is often unclear whether they are comparable to that of the LCME or COCA for U.S. medical school programs. Without a comparable accreditation system, U.S. licensing boards are left without uniform standards for determining the quality of the medical education provided to its potential licensee graduates of non-LCME or COCA-accredited schools.

In recent years, several factors have renewed medical boards' interest in this issue. One factor is the number of U.S. citizens attending medical schools outside the United States. The number of these U.S.-IMGs has increased during the past decade as evidenced by the number of U.S. citizens obtaining certification from the Educational Commission for Foreign Medical Graduates (ECFMG) annually, which tripled from 527 in 1995 to 1,932 in 2005. U.S. citizens as a percentage of all individuals certified by the ECFMG rose from nine percent in 1998 to more than 20 percent throughout the period 1999–2006.⁶

Second, there appears to be a strong consensus (based upon demographic projections) that the United States will experience a shortage of physicians within the next 15 years.^7,8 United States medical school programs, both allopathic and osteopathic, have responded with plans for increasing enrollment 30 percent by 2015.^9,10 Recent data from AAMC shows that progress in meeting this target is strong (17 percent increase in matriculants by 2012) but likely to fall short.¹¹ Similarly, the American Association of Colleges of Osteopathic Medicine (AACOM) predicts a 22 percent increase in matriculants by 2012.¹² The AAMC has also called for removing the cap on GME positions reimbursed by Medicare and explicitly rejected the notion of a decrease in IMG numbers. Thus, it seems likely the United States will continue to rely upon the IMG community to meet a significant portion of its medical needs.¹³ Some might argue that this is already the case and point to Ross University in Dominica and St. George's University in Grenada. These two medical schools currently have the largest number of residents in ACGME-accredited residency programs.¹⁴

It should also be noted that the estimated number of medical schools worldwide continues to increase, particularly in the Caribbean region where many schools draw heavily upon U.S. citizens for much of their enrollment. Depending upon how one chooses to define the Caribbean geographically, the number of medical schools in that region runs between 45 and 60. According to the Medical Board of California, 29 new schools have been established in the region within the last six to seven years. Many of these medical schools are for-profit endeavors utilizing non-traditional educational practices, e.g., no formal examinations for admission, awarding credit for prior experience in related health care professions, granting credit hours based upon limited on-site education.^15,16

Finally, even if a medical licensing board was inclined to do so, most do not possess the necessary resources to thoroughly evaluate the curriculum and operations of individual international medical schools. This becomes readily apparent when a particular incident or case casts the media spotlight on a specific school or its graduates resulting in questions about the school's status with the board. Two examples from recent years involved the University of Health Sciences at St. Johns, Antigua and advance standing provided to dentists who subsequently earned an M.D. degree. The resulting media and legal attention focused on the assumptions and inferences the public make when the M.D. credentials are used professionally and the ability of a medical board to limit the professional usage of the M.D. credential by an unlicensed individual.¹⁷

With these considerations as background, it is not surprising that medical boards might have questions relative to licensing graduates of international medical schools.

While boards carry a fundamental charge that includes public protection, they sometimes receive mixed messages on this topic. While the public might call for closer scrutiny of licensees from international medical schools, others urge caution lest addressing one problem exacerbates another, i.e., heightened scrutiny or added requirements might result in delays in licensing physicians or reducing the licensee population. This is a particularly important public issue in regions facing a shortage and/or maldistribution of physicians and one that will only become more critical if the current physician workforce projections remain accurate.^18,19

Pressure can also arise in states where specific medical schools have been identified as failing to meet adequate standards for providing medical education. In some instances, schools have been added to a non-approved list whose graduates are not eligible for licensure in that jurisdiction. Several boards responded to an FSMB survey noting pressure from residency programs to either allow the program to accept physicians from non-approved schools or revise the board's listing of acceptable medical schools whose graduates can be licensed in their jurisdiction.

With this background in mind, the FSMB formed a Special Committee to Evaluate Undergraduate Medical Education. The committee issued its final report in spring 2006 offering several recommendations.²⁰ The report's first recommendation called for the FSMB to closely “monitor efforts underway in various quarters to establish approval or accreditation mechanisms for international medical schools.”

Among the more promising efforts is that of the Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM). As a legally constituted body established by the Caribbean community, CAAM appears to represent the most significant ongoing effort for the establishment of an accreditation system under governmental auspices that would embrace a region already host to numerous medical schools. The United Kingdom has already designated CAAM as “the appropriate body” to assume the accreditation function previously conducted by the General Medical Council for medical schools in the Caribbean region. Site visits have been conducted and accreditation decisions rendered for a number of schools in the region. Full accreditation has been provided to the University of the West Indies; provisional accreditation status has been granted to St. George's University, the University of Guyana, St. James School of Medicine and British International University.²¹

The primary recommendation of the special committee report called for the FSMB to collaborate with other entities to establish a national clearinghouse of data and information on international medical schools. The intent is for the clearinghouse to expand on information provided through the International Medical Education Directory (IMED), published by the ECFMG Foundation for the Advancement of International Medical Education and Research (FAIMER) and available at www.faimer.org. The report identified numerous possible 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 utilized 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 Medical Board of California 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 USMLE 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 if an affiliation agreement exists with the hospital(s) where clerkships are being conducted.

The merits of a national clearinghouse would seem self-evident. One need only compare the limited information on international medical schools with the extensive, detailed information available on LCME and COCA-accredited programs to recognize there is a fundamental imbalance needing correction. Neither medical licensing boards, nor the public are well-served by this situation.

While licensing boards are an obvious beneficiary of the proposed clearinghouse, others would benefit from access to objective information on international medical schools. Prospective medical students and residency program directors are two obvious groups. From a personal perspective, it has not been unusual for prospective students and/or their parents to contact the FSMB with questions regarding the ‘licenseability' of graduates from international medical schools. Almost without exception, these conversations involve U.S. citizens considering medical school in the Caribbean region.

A workgroup with representatives from the FSMB, the ECFMG and state medical boards began work in early 2007 to explore the feasibility of a national clearinghouse. The workgroup recognizes that gathering information and data on 1,800+ international medical school programs is impractical, if not impossible. One approach being considered would focus data-gathering efforts on those schools already providing the largest number of prospective IMG-licensees in the United States. This approach seems feasible when one considers that a mere ten international schools contributed 60 percent of the total number of U.S. citizens certified by the ECFMG between 1998 and 2002.²²

Another approach that might be considered involves building upon currently available resources such as the IMED. As a free, publicly available resource, IMED might be able to incorporate additional information or data elements such as the quality indicators listed in the special committee report. This might quickly provide a detailed portrait of international schools that have, and/or currently are, placing a large number of physicians in the U.S. workforce.

Establishing a viable clearinghouse, even one narrowly focused on a limited number of schools, presents a significant undertaking. The critical challenge will be garnering cooperation from multiple parties. This includes not merely international medical schools, but U.S. governmental entities and organizations already in possession of relevant data. Success or failure will depend upon the clearinghouse's ability to obtain desired information from third parties, some of whom may be reticent about the subsequent use of the data.

A successfully established clearinghouse offers several benefits. For example, the clearinghouse would provide 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 school carry considerable weight with other jurisdictions that, while possessed of similar authority to approve schools, lack the resources to implement formal review protocols and site visits for international schools.²³

Finally, there is a complementary project arising from the workgroup and already underway which calls for the development of a primer on IMGs and international medical education. The intent is to provide both state medical boards and the public with a web-based resource that answers many commonly posed questions and provides extensive information and data on IMGs. This joint effort of FSMB and ECFMG staff is scheduled for completion in fall 2008. The topical outline for the primer now includes draft chapters on the following subjects:

• IMGs and Entry into the U.S. Health Care System

• Becoming a Licensed Physician in the United States

• ECFMG Certification

• IMG Demographics

• International Medical Education

• IMGs and Residency Training in the United States

• Licensing and Credentialing IMGs

• Immigration and Visas for IMGs

• Acculturation Services for IMGs

Despite the challenges facing state medical boards in this arena, there is ample reason to hope for success. Potential allies and partners abound, all of whom bring extensive expertise to international medical education: the ECFMG, the CAAM, 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 which 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 upon the situation facing American medical education nearly a century ago. In a seminal Carnegie Foundation report, Abraham Flexner proclaimed state medical boards as the key instrument for strengthening U.S. medical education. Flexner wrote, “state medical boards are the instrument through which the reconstruction of medical education will be largely effected.”²⁴ None would deny the tremendous successes in U.S. medical education stemming subsequently from the establishment of meaningful accreditation mechanisms in this country. 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.

• Copyright 2008 Federation of State Medical Boards. All Rights Reserved.