1. Improving Standards in U.S. Medical Education Flood International Consulting Agency

2. History of the International Medical Graduate (IMG) System 1950s: explosive growth in health care services and trained medical personnel A large number of positions available in U.S. residency programs U.S. medical schools’ output not enough to fill the demand Korean and Vietnam Wars compounded the need for more doctors Ultimately, physicians began being recruited from foreign countries

3. Development of the ECFMG 1954: Cooperating Committee on Graduates of Foreign Medical Schools (CCGFMS) formed CCGFMS recommended a system to evaluate qualifications of foreign graduates (IMGs) Evaluation included administration of exams to graduates in the medical sciences and English language

4. Development of the ECFMG 1956: CCGFMS formed the Evaluation Service for Foreign Medical Graduates (ESFMG), a private, non-profit organization ESFMG was established to implement CCGFMS recommendations for assessing IMGs for accredited programs of graduate medical education End of 1956: ESFMG became the Educational Council for Foreign Medical Graduates (ECFMG) 1958 to 1973: ECFMG evaluated the readiness of IMGs to enter U.S. residency programs

5. Development of the ECFMG Evaluation process included examinations and validation of medical credentials IMGs successfully completing evaluation became “ECFMG Certified” for U.S. residency programs 1974: ECFMG merged with the Commission on Foreign Medical Graduates and also began following visa sponsorships and researching IMGs ECFMG was renamed Educational Commission for Foreign Medical Graduates and maintained its acronym

6. Improving Evaluation Methods for International Medical Graduates 1986: ECFMG began to verify credentials directly with 1,300+ medical schools worldwide 1988 to 2007: ECFMG introduced clinical skills testing and computer-based exams to its certification process Clinical skills component incorporated into United States Medical Licensing Examination (USMLE) for both U.S. and international medical graduates

7. Profile of the IMG Population

8. Analysis of the IMG population In over 50 years, what effect has the IMG program had on U.S. health care? 1970 to 1994: –Total physician population increased by 350,386 (or 104.9%) with IMGs accounting for more than one-fourth (27.8%) of this increase (adding 97,359 physicians) –The number of non-IMGs physicians grew by 91.4%, while IMGs physicians increased by 170.2%.

9. Analysis of the IMG population 2005: Of the 794,893 physicians in the U.S., 185,234 were IMGs IMGs currently make up between 23% and 25% of the U.S. physician population

10. IMG Percentages by Specialty Percentage of IMG population within specialties: Internal Medicine - 30.8% (59,974) Anesthesiology - 29.9% (12,802) Psychiatry - 29.8% (14,849) Pediatrics - 28.6% (19,298) Source: AMA Membership Department - 2005 Fact Book

11. More IMG Percentages by Specialty General/Family Practice - 17.9% (19,868) Obstetrics/Gynecology - 16.5% (7,492) Radiology - 15.1% (5,962) General Surgery - 13.9% (17,579) Other - 23.0% (27,410) Source: AMA Membership Department - 2005 Fact Book

12. IMGs Trained by Country Top 5 countries in which IMGs are trained: India - 24.0% (44,585) Philippines - 10.6% (19,656) Mexico - 6.7% (12,448) Pakistan - 5.7% (10,689) Dominican Republic - 3.8% (7,147) Source: 2005 AMA Membership Fact Book

13. IMG Distribution by U.S. State 1. New Jersey10,904(39.6%) 2. New York25,603(38.6%) 3. Florida16,056(33.6%) 4. Illinois10,609(32.3%) 5. Maryland 5,768(26.9%) 6. Michigan 7,021(26.7%) 7. Massachusetts 5,432(26.7%) 8. Connecticut 3,022(25.1%) 9. Ohio 7,623(24.4%) 10. California21,426(22.6%) 11. Texas10,478(22.4%)

14. Current Trends in U.S. Medicine

15. Current Trends in U.S. Medicine U.S. allopathic medical schools continue to produce more specialists than primary care physicians Osteopathic and international medical graduates have been increasing to compensate for a lack of primary care physicians Patient population in the U.S. continues to diversify U.S. medical schools are not producing culturally and racially diversified physicians as compared to the patient population

16. More Trends in U.S. Medicine Latino/Hispanic and other minority populations will continue to increase and cultural differences will affect American health care More Americans will be uninsured and will not have equal access to health care U.S. medicine is becoming more divided and complex with soaring costs Medical education differs from institution to institution There is a shortage of “certified” educators to train students

17. The Typical U.S. Problem U.S. medical school students fail to remain in the state of their training Most graduates are attracted to large U.S. cities due to perceived economic, social, and personal benefits As a result, local “brain drains” occur and resources are wasted at local levels Retention of physicians in rural locations in the U.S. is abysmally low

18. The Typical U.S. Problem Community hospitals suffer and the quality of health care decreases Some hospitals in rural or urban areas are forced to close because of the lack of qualified personnel Various U.S. States seek IMGs to solve this problem IMGs fulfill the needs of struggling communities and outsourcing of labor abroad is a rising trend

19. IMGs as the Solution to Primary Health Care Needs IMGs satisfy the needs of the primary health care system IMGs fill gaps left by U.S. medical schools by providing services to difficult areas of the country IMGs provide affordable health care to needy and keep community programs operational IMGs are more diverse and representative of the general population of the United States

20. Current Issues in U.S. Medical Training & Education

21. A Need for Standards in Medical Training & Education Internal problems exist within the medical education and training system Includes both U.S. accredited medical schools and international medical schools Despite LCME recommendations, there is no true standard in medical education Particularly true for international medical schools whose students train in the U.S.

22. “Although accrediting organizations specify broad areas that the curriculum should cover and assess, for the most part individual medical schools make their own decisions about methods and standards of assessment. This model may have the advantage of ensuring consistency between the curriculum and assessment, but it also makes it difficult to compare students across medical schools for the purpose of subsequent training. 6 6 7 The ideal balance between nationally standardized and school-specific assessment remains to be determined…” 7 Source: Ronald M Epstein, MD, “Assessment in Medical Education,” New England Journal of Medicine. Jan 25, 2007. Vol 356: 387-396. A Need to Standardize Assessment

23. Abraham Flexner and Medical Education 1910: Abraham Flexner was a research scholar at the Carnegie Foundation for the Advancement of Teaching He began to evaluate and assess medical education His report criticized American medical schools and teachers in that period He found inadequate curricula and facilities at a number of schools Medical training was nonscientific in contrast to the university-based system of Germany

24. Flexner’s Contributions to U.S. Medicine Flexner envisioned training physicians from a scientific approach in academically-oriented hospitals similar to the German model His approach was eventually adopted by well- known universities like Harvard and Johns Hopkins Flexner’s report is responsible for present university-based hospitals A “publish or perish” culture emerged in which research began to surpass the importance of teaching Public health views became less important in today’s modern health care system

25. Medicine as a Business Rather Than a Calling Early 20 th century: Research was mainly a combination of investigation, patient care, and teaching at the bedside 1960s: Research became more molecular based and lab intensive Clinical teachers became increasingly “out of touch” with patient care and more focused on publishing or satisfying the business needs of medicine Medical students and residents suffered because faculty spent less time teaching and emphasized satisfying productivity issues Clinical faculty were no longer Flexner clinician- investigators and training quality physicians lost focus over time

26. How Do We Train Our Future Physicians? A sample of education models used by LCME, AOA and some international medical schools: System-based approach Problem-based learning Outcome-based learning Opinion-based learning Evidence-based learning Online Learning Early clinical exposure Cooperative model of education What is the standard?

27. Good Doctor Does Not Necessarily Equal Good Instructor Are physicians qualified to teach? Medical schools are developing programs to train future physicians as educators Physician instructors should be trained and certified to teach Standards are needed for both U.S. and international medical schools

28. Improvements Are Needed There are too many different approaches on how to teach basic sciences The quality of clinical clerkships varies drastically from state-to-state Organizational issues plague most programs and hamper students’ learning

29. Graduate Medical Education Directory Utilization of ACGME (“Green Book”) accredited programs for medical student training Varying degrees of importance placed on “Green Book” programs International medical schools create umbrella programs termed “Blue Book” International medical schools have physicians sponsor students in an effort to circumvent contracting with ACGME sites Overall, there is no standard for clerkship training for international medical schools

30. Medical Education with International Medical Schools Too many variations in curricula Training facilities are overcrowded and operated as for-profit businesses Students are seen as products or widgets in a business Clinical training sites in the U.S. vary greatly from state-to-state: university based programs vs substandard outpatient clinics For-profit and unregulated consulting businesses complicate the process and abuse students Lack of equal access to university-based training sites

31. Medical Education with International Medical Schools Discrimination exists Lack of independent oversight or supervision of training Overcrowding at training sites and “bumping” students from their assigned schedules Forced relocation from state-to-state with no reimbursement for last minute schedule changes

32. The Benefits of Flood International Consulting Agency Standardizing U.S. Medical Education for International Medical Schools

33. The Goals of Flood International Consulting Agency Standardization of U.S. Medical Education for International Medical Schools Encourage the LCME to be more stringent on standards for U.S. accredited medical schools Creation of an independent body to ensure a quality medical education at schools and hospitals Simplify the business aspects of U.S. medical education and emphasize training future physicians

34. Improve the Quality of Instruction Creation of policies to enforce the “quality of instruction” Establish consequences for not following standards or otherwise circumventing standards Creation of clinical centers of learning in the U.S. for international medical students Expand 5 th pathway programs to include students without the internship requirement Train physicians to become certified instructors and establish a more academic setting at clinical sites

35. Protect medical students’ rights Require hospitals and medical schools to provide for students’ basic needs Establish significant consequences for institutions or physicians who abuse the system and/or students Protect Medical Students’ Rights

36. Simplify the Evaluation and Licensure Process for IMGs Create an international, LCME-like, evaluation committee Require international medical schools to undergo regular inspections and meet certain standards for student loan participation Eliminate state medical board laws, approval processes, and lists that make U.S. licensure complicated Establish laws that forbid pseudo-accrediting organizations from forming and regulate consumer advocate activity

37. Before After Numerous unregulated international medical schools within the ECFMG process Varying levels of education & training Quality of facilities & training suspect Numerous abuses of medical students 50 state medical boards have differing licensure requirements New evaluating committee limits the number of international medical schools participating in the ECFMG process New standard will force foreign medical schools to improve standards and protect students. FICA will work with all medical organizations to ensure a smooth process Simplify the licensure process for IMGs. Eliminate different laws and create one (1) standard agreed to by all U.S. states Benefits of Improving Standards

38. FICA: The New International “LCME” FICA will take responsibility for evaluation of international medical schools State medical boards and the ECFMG can depend on FICA’s activities FICA will improve standards of education and follow guidelines from the LCME, GMC, and others FICA will help to simplify the complexity of the international process and improve quality FICA’s role will result in: - additional quality physicians for the increasing U.S. patient population - a diverse U.S. physician workforce - quality physicians for U.S. regions needing of health care providers - a better image and acceptance of international medical graduates - standardization of medical training for all physicians who will practice within the United States.