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Impact of International Medical Graduates on U.S. and Global Health Care: Summary of the ECFMG 50th Anniversary Invitational Conference

2006; Lippincott Williams & Wilkins; Volume: 81; Issue: Supplement Linguagem: Inglês

10.1097/01.acm.0000243340.89496.43

1938-808X

Barbara Gastel,

Diversity and Career in Medicine

Since 1956, the Educational Commission for Foreign Medical Graduates (ECFMG) has been certifying international medical graduates (IMGs) for entry into U.S. graduate medical education. More recently, it also has participated more broadly in advancing international medical education and thereby contributing to world health. In keeping with this scope, the ECFMG convened, in honor of its 50th anniversary, an invitational conference titled “Impact of International Medical Graduates on U.S. and Global Health Care.” Held in Philadelphia on July 21 and 22, 2006, the conference brought together 218 experts, representing 24 countries, to hear and discuss plenary presentations, participate in concurrent sessions, and share ideas informally. The conference included plenary sessions, at which the authors of the nine papers commissioned for the conference presented highlights of what they had written. It also included concurrent sessions, at which participants heard brief presentations and then discussed issues relating to IMGs. The current summary provides a brief overview of the presentations and concurrent sessions. Readers wanting more detail can consult the rest of this set of proceedings, which contains the full papers, a report on the concurrent sessions, and a list of participants. IMGs and International Medical Education: Past, Present, and Future Reflections The conference opened with brief remarks by Joel A. DeLisa, MD, MS, chair, ECFMG Board of Trustees, who began by citing the ECFMG values of collaboration, professionalism, and accountability. He then set the context for the conference by noting a variety of trends in medicine, including increasing globalization; by mentioning that the more than 150,000 IMGs in the United States constitute about one quarter of the U.S. physician workforce; and by speculating about possible future initiatives, such as the development of global standards and global accreditation. The rest of the morning session, titled “IMGs and International Medical Education: Past, Present, and Future Reflections,” consisted of three presentations and associated discussion. The first speaker, James A. Hallock, MD, president and chief executive officer, ECFMG, spoke on “Celebrating 50 Years of Experience: An ECFMG Perspective.” He explained that the ECFMG is a private, nonprofit, nongovernmental organization that, as authorized in federal regulations, serves as the certifying agency for IMGs entering the United States for postgraduate medical education. ECFMG Certification, he said, assures residency program directors and the U.S. public that IMGs have met the minimum standards to enter residency programs in the United States. He then summarized the certification process, which includes providing suitable documentation of undergraduate medical education and passing Step 1 and Step 2 of the United States Medical Licensing Examination (USMLE), and he provided an overview of the history of the ECFMG. He also presented the ECFMG mission, values, and purposes and identified domestic and international collaborators. He noted that the countries now providing the largest numbers of IMGs are India, the United States itself (via U.S. citizens who attend medical school overseas), the Philippines, and Nigeria. Next he described services the ECFMG provides to other entities for verifying the credentials of IMGs. He also traced the history of testing of IMGs, including the pioneering work of the ECFMG in developing examinations for clinical skills assessment—work that lay the foundation for the clinical skills examination within the USMLE. In addition, he described the participation of the ECFMG in the exchange visitor sponsorship program, identified areas of research by the ECFMG, and introduced the Foundation for Advancement of International Medical Education and Research (FAIMER), a nonprofit foundation established by the ECFMG in 2000. In closing, he identified future directions, including continuing to serve as the certifying entity for IMGs, collecting data and building databases, sharing information to inform policy, and collaborating “in the global movement to standard setting, assessment of individuals and institutions, and accreditation with the goal of improving health care.” Next came the presentation “Roles and Contributions of IMGs: A U.S. Perspective,” by Jordan J. Cohen, MD, president emeritus, Association of American Medical Colleges (AAMC). Dr. Cohen noted that IMGs make critical contributions to access to medical care in the United States by serving as about one fourth of the U.S. physician workforce. He also explained that IMGs help to fill specialty gaps by serving disproportionately in primary care specialties that are relatively unpopular with U.S. medical graduates, help to fill geographic gaps by practicing in areas with shortages of physicians, and contribute to academic medicine. To illustrate contributions of IMGs, he presented brief profiles of several IMGs who have distinguished themselves in research, teaching, public service, administration, and other realms. He anticipated that, with the demand for physicians in the United States expected to increase substantially in coming years, IMGs will continue to play a critical role, even though the AAMC has called for increasing enrollment in U.S. medical schools 30% in the next decade. In closing, he identified the potential for the AAMC to collaborate with the ECFMG in developing a suitable mechanism to assess medical schools outside the United States. He also noted the potential to collaborate with FAIMER in expanding support for medical education in countries providing IMGs, in order to help compensate for brain drain in those countries. The last speaker at the session, Professor Ronald M. Harden, general secretary, Association for Medical Education in Europe, gave a fast-paced, interactive multimedia presentation titled “International Medical Education and Future Directions: A Global Perspective.” Harden identified factors contributing to internationalization in medical education: globalization of health care, government pressures, improved channels of communication, a common vocabulary, standards for outcome-based education, staff development, and competitiveness and commercialization. He then considered international medical education along three dimensions: those of the student, the teacher, and the curriculum. He presented his vision for the future: “transnational medical education,” in which students from a variety of countries and teachers from a variety of countries interact electronically and in which an international frame of mind is integral to the curriculum. To help illustrate the transnational approach, he showed materials from IVIMEDS, The International Virtual Medical School. Exploring Issues Relating to International Medical Graduates Concurrent small-group sessions and then a plenary session featuring reports from these sessions occupied the afternoon of the first day of the conference. A set of five concurrent sessions was offered twice, allowing each conference attendee to discuss two topics from among the five offered: workforce and distribution, accreditation, improving international medical education, IMGs and the challenge of acculturation, and quality of international medical graduates. For each topic, the concurrent session began with a brief presentation by the moderator; discussion followed. The concurrent session “Workforce and Distribution” (facilitator: John R. Boulet, PhD, assistant vice president for research and evaluation, ECFMG) began with a presentation consisting largely of statistics on IMGs, defined as physicians who had graduated from medical schools outside the United States and Canada. Among the statistics presented were numbers of USIMGs (IMGs who were U.S. citizens upon entering medical school) and non-USIMGS (IMGs who were not U.S. citizens upon entering medical school), percentages of residents in various specialties who are IMGs, percentages of U.S. medical graduates and IMGs providing primary care, and the percentages and numbers of physicians in various U.S. states who are IMGs. Dr. Boulet also identified the countries and international medical schools contributing the most IMGs. Points emerging from the discussion included the following: The planned increase in output of U.S. medical schools must be accompanied by a corresponding increase in the number of residency positions available, especially in primary care; otherwise, IMGs could be forced out of the system, and shortages will persist. The U.S. government could continue to use immigration law to address shortages and geographic maldistribution of physicians. IMGs contribute diversity to the physician workforce, thus helping to serve the diverse U.S. population. Globalization could result in U.S. physicians’ migrating to other countries, and it is not guaranteed that IMGs will continue to seek graduate medical education in the United States. Developed nations have a responsibility to address issues of “brain drain.” In the concurrent session on accreditation (facilitator: Frank A. Simon, MD, director of undergraduate medical education policy and standards, American Medical Association), topics addressed in the opening presentation included key features of accreditation, the proportion of countries having accreditation of medical education, and aspects of the accreditation processes in those countries. Among points raised in the discussion were the following: Perhaps eventually requirements for ECFMG certification could include graduation from a medical school accredited by a local authority. An international accreditation system would aid in assessing the qualifications of prospective residents. Several sets of standards are needed so that there are modifications for local conditions. Views vary on whether there should be an international organization to “accredit the accreditors.” Unintended consequences of a system to assess international medical schools could include reduction in the physician workforce because of the closing of schools failing to meet standards, collaboration among medical schools to meet the standards and thus improvement of medical education, and facilitation of physician migration, which could increase brain drain but also could increase globalization. The introductory presentation in the session on improving international medical education (facilitator: John J. Norcini, PhD, president and chief executive officer, FAIMER) focused largely on the FAIMER Institute, a two-year fellowship program for international medical faculty. In each of the two years, it was noted, the fellows receive two or three weeks of instruction in the United States and then return to their home institutions, where they participate in distance education and work on a project that should lead to improvement of community health through enhancement of medical education. The discussion that followed was intended to aid FAIMER in strengthening the link between its education strategy and the improvement of the health of populations. Among the suggestions that emerged in this regard were the following: Include curriculum, such as content on public health, that promotes such links. Choose and nurture fellows in ways that promote such links, for example by recruiting individuals already interested in community health and perhaps accepting teams of participants. Require FAIMER Institute projects to focus on some aspect of community health, and encourage sustainability of projects. Favor projects that require students to work in communities. In the session on international medical graduates and the challenge of acculturation (facilitator: Gerald P. Whelan, MD, director, Acculturation Program, ECFMG), the opening presentation began with definitions of acculturation and culture. It also explored similarities and differences between cultural competence and acculturation. Participants then identified and discussed challenges that IMGs face in three realms: language and other aspects of communication, medical culture, and popular culture. Among challenges identified regarding communication were English-language idioms, medical slang, norms of nonverbal communication, and regional and ethnic dialects. Aspects of medical culture noted to pose challenges included the physician–patient relationship in the United States, the prominence of multidisciplinary health teams, confidentiality, the importance of documentation, and legal issues. Challenges identified regarding popular culture included those related to regional variations in American culture, survival skills (such as obtaining a driver’s license, credit cards, and housing), and familiarity with topics of popular discussion. It was noted that acculturation must be a two-way street and thus that resources are needed not only for IMGs but also for faculty members who teach them. In the fifth concurrent session, on quality of medical graduates, facilitator Stephen H. Miller, MD, MPH (president and chief operating officer, American Board of Medical Specialties) noted that quality can be assessed through both cognitive measures (examinations) and performance ratings. He also provided extensive data on quality, including data showing that in recent years, lower percentages of USIMGs than of non-USIMGs and U.S. medical graduates have passed Step 1 and Step 2 Clinical Knowledge of the USMLE. In the discussion, those at the session repeatedly said they wanted more data relating to quality; types of requested data differed depending on whether the participant was, for example a residency program director or a member of a state licensing board. Participants also considered possible reasons for, implications of, and remedies for the differences in performance of USIMGs and non-USIMGs. In addition, participants emphasized the need to track better the performance of both IMGs and U.S. medical graduates after licensure and certification. The Prospective Landscape for IMGs in the United States and Abroad: Views From Other Stakeholders The final session of the conference, held the morning of the second day, featured presentations by six speakers. In keeping with the title of the session, “The Prospective Landscape for IMGs in the United States and Abroad: Views from Other Stakeholders,” the speakers recommended future directions. They also provided historical perspective. Donald E. Melnick, MD, president, National Board of Medical Examiners (NBME), traced the intertwined histories to the ECFMG and the NBME in the first presentation of the session, “From Defending the Walls to Improving Global Medical Education: Fifty Years of Collaboration between the ECFMG and the NBME.” In his presentation, which included archival photographs, Dr. Melnick showed how, from the beginning, the two entities have worked together in assessing IMGs. He also highlighted a recent ECFMG-NBME partnership, the Clinical Skills Evaluation Collaboration, or CSEC. Dr. Melnick noted that whereas both the NBME and the ECFMG were established to help ensure that only qualified physicians train and practice in the United States, both are now recognizing the contributions they can make to improving medical education throughout the world. James N. Thompson, MD, president and chief executive officer, Federation of State Medical Boards of the United States, Inc., spoke on “Future of Licensure in the United States: A View from the FSMB.” Thompson explained that state medical boards protect the public through licensure of physicians who meet the required standards, regulation to establish standards for licensure and practice, and disciplinary action of physicians not meeting standards. He noted the need to develop means to ensure the ongoing competence of physicians seeking relicensure, and he identified changes in medicine and society that may call for new models of licensure. In addition, he described a recently instituted effort to determine future directions, the Physician Accountability for Physician Competence Summits. Among possibilities he noted for the future were licensure limited to specific medical specialties, national licenses, and international licenses based on international standards. Next came a presentation by Elias A. Zerhouni, MD, director, National Institutes of Health (NIH). In opening his presentation, titled “IMGs in the United States: A View from an ECFMG Certificant,” Dr. Zerhouni said he had immediately accepted the invitation to speak because “it was about time that I came to thank you.” Zerhouni, who is from Algeria, told how he sneaked out of an internship rotation there to fly to Paris for the ECFMG examination. He then told of coming to the Johns Hopkins School of Medicine for a short research fellowship and ultimately becoming chief resident in his chosen field, radiology. Zerhouni, who said he initially resisted working to improve his English, as he planned to stay only briefly in the United States, emphasized the importance of communications skills and of international mentoring. Quoting Louis Pasteur’s statement that “science knows no country,” as he noted the first NIH director had, Zerhouni summarized international activities of NIH and expressed interest in establishing links between FAIMER and the Fogarty International Center, a component of the NIH. Hans Karle, MD, president, World Federation for Medical Education, spoke on “Global Standards and Accreditation: A View from the WFME.” After introducing the WFME, a nongovernmental organization associated with the World Health Organization (WHO), Karle presented reasons, including globalization of medicine, that global standards are needed for medical education. He then described the WHO/WFME strategic partnership to improve medical education, which includes assistance in developing accreditation systems. He also summarized the WHO/WFME Guidelines for Accreditation of Basic Medical Education and noted that the WFME global standards for medical education could serve as a foundation for accreditation. With regard to international quality assurance and recognition, he called for international partnerships, including collaboration with the ECFMG and FAIMER. In addition, he identified global databases of medical schools and described the forthcoming WHO World Health Professions Education Institutions database, which he said could serve as a tool to “accredit the accreditors.” In “IMGs in the Physician Workforce: A View from Canada,” W. Dale Dauphinee, MD, executive director, Medical Council of Canada, focused largely on how internal migration of physicians educated in Canada influences recruitment and movement of IMGs. He showed that graduates of Canadian medical schools tend to move to the more prosperous provinces of Canada and the more urban areas within given provinces, leaving gaps to be filled by IMGs, who constitute about 22% of physicians in Canada. He also emphasized the need, made evident by unhappy experience, to coordinate federal immigration policy and provincial availability of residency positions, and he noted the work of the Canadian Task Force on Licensure of International Medical Graduates. In closing, he considered possible new roles for independent, nonadvocacy bodies such as the ECFMG. Such roles, he said, might include promoting standards for ethical recruitment of IMGs and providing support for students to receive high-quality medical educations in their own countries. The final speaker, Jamsheer Talati, MB, BS, FRCS, Habiba Subjali Jiwa Professor of Surgery, The Aga Khan University, Pakistan, presented “Medical Education and Health Care: A View from Pakistan.” Talati considered four possible scenarios regarding the numbers of physicians needed in Pakistan in 2010 and 2020, and he estimated the numbers of physicians that would be available; he concluded that, given the demand for a higher ratio of physicians to population, major shortages in the physician workforce were likely. He also observed although numerically the migration of physicians from Pakistan to other countries does not contribute greatly to the shortage of physicians, this migration has a disproportionate impact, as those leaving tend to be among those with the greatest ability and motivation. Talati said the solution to the shortages was not to expand medical colleges, as quality would suffer, but rather to take other measures, such as shortening medical education through skill laboratories and making greater use of nonphysician health workers. He said the issues and solutions are not unique to Pakistan but rather are similar throughout the world. A key, he said, was assessment, which drives improvements. Closing Remarks Carol A. Aschenbrener, MD, senior vice president, Division of Medical Education, AAMC, and member, ECFMG Board of Trustees, presented a closing commentary, much of which has been incorporated into the preface to the current proceedings. She noted that three themes had emerged from the conference: First, IMGs have made critical contributions to health care in the United States. Second, more data are needed about the quality of international medical schools and the performance of international graduates. And third, collaboration has been and promises to be of great importance and value, as indicated in a number of the presentations. Aschenbrener said that as organizations age, they can avoid decline by seizing new opportunities and thus revitalizing themselves. She then noted that ECFMG president Hallock had identified such an opportunity: “collaboration in the global movement to standard setting, assessment of individuals and organizations, and accreditation.” With successful collaboration in this realm, she said, the 75th birthday of the ECFMG could be occasion for a truly global celebration. Barbara Gastel, MD, MPH Dr. Gastel is associate professor of integrative biosciences and of humanities in medicine, Texas A&M University, College Station, Texas.