Results of the second Clinical Skills Assessment Examination of the ECFMG

To test the hypothesis that the clinical skills of many foreign medical graduates entering residencies in the United States are deficient, the Educational Commission for Foreign Medical Graduates (ECFMG) administered a second, more extensive pilot examination called the Clinical Skills Assessment Examination. The test was constructed after identifying those clinical skills considered to be suitable for testing in a large-scale examination conducted at multiple locations. The test was given to 635 foreign medical graduates (including 53 U.S. citizens) who had been certified by the ECFMG and to a reference sample of 123 graduates of U.S. medical schools. All of the graduates took the test prior to their first postgraduate year of training. The results did not differ significantly from those of a previous test. The clinical skills of 28% of the graduates of foreign medical schools who took the examination were found to be inadequate when compared with those of graduates of U.S. schools. The conclusion reached was that a clinical skills examination is feasible for inclusion in the ECFMG certification process.     

Addressing the urban pipeline challenge for the physician workforce: the Sophie Davis model.

The convergence of numerous trends indicates that a physician shortage by 2020 is likely. There is a 25% growth in the overall population, but that of the college-age sector is increasing by only 5%. The numbers of African Americans and Latinos in that sector will increase more than will members of other population groups; these two groups are most affected by the uneven quality of science education in urban high schools. Challenges to create a pipeline of a large, diverse, and qualified pool of medical school applicants are great, and are influenced by the actual and perceived cost of medical school tuition and the competition from other professions. Since 1973, the Sophie Davis School of Biomedical Education, a seven-year joint BS/MD program, has expanded access to medical school education for talented inner-city youths, including minorities and those with limited financial resources. Students receive a BS degree and their first two years of medical school education and, upon successful completion of the United States Medical Licensing Examination Step 1, transfer to one of five cooperating medical schools in New York State that confer the terminal MD degree. Sophie Davis integrates medical studies in the baccalaureate program, using actual performance in medical studies as a predictor of success. Of the more than 1,400 of its graduates, 25% are African American, 8% are Latino, 28% are Asian American, and 39% are white. Over 25% of its current student body comes from federally defined low-income families, and almost three-quarters qualify for New York State financial aid. The Sophie Davis School of Biomedical Education is a model that offers a partial response to those factors that will challenge the achievement of an adequate supply of physicians for our urban communities. The author describes the model in detail and explains how it helps talented but unevenly educated students rise to the challenge of a medical education.     

Influence of a problem-based learning curriculum on the selection of pathology as a career: evidence from the Canadian match of 1993-2004

Since the introduction of problem-based learning (PBL) to North American medical education more than 30 years ago, there have been a number of analyses of its educational outcomes. Several authors have suggested that PBL may influence medical students' career choices. The balance of opinion in the pathology literature appears to assume that PBL curricula limit students' contact with pathologists and hypothesizes that PBL may impair recruitment into pathology residency programs. To evaluate this latter hypothesis, evidence from the 1993-2004 Canadian residency match was considered. During this period, 8 of 13 English-language medical schools in Canada changed from a non-PBL to a PBL curriculum; 1 had been using a PBL curriculum even before the 1993 start point and 4 remained using a non-PBL curriculum throughout the period under consideration. The proportion of medical school graduates ranking pathology first in their residency application match is compared between PBL and non-PBL medical schools. On average, 1.1% of non-PBL graduates and 1.2% of PBL graduates ranked a pathology residency program first. In general, there were proportionately slightly more pathology recruits from non-PBL schools at the beginning of the 1993-2004 period and slightly more pathology recruits from PBL schools toward the end of the period. In the absence of a nationally or internationally recognized standard for what constitutes a PBL school, this analysis must remain somewhat subjective. However, it does indicate that graduates from PBL schools are approximately as likely as those from non-PBL schools to rank pathology first in residency applications.     

Mandatory postgraduate medical training in Japan--present state of Nihon University as a private medical school

This is a time of considerable uncertainty about the future of the postgraduate medical education policy of the Japanese government. Strong and visionary academic leadership of laboratory physicians in private medical schools is needed. The medical schools must not only adapt to a changing health care system, but also maintain excellence in education, patient care, and clinical research. In Japan, tradition has it that the comparatively few faculty members at national medical schools are mostly promoted only on the basis of research in experimental medicine, therefore, young medical graduates are increasingly drawn to bench work or molecular medicine, not to clinical practice. Single-minded specialization tends to produce single track minds, which may lack balanced judgment in approaching the appropriateness of both investigation and management. For continuity of care and containment of costs, a year or two of general professional training after graduation preceded by a broad medical education is an invaluable investment. All medical graduates, whatever their intended or unintended final destination (even if not clinical), should spend more than six months in medicine and four or five months in surgery, at least half of each to be spent in the general disciplines, including responsibilities for acute emergency admissions. As certified laboratory physicians we must attempt to attract graduates into laboratory medicine by developing imaginative training programs including common laboratory procedures such as Gram's stain, Wright-Giemsa stain and point of care testing at the patient's bedside or in ambulatory clinics, not only in central clinical laboratories.     

Establishing a national clearinghouse on international medical education programs: an idea whose time has finally come.

In 2006, a special committee appointed by the Federation of State Medical Boards (FSMB) issued a report that evaluated undergraduate medical education in the United States and abroad. With accreditation systems that can provide reasonable and adequate assurance for the quality of medical education in this country, the committee focused its attention on international medical school programs. Because international medical graduates (IMG) comprise a quarter of the physician workforce, U.S. medical licensing boards continue to seek useful and appropriate information on the medical schools of their licensees.Among the report's recommendations is one calling for the establishment of a national clearinghouse of information and data on international medical schools. A workgroup with representation from the FSMB, the Educational Commission for Foreign Medical Graduates, and state medical boards has been formed to establish this clearinghouse. The clearinghouse workgroup is considering various quality indicators suggested by the special committee report such as admission requirements, policies relative to advanced standing, and aggregate performance data on the United States Medical Licensing Examination. The challenges facing the clearinghouse are significant (e.g., gaining cooperation from multiple parties in the United States and abroad, prioritizing data collection efforts). One likely means for facilitating success may be to concentrate data-collection efforts primarily on the 8 to 10 schools currently supplying the largest number of IMGs seeking medical licensure in the United States. In this way, the clearinghouse will provide licensing boards with a resource for standardized information on those medical schools commonly presented by their IMG licensees.     

The measurement of outcomes in the assessment of educational program effectiveness

Postsecondary accrediting agencies recognized by the U.S. Secretary of Education and the Council on Postsecondary Accreditation, including the Liaison Committee on Medical Education (LCME), are required to evaluate educational program effectiveness by determining that institutions and programs document the achievement of their students and graduates in verifiable and consistent ways, indicating that institutional and program purposes are met. For the assessment of medical education programs this represents a departure from the traditional method of inferring quality from institutional compliance with standards for program organization and function. In the new assessment calculus, success is measured as the integrated product of the outcomes, the indicators of achievement that medical schools already are collecting from many sources, for instance, data on premedical achievement and attributes, medical school performance, graduate education ratings and test results, specialty certification, licensure, and practice. Although a recent LCME enquiry showed that 80% of U.S. medical schools were collecting outcome data on students and graduates, there was a lack of coherence and system, little integrated analysis, rare longitudinal study, and limited use of the information to evaluate and revise the curriculum or to validate admissions, promotion, and graduation criteria. The longitudinal study of the quantified results of educational programs need not resurrect old controversies about the linkage between learning in medical school and the quality of doctors' later practice. The purpose of examining outcomes is to gain sharper focus on the achievement of distinctive institutional goals, to facilitate program improvement and renewal, and to better assure the competence of graduates within the boundaries of achievement that schools have drawn as their educational objectives.     

Performances of U.S. osteopathic and Canadian medical school graduates on the American Board of Internal Medicine Certifying Examinations, 1984-1988

The performances of Canadian medical school graduates and U.S. osteopathic medical school graduates who first took the American Board of Internal Medicine Certifying Examination between 1984 and 1988 were compared with the performances, during the same period, of U.S. and foreign medical school graduates. Approximately 100 Canadian graduates took the examination each year; by 1988 the number of osteopathic graduates taking it was 102, double the number participating in 1984. Nearly all the Canadian graduates attended university or university-affiliated residencies, whereas half of the osteopathic graduates attended non-university-affiliated programs. For their overall clinical competence and for the eight components of clinical competence, the Canadian graduates were rated highest, followed by the U.S., osteopathic, and foreign graduates. The Canadians' average examination scores were also highest. The authors discuss the relatively low level of performance of the osteopathic graduates, but conclude that these graduates appear to be an untapped source of talented physicians for internal medicine residencies. The limitations of studying self-selected groups of candidates are also discussed.     

Concussion education in Canadian medical schools: a 5 year follow-up survey

Background

Despite concussion now being recognized as a public health priority in Canada, recent studies—including our 2012 survey of Canadian medical schools—have revealed major gaps in concussion education at the undergraduate medical school level.

Methods

We re-surveyed all 17 Canadian medical schools using a questionnaire divided in two categories: (1) concussion-specific education (2) head injury education incorporating a concussion component to determine whether there have been any improvements in concussion education at the medical school level during the last five years. For each year of medical school, respondents were asked to provide the estimated number of hours and teaching format for each category.

Results

We received replies from 13 of the 17 medical schools (76%). 11 of the 13 (85%) medical schools now reported providing concussion-specific education compared to 29% in our 2012 survey. The mean number of hours dedicated to category 1 learning in 2017 was 2.65?h compared to 0.57 in 2012, and the mean number of hours of category 2 increased to 7.5 from 1.54.

Conclusion

Our follow-up study reveals increased exposure to concussion-related teaching in Canadian medical schools during the last five years. Persistent deficiencies in a minority of schools are highlighted. These should be addressed by reiterating the importance of concussion education for undergraduate medical students and by developing clear concussion-specific objectives at the national licensure level.

     

A snapshot of the status of problem-based learning in U. S. medical schools, 2003-04.

PURPOSE: Although the use of problem-based learning (PBL) is widespread in U.S. medical schools, its true prevalence is unknown. This study examined the prevalence of PBL in preclinical curricula. METHOD: In 2003, a Web-based questionnaire was sent to education deans or directors of medical education at the 123 Liaison Committee on Medical Education-accredited medical schools in the United States. The respondents indicated whether or not they were using PBL and what percentage of faculty-student contact hours in the preclinical years used PBL. RESULT: All 123 schools responded. Of them, 70% used PBL in the preclinical years. Of schools using PBL, 45% used it for less than 10% of their formal teaching, while 6% used it for more than half of their formal teaching. Of the 30% of schools not using PBL, 22% had used it in the past, and 2% had plans to incorporate it in the future. CONCLUSIONS: Use of PBL is widespread in the preclinical curricula of U.S. medical schools. That use is limited, however, since fewer than 6% of programs use it for more than 50% of their instruction.     

A standardized patient enrolled in medical school considers the national clinical skills examination.

The National Board of Medical Examiners' recent decision to include a clinical skills examination as part of the licensing requirements for U.S. medical graduates has generated widespread discussion about the role of standardized patients in medical education. The author demonstrates that while specific clinical skills can and should be integrated into the medical school curriculum, any assessment of these skills using interactions with standardized patients must allow for a fuller range of responses and immediate, multifaceted feedback (content, process, and patient satisfaction) than would be allowed in the proposed Step 2 Clinical Skills. The presence of a national examination would pressure medical schools to adopt the very limited model of patient-physician interaction favored by the National Board of Medical Examiners. In addition, the author argues that the cost of registering for the examination and traveling to one of the few test sites on borrowed money is not justified to verify skills that may be reliably assessed locally.     

Preparing for change: the plan, the promise, and the parachute.

The University of California's (UC's) medical education programs are on the brink of change. In January 2007, the UC system completed a multiyear health sciences planning effort that is the most comprehensive undertaken in decades. For medical student education, the plan calls for an approximately one-third increase in enrollment across the system -- from approximately 650 current medical school graduates per year to a projected 920 graduates annually by the year 2020. During the same period, California's population is expected to increase in size and diversity in ways unmatched by any other state in the nation.The plan calls for development of new programs that will increase enrollment in unique and unprecedented ways. The first phase of this growth is under way and is planned to continue through a series of programs that seek to address the needs of California's medically underserved communities. Areas of focus include rural health and telemedicine (Davis); the Spanish-speaking Latino community (Irvine); diverse, disadvantaged communities (Los Angeles); health disparities and health equity (San Diego); and the urban underserved (San Francisco and Berkeley). In November 2006, UC medical schools received $200 million in bond funding to support this growth and to create new telemedicine programs to increase access to services provided by faculty physicians. In the coming years, UC medical schools will face demographic and budgetary challenges that will require perseverance, creativity, and certain leaps of faith. Public expectations are high.     

Sixteen years' experience with a required third-year family medicine clerkship at Jefferson Medical College.

Jefferson Medical College has developed a program to successfully meet the goal of teaching ambulatory care to all medical students, by providing each of its 223 third-year students with a required six-week clerkship in family medicine. The structured clerkship takes place at one of seven residency-based family practice centers, is supplemented by a formal curriculum, and is based on the active clinical involvement of caring for patients under full-time family medicine faculty supervision. This clerkship has been in existence for 16 years, and has added over 400,000 student-patient encounters to the clinical education of over 3,500 students. Student evaluations of the clerkship have rated it the highest of the six required core clerkships at Jefferson. In addition, over 16% of Jefferson graduates have entered family medicine residency training programs, a rate higher than that of any other school in the northeastern United States, and significantly higher than the average for all U.S. medical schools (12%). Jefferson's experience suggests that ambulatory care can be taught as a core component of the clinical education of all medical students. To be successful, however, strong institutional support, a structured curriculum, an adequate number of patients, a dedicated faculty, a sufficient number of training sites, an appropriate evaluation process, and significant financial support are all necessary.     

Physician workforce shortages: implications and issues for academic health centers and policymakers.

A physician shortage is likely given current levels of medical education and training. Because an increase in physician supply through expansion of U.S. medical school capacity will require ten or more years, there is little time left to affect the supply of new physicians in 2020 when a substantial number of baby boomers will be over 70 years of age. Even with a substantial increase in medical education and training capacity, it is unlikely that all of the increased demand for health services can be met with physicians. In addition to the challenges of expanding medical school enrollment, the nation will need to grapple with other ramifications of demand exceeding supply. This includes assessing how to deliver services more effectively and efficiently and the future roles of the physician and other health professionals. These challenges are particularly difficult for medical schools and teaching hospitals, the cornerstones of medical education and training in the United States. Osteopathic and off-shore schools targeted to Americans have been willing and able to grow more quickly and less expensively than U.S. medical schools, in part because of their more narrow approaches to medical education. In addition, physicians from less developed countries continue to migrate to the United States in significant numbers. Medical schools, teaching hospitals, and policymakers will need to address several major questions as they respond to the shortages. They will either confront and address these issues in the next few years or they will be forced to change by others in the future.     

International medical graduates: the Australian perspective.

Australia, like many other developed countries, has faced medical workforce shortages. This situation has been attributed to the increasing demands from an aging population and a decline in the hours worked by medical practitioners. These shortages, which are usually in the areas of greatest medical need in Australia, have led to an increasing dependence on international medical graduates (IMGs). The Australian government is slowly moving towards self sufficiency by expanding education and training opportunities for Australian doctors. In the interim, Australia relies heavily on IMGs to supplement the medical workforce. Australia's population is concentrated in the coastal regions, and IMGs are often required to service the more sparsely populated rural and remote areas, which find it difficult to attract and retain local medical graduates.Health funding in Australia is provided jointly by the federal (central) government and six state and two territory governments. Funding from the federal government provides for university based medical education and general practice postgraduate training. State and territory governments fund postgraduate specialist training and provide funding for a public hospital system.Although a national accreditation process for IMGs exists, many IMGs are recruited directly to Australian hospitals and community practices without adequate assessment of their qualifications or language and clinical skills. The current two-tiered system, in which service demands can override quality and standards, can no longer be tolerated. There is an urgent need for a uniformly applied national standard for all IMGs entering Australia and for a strategy to implement it.     

The effects of a changing environment on relationships between medical schools and their parent universities.

Medical schools differ from other university graduate schools in that community settings, hospitals, and ambulatory care facilities are required for medical education, and most of these settings are either owned by or closely affiliated with the university. Thus, the extraordinary changes in recent years in the organization, delivery, and financing of health care have required the attention not only of the leadership of academic medical centers (i.e., medical schools and their owned or closely affiliated teaching hospitals) but also of the administrators and boards of their parent universities. Many university-wide structures and policies that previously served the medical school well in accomplishing these missions may now be viewed as inflexible by the faculty and administration of the school. Conversely, the historically distant governance and administrative oversight of the medical school has become a concern for some at the university, given the huge budgets of the school, its faculty practice, and its affiliated hospital(s). From information derived mainly from annual visits to 14 medical schools from 1996 through June 2000, the authors review the issues between medical schools and their parent universities and the strategies being used to resolve them. These strategies include changes in the governance, organization, and management of the medical school, such as unified authority for health affairs, reengineered administrative systems, and increased autonomy in decision making. The authors conclude that these strategies appear to be working on behalf of not only the medical school but, in some instances, the university at large. They also comment on possible negative implications of the greater separation of the medical school from its parent university.     

The association between students' research involvement in medical school and their postgraduate medical activities

The authors examined the impact of students' research involvement during medical school on their postresidency medical activities. The three medical schools involved--The Pennsylvania State University College of Medicine (PSU), The University of Connecticut School of Medicine (UCONN), and The University of Massachusetts Medical School (UMASS)--have nearly indistinguishable applicant, matriculant, and curriculum profiles. However, at PSU a research project is a curriculum requirement for students who did not do medical research prior to entering medical school. Questionnaires were sent to all graduates from the classes of 1980, 1981, and 1982. A total of 567 graduates completed the questionnaires, an overall response rate of approximately 76%. Medical school research experience was reported by 83% (183) of the PSU graduates, 34% (52) of the UCONN graduates, and 28% (54) of the UMASS graduates. When compared on a school-by-school basis, the graduates from the three schools did not differ with respect to residency specialty training, fellowship training, academic appointments, career practice choices, or postgraduate research involvement. However, when all the graduates studied were examined as a single group, medical school research experience was found to be strongly associated with postgraduate research involvement.     

The programs and context of medical education in Argentina.

There are 29 medical schools in Argentina (this number has increased rapidly in the last decade) offering a 6-year curriculum that usually consists of 3 years of basic science, 2 years of clinical sciences, and one internship year. Annually, 5,000 physicians graduate from these programs. Admission requirements vary depending on each university's policy. Some do not have entry requirements; others require a course, usually on the basics of mathematics, biology, chemistry or physics, and some introduction to social and humanistic studies. Each year, there are approximately 12,000 first-year medical students attending the 29 schools, which suffer a high dropout rate during the first years because of vocational problems or inability to adapt to university life. Some schools have massive classes (over 2,000 students), which makes it difficult for the schools to perfect their teaching. The number of full-time faculty members is low, and some of them have appointments at more than one medical school. Residency programs offer an insufficient number of places, and fewer than 50% of the graduates can obtain a residency position because of strict admission requirements. Coordination between the Ministry of Health, representing the health care system, and the Ministry of Education, representing the medical education system, needs to be improved. Despite the problems of medical education in Argentina, the movement to improve the education of health care workers is growing. The author offers two recommendations to help accomplish this goal.     

Educational program of clinical laboratory medicine to develop the ability to use proper laboratory examinations in medical practice

A model core curriculum for medical education was proposed in 2001 as a guideline to standardize and improve the educational program in Japanese medical schools. Many subjects involved in clinical laboratory medicine were listed in this model core curriculum. Original and characteristic educational curricula in each medical school were also required in this guideline. In our university, we constructed the educational program of clinical laboratory medicine with lectures, clinical practice, and small group seminars including reversed CPC, according to the guideline. We need further trials to achieve the goal, i.e. education to develop the ability to use proper laboratory examinations in medical practice, as a good clinical doctor.     

Assessing medical students' clinical sciences knowledge in France: a collaboration between the NBME and a consortium of French medical schools.

PURPOSE: The French government, as part of medical education reforms, has affirmed that an examination program for national residency selection will be implemented by 2004. The purpose of this study was to develop a French multiple-choice (MC) examination using the National Board of Medical Examiners' (NBME) expertise and materials. METHOD: The Evaluation Standardisée du Second Cycle (ESSC), a four-hour clinical sciences examination, was administered in January 2002 to 285 medical students at four university test sites in France. The ESSC had 200 translated and adapted MC items selected from the Comprehensive Clinical Sciences Examination (CCSE), an NBME subject test. RESULTS: Less than 10% of the ESSC items were rejected as inappropriate to French practice. Also, the distributions of ESSC item characteristics were similar to those reported with the CCSE. The ESSC also appeared to be very well targeted to examinees' proficiencies and yielded a reliability coefficient of.91. However, because of a higher word count, the ESSC did show evidence of speededness. Regarding overall performance, the mean proficiency estimate for French examinees was about 0.4 SD below that of a CCSE population. CONCLUSIONS: This study provides strong evidence for the usefulness of the model adopted in this first collaborative effort between the NBME and a consortium of French medical schools. Overall, the performance of French students was comparable to that of CCSE students, which was encouraging given the differences in motivation and the speeded nature of the French test. A second phase with the participation of larger numbers of French medical schools and students is being planned.     

Training program at medical school of Chieti, Italy

We describe the changes in medical training program offered at the G. D'Annunzio University Medical School in Chieti-Pescara, Italy, which took place over the last decade. The new curriculum differs from the previous one in several important aspects, including limited number of students admitted to school depending on the estimated needs for physicians, obligatory class attendance, student attendance in preclinical laboratories, formative credits as a measure of student activity, and elective subjects. Furthermore, all medical graduates are allowed to take the State exam to obtain the licence to practice, which was not the case previously. As a result of these major changes, a higher number of students graduates in due time. The changes made in the medical education curriculum in Italy have enabled Italian medical graduates to work in European Community Hospitals, because their medical degree is recognized in other EU countries. The main motif that drives the Medical School in Chieti-Pescara is the achievement of high quality in medical education and biomedical research by creating as strong a relationship between education and research as possible.