THE CHALLENGE OF MEETING THE EDUCATIONAL NEEDS OF INTERNATIONAL MEDICAL STUDENTS AT SILESIA UNIVERSITY MEDICAL SCHOOL FOR THE CLINICAL FACULTY A FORMIDABLE TASK! WILLIAM H. HARVEY, PH.D. APRIL 29,2009

The Center of the Medical Educational Enterprise is: THE MEDICAL STUDENT!

Primary purpose of any medical school: Educate the student to become a highly competent, well trained physician. Measure of that success for competency training here or abroad is medical student achievement.

Measure of that achievement: High pass on Step I and Step 2 of USMLE Successful residency placement Successful achievement on Step 3 of USMLE Licensure in the state of choice The medical school is less successful in its mission if it cannot provide the student the essential tools, resources or training to succeed in these activities

International Medical Schools have special challenges! IMS work with students in different cultural setting often with language challenges. Students may not has as strong academic skills as students in American medical schools. Some may not be as mature socially, academically or have poor time management or poor study skills. IMS may not have support systems to help students struggling academically, emotionally or socially.

Good IMS facilities will include: Strong, committed faculty Good, up to date facilities Good library, with internet access to Medline and other relevant research sources Access to financial aid Comfortable, safe and affordable housing Comprehensive and modern clinical exposure

My responsibility as a consultant to SILESIA is to evaluate: The living environment of SILESIA The learning environment of SILESIA The teaching environment of SILESIA

These inseparable elements all contribute to: The total professional development of the medical students as measured by Board scores and residency placement. Consequently, these motivated students return to their homes, participate in post graduate training, become practicing physicians or engage in bio-medical research or a variety of other pursuits.

Assumptions for the medical student IMS will provide an environment comparable as possible to American medical school An attempt to create a learning, teaching, social environment that maximizes teaching and learning in the basic sciences and in the clinical rotations The outcome being competitive board scores and good residency placement

Good IMS will also include:  Good student support services  Good clinical placement  Good residency placement  These latter two issues DEPEND UPON PERFORMANCE ON USMLE Step 1 + 2

Partnering between faculty and students It is very important that faculty and administrators are aware of the changing nature of the USMLE exams! The medical student may have to take the initiative to remind the faculty how they can help students prepare for the USMLE! It is OK to teach the content of the USMLE exam!

The Ultimate responsibility is the students! You can try to work with the student and their peer group in preparing for these examinations, but ultimately they alone are responsible for being prepared. They cannot blame the faculty, school or administration for their lack of preparation.

The 500 kilo canary!! IS STEP 1 AND 2 OF THE USMLE

 Quick links  Step 1  Description  2009 USMLE Bulletin: Exam Contents

What does the USMLE do? The USMLE accesses a physician’s ability to apply knowledge, concepts, and principles that are important in health and disease and that constitute the basis of safe and effective patient care.

Changes in the USMLE In 2006, the USMLE completed its transition to FRED: FRED is a CBT format similar to the old CBT developed by Prometric, Inc. Dramatic increase in questions in broad based knowledge (more later)

Typical USMLE Question The typical question screen in FRED has a question followed by a series of choices: you have a countdown timer, a review button: one clicks next to advance: screen will contain figures or color illustrations, typically to the right of question: gross photos, histo slides, radiographs, EMS etc.

Steps to complete ECFMG certificate Graduate from a medical school listed in the IMED. See Pass Step 1 and 2 within a seven year period Pass Step 2 CK and CS exams (communication test) Have medical credentials verified by the ECFMG Obtain an ECFMG certificate

IMGs in the US In 2008, out of 902,053 physicians, 228, 665 IMGs received degrees from 127 countries accounting for 25.3% of the total physician count! In last 24 years non-IMG grew by 91.4% In last 24 years IMG grew by 170.2% The nation is projected to face a shortage of physicians between 85,000 and 96,000 in 2020! = more reliance on IMGs

Critical for the IMS Generally residency programs look for USMLE 1 scores above 200/82. THE HIGHER THE BETTER!!

Median Step I scores for matches 208 psychiatry and family medicine 220 internal medicine and emergency med 234 orthopedic surgery and radiology 239 otolaryngology and dermatology 243 plastic surgery »NGME

IMGs in the Match Applicant U.S. IMG % U.S accept Non-U.S %Non accept U.S. Grads 14,719 15,008 15,206 % U.S. accept Council on Graduate Medical Education (COGME)

Changes in IMG population Numbers of non-US IMGs are down: multiple issues here! More selective population of non-US IMG Residency placement of non-US IMG same as US IMG

USMLE Exams Step 1 basic mechanisms and principles 336 questions/7 blocks 8hr passing score ~ 185(12/06/06) Step 2 Clinical diagnosis and pathogenesis: CK- 182/ questions-9h CS - Pass/Fail - 12 stand. patients (test of communication skills etc.) (IMS may take Step 2 CK prior to Step 1) Step 3 Clinical management 500 questions/10 blocks 16 hr (2days) passing score ~ 184/75

USMLE Step I includes Anatomy Pathology Physiology Genetics Neurology Behavioral Sciences Microbiology Pharmacology Cell Biology Immunology Nutrition

USMLE Step 1 and the IMG USMLE is computerized 336 multiple choice questions. Consists of seven~ 60 minute blocks each with 48 questions (total of 336 questions) Passing is minimum of ~ 185 where mean is ~ 220 Passing is equivalent to answering 60-70% of questions correctly In 2008, 95% of NBME registrants passed In 2008, 71% of ECFMG registrants passed NOTE: BETTER CHANCE OF PASSING OVER FAILING

Accreditation Council for Graduate Medical Education (ACGME)

HURRAH! BETTER CHANCE OF PASSING EXAM THAN NOT PASSING EXAM!!

Additional factoids on Step 1 Over 3/4 of questions include clinical vignettes and begin with a description of a patient About 65% of questions are pathology based Step 1 is required for both ECFMG certification and registration for CSA Step 1 is the only objective tool available to compare IMGs with U.S. graduates. THE LATTER IS A CRITICAL STATEMENT

Factoids continued Official website: and Eligibility: students and graduates of IMED listed schools (list at Students must have completed at least two years of medical school for eligibility. Eligibility period: a three month period of their choice

DETAILS OF THE BASIC SCIENCES WILL BE FOUND AT THE FOLLOWING WEBSITE: 1 content.html ALL THE BASIC SCIENCE CURRICULUM IS COVERED HERE!

THIS SITE INCLUDES: General description of USMLE 1 subject matter expectations General principles: All subject matter in basic science courses Systems: Hematopoietic and Lymphoreticular Central and Peripheral Nervous Skin and Related connective tissues Musculoskeletal Respiratory Cardiovascular Gastrointestinal Renal/Urinary Reproductive Endocrine

DETAILS OF CLINICAL SCIENCES: STEP 2 Are to be found at : 2.html Please visit this site for details for Step 2, CS and CK exams

Master basic clinical skills Conduct competent medical interview Perform competent physical examination DO: start IV, draw blood, basic cardiopulmonary resuscitation, sterile technique, and others DO: (minimally on models): spinal tap, childbirth, incision and drainage, others Watch: GI endoscopy, bronchoscopy, joint taps, setting fractures, others Use reports of: x-rays, EKGs, pap smears, blood chemistry, others

STEP 2: Diagnosis and Pathogenesis Clinical knowledge: 370 questions: 9h: pass of 182 (75%?) Clinical skills: Pass/fail: 12 standardized patients: 11/12 communication skills

CS portion of Step 2 includes assessment of: Professionalism Problem solving ability Communication skills Life long learning Ethical/cultural/racial/gender sensitivity Humanism Community and public health awareness

CONNECTION BETWEEN STEP I AND 2? YES!! STUDENTS WHO DO WELL BY STEP I WILL DO WELL ON STEP 2!!

Factoids continued USFMG students perform better than IMG on behavioral sciences About 65% of questions are pathology based Generally, non-U.S. medical students perform worst in behavioral science and biochemistry Better in gross and pathology

Standardization of exam Mean Step 1 score for U.S. medical students rose from 200 in 1991 to 215 in 2000 and have been relatively consistent since Related to exam design: profile of exam: doesn’t change over the years, such that a 200 in 2008 is comparable to a 200 in 2000

What do these scores mean? Passing the CBT Step 1 corresponds to answering 60-70% of the questions correctly. This is a passing score of about Passing the CBT Step 2 corresponds to answering about 75% of the questions: 182

A CURSE AND A BLESSING THEY CANNOT RETAKE THE EXAM IF THEY PASS IT!!!! WHAT ARE THE IMPLICATIONS OF THIS?

STEP 1+2 SCORES CRITICAL THESE ARE THE ONLY OBJECTIVE STANDARDS THAT ARE AVAILABLE FOR COMPARING THE EDUCATIONAL EXPERIENCE OF THE IMG WITH THE US TRAINED MEDICAL GRADUATE!

CONSEQUENCES! IN THE ABSENCE OF COMPETITIVE SCORES, THE IMG IS IS POORLY POSITIONED TO ATTAIN A RESIDENCY PROGRAM OF THEIR CHOICE OR MAY, WORST OF ALL, NOT BE ABLE TO OBTAIN A RESIDENCEY AT ALL!

CBSSA Competency Basic Science Self-Assessment Offered by NBME Tests in basic sciences: questions similar to USMLE 200 questions (paced or non-paced) $45 for service Available at THEY SHOULD DO THIS EXAM!!!

Some additional thoughts Students who tend to score well on NBME exams (shelf) tend to do well on Step 1 Likewise with CBSSA practice exam! Likewise with GPA, MCAT, GRE scores correlate strongly Typically 5-7 weeks of preparation is typical for Step 1 Practice exams are shorter and less clinical than the real ones Use practice exams as diagnostic devices to evaluate strengths and weaknesses

Additional thought: BROAD BASED KNOWLEDGE IS MORE IMPORTANT THAN IT WAS IN EXAMS IN PREVIOUS YEARS. EXAM TESTS BASIC SCIENCE MATERIAL AND ITS APPLICATION TO CLINICAL SITUATIONS. AGAIN, 3/4 OF QUESTIONS ARE CLINICAL VIGNETTES!

Sources for clinical vignettes: Comprehensive: Pretest Clinical Vignettes for USMLE Step 1: McGraw-Hill Anatomy: Underground Clinical Vignettes:Anatomy, Bhishan Blackwell Behavioral Sciences: Underground Clinical Vignettes: Behavior Sciences, Blackwell Biochemistry: Underground Clinical Vignettes: Biochemistry, Blackwell Microbiology: Underground Clinical Vignettes: Microbiology, Blackwell Pathophysiology: Underground Clinical Vignettes: Pathophysiology, Blackwell vol, 1,2,3 Pharmacology: Underground clinical Vignettes: Pharmacology, Blackwell Physiology: BRS Physiology Cases and Problems, Costanzo, Lippincott General: First Aid Cases for the USMLE Step 1 (250+ vignettes), McGraw Hill

Personal contact information William H. Harvey, Ph.D. Department of Biology Earlham College Richmond, IN Fax: