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Global Approaches to Medical School Regulation: A Critical Discourse Analysis
Abstract
Although medical school regulation is ubiquitous, the extent to which it should be based on global principles is unclear. In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG), announced that from 2023, overseas doctors would only be eligible for certification to practise in the United States if they had graduated from a medical school that was accredited by a ‘recognised’ agency. This policy empowered the World Federation for Medical Education (WFME) to create a recognition programme for regulatory agencies around the world, despite a lack of empirical evidence to support medical school regulation. In this study, I employ critical discourse analysis, drawing on the theoretical perspectives of Michel Foucault and Edward Said, to identify discourses that enabled this ‘globalising’ policy decision to take place. The dataset includes a series of documents gathered around three key events: the Edinburgh declaration by WFME in 1988, the first set of global standards for medical schools by WFME in 2003, and the ECFMG ruling about medical school accreditation in 2010. Two discourses, endorsement and modernisation, were dominant throughout this entire period, and framed the move to globalise medical school regulation in terms of altruism and improving medical education worldwide. A discourse of resistance was present in the earlier period of this study but faded away as WFME aligned itself with ECFMG. Two further discourses, protection and control, emerged in the later period of this study, and framed the ECFMG ruling in terms of nationalism and protecting American interests. This study introduces Said’s ‘contrapuntal’ analysis to the field of medical education, synthesising it with Foucauldian principles to propose a new conceptualisation of the relationship between ECFMG and WFME. It goes on to consider the implications of this association for the legitimacy of WFME as an organisation that represents all of the world’s medical schools.
... 8 A contrapuntal reading, though, might actively amplify voices that see these movements as destructive due to 'brain drain' and workforce shortages, or else those who see their local cultures and values being marginalised. 9 As Said recognised, such contrapuntal reading necessitates a 'stubborn confrontation' with normative practices and can, therefore, be less than comfortable. 6 As Locke highlighted, each reading of a text involves some interaction with it, and importantly, some thinking. ...
Issue: The World Federation for Medical Education (WFME) was established in 1972 and in the five decades that followed, has been the de facto global agency for medical education. Despite this apparently formidable remit, it has received little analysis in the academic literature. Evidence: In this article, we examine the historical context at the time WFME was established and summarize the key decisions it has taken in its history to date, highlighting particularly how it has adopted positions and programmes that have seemingly given precedence to the values and priorities of countries in the Global North. In doing so, we challenge the inevitability of the path that it has taken and consider other possible avenues that such a global agency in medical education could have taken, including to advocate for, and to develop policies that would support countries in the Global South. Implications: This article proposes a more democratic and equitable means by which a global organization for medical education might choose its priority areas, and a more inclusive method by which it could engage the medical education community worldwide. It concludes by hypothesizing about the future of global representation and priority-setting, and outlines a series of principles that could form the basis for a reimagined agency that would have the potential to become a force for empowerment and global justice in medical education.
From the perspective of peripheralised countries, internationalisation is imbalanced and hegemonic, as it is predominantly constructed by universities in the Global North. We explore the imbalanced inter-nationalisation from the cases of sub-Saharan Africa through the dominance of Western knowledge systems and brain drain; China through isolation and playing 'catch up'; and Indonesia through the financial crisis, the bailout conditions of the International Monetary Fund and World Bank and marketisation. By taking the cases of sub-Sahara Africa, China and Indonesia, this article problematises the idea of internationalisation and argues that it further relegates universities from the peripheralised countries to the margin.
Background
Accreditation systems in medical education aim to assure various stakeholders that graduates are ready to further their training or begin practice. The purpose of this paper is to explore the current state of medical education accreditation around the world and describe the incidence and variability of these accreditation agencies worldwide. This paper explores trends in agency age, organization, and scope according to both World Bank region and income group.
Methods
To find information on accreditation agencies, we searched multiple online accreditation and quality assurance databases as well as the University of Michigan Online Library and the Google search engine. All included agencies were recorded on a spreadsheet along with date of formation or first accreditation activity, name changes, scope, level of government independence, accessibility and type of accreditation standards, and status of WFME recognition. Comparisons by country region and income classification were made based on the World Bank’s lists for fiscal year 2021.
Results
As of August 2020, there were 3,323 operating medical schools located in 186 countries or territories listed in the World Directory of Medical Schools. Ninety-two (49%) of these countries currently have access to undergraduate accreditation that uses medical-specific standards. Sixty-four percent ( n = 38) of high-income countries have medical-specific accreditation available to their medical schools, compared to only 20% ( n = 6) of low-income countries. The majority of World Bank regions experienced the greatest increase in medical education accreditation agency establishment since the year 2000.
Conclusions
Most smaller countries in Europe, South America, and the Pacific only have access to general undergraduate accreditation, and many countries in Africa have no accreditation available. In countries where medical education accreditation exists, the scope and organization of the agencies varies considerably. Regional cooperation and international agencies seem to be a growing trend. The data described in our study can serve as an important resource for further investigations on the effectiveness of accreditation activities worldwide. Our research also highlights regions and countries that may need focused accreditation development support.
The collapse of the Soviet Union in 1991 left many ex-republics in a financial and administrative crisis for the ensuing two decades. Previously centralised processes like recertification of doctors and healthcare workers and continuing medical education fell by the wayside. Continuing medical education and continuing professional development in Armenia have evolved through multiple phases from Soviet, to immediate, mid and late-transitional post-Soviet periods, to current modernising efforts. This manuscript describes the phases of evolution of continuing medical education chronologically and details the legislative and regulatory framework surrounding each stage of development. Armenia is currently implementing a credit system of continuing medical education with the aim to introduce and adopt new and efficient approaches in this field. Continuing education credits fall into three categories: didactic or theoretical knowledge, practical skills and self-education/self-development. To recertify, professionals must collect credits from all three groups with specified minimum amounts according to their degrees. Armenia’s guiding principle is to harmonise the continuing medical education and professional development model with internationally accepted criteria in order to contribute to the international mobility of healthcare workers and to provide for true on-going professional development and knowledge that will benefit our doctors, nurses and above all our patients.
Purpose
Free Open Access Medical Education (FOAMed) is a worldwide social media movement designed to accelerate and democratise the sharing of medical knowledge. This study sought to investigate the content shared through FOAMed during the emerging COVID-19 pandemic.
Study design
Tweets containing the #FOAMed hashtag posted during a 24-hour period in April 2020 were studied. Included tweets were analysed using the Wiig knowledge management cycle framework (building knowledge, holding knowledge, pooling knowledge and using knowledge).
Results
1379 tweets contained the #FOAMed hashtag, of which 265 met the inclusion criteria and were included in the analysis. Included tweets were posted from 208 distinct users, originated from each world continent and were in five different languages. Three overarching themes were identified: (1) signposting and appraising evidence and guidelines; (2) sharing specialist and technical advice; and (3) personal and social engagement. Among 12 subthemes within these groupings, 11 aligned to one of the four dimensions of the Wiig knowledge management cycle framework, and the other focused on building and managing social networks. Almost 40% of tweets related directly to COVID-19.
Conclusion
#FOAMed tweets during the COVID-19 pandemic included a broad range of resources, advice and support. Despite the geographical, language and disciplinary variation of contributing users and the lack of organisational structure uniting them, this social media medical community has been able to construct, share and use emerging technical knowledge through a time of extraordinary challenge and uncertainty for the global medical community.
Objectives
The global distribution of health professionals and associated training programmes is wide but prior study has demonstrated reported scholarship of teaching and learning arises from predominantly Western perspectives.
Design
We conducted a document analysis to examine authorship of recent publications to explore current international representation.
Data sources
The table of contents of seven high-impact English-language health professional education journals between 2008 and 2018 was extracted from Embase.
Eligibility criteria
The journals were selected according to highest aggregate ranking across specific scientific impact indices and stating health professional education in scope; only original research and review articles from these publications were included for analysis.
Data extraction and synthesis
The table of contents was extracted and eligible publications screened by independent reviewers who further characterised the geographic affiliations of the publishing research teams and study settings (if applicable).
Results
A total 12 018 titles were screened and 7793 (64.8%) articles included. Most were collaborations (7048, 90.4%) conducted by authors from single geographic regions (5851, 86%). Single-region teams were most often formed from countries in North America (56%), Northern Europe (14%) or Western Europe (10%). Overall lead authorship from Asian, African or South American regions was less than 15%, 5% and 1%, respectively. Geographic representation varied somewhat by journal, but not across time.
Conclusions
Diversity in health professional education scholarship, as marked by nation of authors’ professional affiliations, remains low. Under-representation of published research outside Global North regions limits dissemination of novel ideas resulting in unidirectional flow of experiences and a concentrated worldview of teaching and learning.
International medical school graduates (IMGs) play a vital role in the health care system of the United States. They constitute roughly one-quarter of the physician workforce, comprising a significant proportion of the primary care providers in high-need rural and urban areas, where they provide equal and, in some instances, better care than U.S. graduates. Nonetheless, they face a series of hurdles in entering U.S. residency programs and throughout their training experiences.
IMGs must expend significant resources to obtain Education Commission for Foreign Medical Graduates certification, which includes Steps 1, 2 Clinical Knowledge and 2 Clinical Skills of the United States Medical Licensing Examination. They encounter the uncertainty of matching and, if successful, obtaining a visa to enter the United States. Once here, they need to adapt to the complexities of the health care system and familiarize themselves with the cultural nuances, professional behaviors, and communication skills of another country. They encounter biases and microaggressions and lack support groups and mentors. Those who choose an academic career are less likely to obtain leadership positions.
This Perspective provides an overview of these challenges and highlights opportunities for change at local and national levels. Specifically, it identifies strategies that would assist IMGs before entry, at entry, during training, at the transition to practice, and in practice. The current COVID-19 pandemic highlights the shortage of physicians in the United States and illustrates the importance of ensuring that IMGs, who are essential health care workers, feel welcome, valued, and recognized for their contributions.
Global medical education is dominated by a Northern tilt. Global universities’ faculty and students dominate research, scholarship and teaching about what is termed global education. This tilt has been fixed in global biomedical education with some acknowledgement from the Global South of the comparative benefits of global exchange. Student exchange is predominantly North to South. Students from the Global South are less likely to visit the North on global medical education visits. Global indigenous and traditional ways of knowing rooted may be suppressed, hidden or misappropriated and repackaged for consumption in the Global South with Global North ways of knowing as a reference point. A global history of colonization has shaped this trend influencing postcolonial theorists and decolonial activists to question the legitimacy and depose the influence of dominant Global North ideas. This is evident in how communication skills, reflective practice and narratives are presented and taught. Global North students must be introduced to Global South ways of knowing before visiting the Global South from a position of critical consciousness. Emancipatory education is best led by transformative Global North–South dialogue.
Introduction
Entering US clinical training requires completing requirements and navigating an application process differing from the Japanese system. Additionally, increases to the number of US medical school graduates have increased competition for US residency positions. We examined profiles of Japanese International Medical Graduates (IMGs) who completed US clinical training, the timelines to securing US clinical positions, and the greatest challenges during this process and methods to overcome them.
Methods
Individual semistructured interviews were conducted with 35 purposively sampled Japanese IMGs. We performed exploratory thematic analysis using iterative data collection and constant comparison.
Results
Twenty percent of participants lived in a native English‐speaking country during childhood. The United States Medical Licensing Examinations were completed at ages 25‐40 years. Challenges were categorized as: (1) English communication, (2) understanding the application process, (3) motivation to persevere through the process, (4) time management to complete Educational Commission for Foreign Medical Graduates requirements, (5) receiving letters of recommendation and overcoming competition for US residency positions, (6) financial cost of the process. Pragmatic generally self‐dependent methods helped overcome challenges 1‐4 and 6. Participants detailed personal or, more commonly, institutional connections to US training programs required to overcome challenge 5.
Conclusions
Japanese IMGs pursue US clinical training from diverse backgrounds commonly without the advantage of prior English fluency. Amidst increased competition internationally to enter US residency coupled with cultural and linguistic differences making this challenge often greater for Japanese IMGs, the competition to participate in institutionalized connections to US training programs is anticipated to increase.
Edward Said is regarded as the originator of colonial discourse theory. He deploys Michel Foucault's notion of discourse to accomplish his project in Orientalism and emphasizes Foucault's notion of discourse and its relation to power, rendering discourse a carceral system. Although Said explicitly expresses the similarity between Orientalism and Foucault's discourse theory, it seems he implicitly suggests that the carceral quality of Foucault's idea affects his formulation of Orientalism. This study examines the validity of Said's understanding of Foucault and shows that Said's construction of Orientalism is based on an imperfect image of Foucault. Argument here is to postulate that Foucault's discourse theory provides space for resistance and his theorization of power helps the idea of struggle in discursive practices. Besides, Foucault himself is trapped in a discourse produced by Said. This study casts light on Foucault's theory of discourse and modifies this misreading.
Medical school education plays a significant role in the advancement of any country. The recent global progressions and changes in medical education will create a great burden on the third world countries, including Libya. In order to measure the quality educational systems, it is relevant to establish a functional system that recognizes and measure the essential abilities to meet quality service needs in communities as well as apply principles of emerging basics for quality medical practice locally and internationally. Since its establishment in 2006 to the present, the national center for quality assurance and accreditation in Libya NCQAA has accomplished its command as the sole accreditation council for the all existing medical schools in Libya. With prospective vision, the NCQAA's role will be to further encourage all medical schools in Libya towards the nonstop improvement to meet the international standards. Furthermore, the 2015 revision of the World Federation for Medical Education (WFME) requires that all medical schools meet the new accreditation standards by 2023. Hence, the next step for NCQAA is to audit the progress and increase the standard of medical education in individual schools, with the eventual goal of reaching superior standard of medical education for all schools in Libya. This commentary describes the current trends in Libyan medical education accreditation and how this concern has inspired the Libyan authorities to take action in this regard.
It aimed to provide the change of accreditation standards of medical schools in Korea by the Korean Institute of Medical Education and Evaluation (KIMEE) from 2000 to 2019. Specifically, the following was explained: the development process, setting principle and direction, items of evaluation, characteristics of the standards, and validity test of 4 cycles. The first cycle of accreditation (2000-2005) was a process to secure the minimum requirement of the educational environment. The evaluation criteria emphasized the evaluation of the core elements of medical education, including facilities and human resources. The second cycle of accreditation (2007-2010) was a process in which the university emphasized its commitment to social accountability and the pursuit of excellence in medical education. It raised the importance of the qualitative standard for judging the contents and fidelity of education. In the post-2nd cycle of accreditation (2012-2018), the certification criteria were developed to standardize the educational environment and educational programs and to use them in the development of curriculum, to continually improve the quality of basic medical education. The ASK2019 accreditation aimed at qualitative evaluation following the World Federation of Medical Education’s accreditation criteria to reach the international level of basic medical education, which stresses the student-centered curriculum, communication with the society, and evaluation through whole basic medical education course. KIMEE has developed the basic medical education evaluation and certification system step by step as above. Understanding the previous process will help to develop the accreditation criteria of medical school in Korea.
Background:
Physicians play a critical role in healthcare delivery. With an aging US population, population growth, and a greater insured population following the Affordable Care Act (ACA), healthcare demand is growing at an unprecedented pace. This study is to examine current and future physician job surplus/shortage trends across the United States of America from 2017 to 2030.
Methods:
Using projected changes in population size and age, the authors developed demand and supply models to forecast the physician shortage (difference between demand and supply) in each of the 50 states. Letter grades were then assigned based on projected physician shortage ratios (physician shortage per 100 000 people) to evaluate physician shortages and describe the changing physician workforce in each state.
Results:
On the basis of current trends, the number of states receiving a grade of "D" or "F" for their physician shortage ratio will increase from 4 in 2017 to 23 by 2030, with a total national deficit of 139 160 physician jobs. By 2030, the West is forecasted to have the greatest physician shortage ratio (69 physician jobs per 100 000 people), while the Northeast will have a surplus of 50 jobs per 100 000 people.
Conclusion:
There will be physician workforce shortages throughout the country in 2030. Outcomes of this study provide a foundation to discuss effective and efficient ways to curb the worsening shortage over the coming decades and meet current and future population demands. Increased efforts to understand shortage dynamics are warranted.
As medical education has become increasingly globalised, universities across the world have sought to raise standards by partnering with well-established institutions and a number of different partnership models have emerged. This article describes an academic collaboration between University College London (UCL), UK, and Newgiza University (NGU), Egypt, to establish modern and innovative undergraduate medicine, dentistry, and pharmacy programmes delivered in Egypt. Academics from UCL and NGU co-developed programmes using established materials, assessments, and processes from the equivalent programmes at UCL. Dedicated project managers, regular steering group meetings, strong working relationships between project teams, and iterative curriculum and assessment development processes were important features of the success of this work. A multidisciplinary first semester included students across all 3 health care programmes. This promoted collaboration between academics at both institutions. Although UCL resources were the basis of this project, the different sociocultural, ethical, professional, and regulatory frameworks in Egypt have meant that a number of adaptations have been necessary, in both curricula and teaching content. Perhaps the most important factor underpinning the success of this project has been the mutual respect and sensitivity of academics and clinicians from both institutions.
Purpose:
Undergraduate medical education (UME) programs participate in accreditation with the belief that it contributes to improving UME quality and ultimately patient care. Linkages between accreditation and UME quality are incomplete. Previous studies focused on student performance on national examinations, medical school processes, medical school's organizational culture types, and degree of implementation of quality improvement (QI) activities as markers of the effectiveness of accreditation. The current study sought to identify new indicators of accreditation effectiveness, in order to better understand the value and impact of accreditation.
Method:
This qualitative study used an expert-oriented evaluation approach to identify novel markers of accreditation effectiveness. From March 2015 to March 2016, leaders and teachers at 16 of the 17 Canadian UME programs were invited to participate in interviews and focus group discussions aimed at identifying measures of accreditation effectiveness. Themes were extracted using the method of constant comparative analysis.
Results:
Sixty-three individuals from 13 (81%) medical schools participated. Eight themes were formulated: Student/graduate performance, UME program processes, quality assurance and continuous quality improvement, stakeholder satisfaction, stakeholder expectations, engagement, research, and UME program quality. The latter 5 themes have not been previously studied as measures of accreditation effectiveness. All themes appear applicable to accreditation of graduate medical education as well. A framework is proposed to guide future research on the impact of accreditation.
Conclusions:
Eight themes were generated, representing direct and indirect indicators of the impact of accreditation. The themes are integrated into a framework proposed to guide future research on the value of accreditation along the continuum of medical education.
Introduction: Medical schools increasingly offer curricula that specifically aim to prepare students for an international medical career. This is challenging as well as controversial: curriculum designers must balance specific local healthcare requirements with global health competencies doctors need in our globalised world. By investigating how international medical programme designers experience this balancing act, this study aims to contribute insights to the debate on local versus global medical education.
Methods: We conducted a multi-centre instrumental case study across three universities with international medical programmes in three countries. The study involved 26 semi-structured interviews with key curriculum designers recruited through purposive sampling. Additionally, we performed a curriculum document analysis. Data were thematically analysed within a multidisciplinary team.
Results: Participants described two profiles of international medical programme graduates: ‘a global physician’, equipped with specific competencies for international practice, and ‘a universal professional’, an overall high-level graduate fit for future practice anywhere. These perspectives presented different curriculum design challenges.
Conclusions: International medical programmes teach us how we can rethink graduate profiles in a globalising world. Yet, educational standardisation poses risks and securing equity in global health education is challenging, as is preparing students to be adaptable to the requirements of a rapidly changing future local healthcare context.
Background: In 2009, an International Working Group (IWG) on the Assessment of Professionalism began collaborating and published recommendations in 2011. Nearly a decade later the IWG reconvened to take stock of the state of practice and research in professionalism and the impact of the 2011 report.
Method: A bibliometric study identified all publications on assessment of professionalism since 2011, noting those that cited the original report. Articles were coded to identify the reason for citation and new trends in assessment. Bibliometric data were supplemented by discussion groups held at key international education meetings.
Results: Six-hundred publications on the assessment of professionalism were found in Google Scholar and 164 in Web of Science since 2011, of which 177 (30%) and 84 (50%) respectively cited the original IWG publication. English language publications were most common (83%), but there were articles in 13 other languages by authors from 40 countries. The report was cited commonly to justify attention to professionalism in general (41%), assessment of professionalism (38%) and to explore professionalism in different countries and professions (25%). A thematic analysis showed that of 9 research areas recommended in 2011, 7 of 9 categories were represented with a large increase in research across languages and cultures.
Conclusions: Though the assessment of professionalism remains a challenge the research base continues to grow, especially related to professionalism across cultures and languages, and a large percentage of publications cite the IWG recommendations. There remains a gap in research and writing about patients’ perspectives.
Since medical education programs in Korea and Japan seem to mutually influence each other, this review article provides a history of Japanese medical education, focusing on the way in which it influenced and was influenced by Korean medical education. In the late 19th century, the University of Tokyo established the core medical school, disseminating its scholarship and system to other medical schools. In the early 20th century, the balance between the quality and quantity of medical education became a new issue; in response, Japan developed different levels of medical school, ranging from imperial universities to medical colleges and medical vocational schools. After World War II, all of Japan’s medical schools became part of the university system, which was heavily regulated by the Ministry of Education (MOE) Standard for the Establishment of Universities. In 1991, MOE deregulated the Standard; since 2000, several new systems have been established to regulate medical schools. These new approaches have included the Model Core Curriculum, 2-year mandatory postgraduate training, and a medical education accreditation system. Currently, most medical schools are nervous, as a result of tighter regulatory systems that include an accreditation system for undergraduate education and a specialty training system for postgraduate education.
Objective
To review the current status of departments of medical education in all public and private medical colleges located in the city of Lahore, Pakistan.
Methods
This was a quantitative, cross sectional descriptive study; conducted from March to October 2015 in Pakistan Medical & Dental Council (PM&DC) recognized medical colleges located in Lahore, Pakistan. Respondents were the heads of departments of medical education or any other well-informed faculty member. A questionnaire was prepared to obtain information about the current status of the departments of medical education (DMEs). The investigator personally visited all medical colleges for data collection. Both verbal and written consents were obtained and the questionnaire was administered to the resource persons. The data was organized and entered in SPSS for descriptive analysis.
Results
Out of the 18 medical colleges in Lahore, six (33.3%) belonged to public sector and 12 (66.7%) were from private sector. All medical colleges reported to have a functional DME. However, eight had established DMEs during the past five years. Only one (5.6%) head of DME was working on full-time basis. Eleven (61.1%) heads of DMEs did not have any formal qualification in medical education. Eight (44.4%) colleges claimed to have adequate human resources for DME. Thirteen (72.2%) colleges mentioned that adequate financial resources were available for running DMEs. It is encouraging to see that DMEs in private sector medical colleges are playing increasingly significant role in managing educational activities. Similarly, the senior management of private sector seems to be relatively more eager to promote educational activities.
Conclusion
There is an increasing recognition towards establishing DMEs in the medical colleges, but their infrastructure, proper functioning and availability of human and financial resources are serious impediments requiring immediate attention.
The main goal of medical education is to provide improved health to all.1 To work towards this goal and to enhance the quality of medical education, the World Medical Association (WMA) and the World Health Organization (WHO) established the World Federation for Medical Education (WFME) in 1972.2 It works to achieve its main goal by promoting high quality by initiating new learning methods, new instructional tools, and innovative management of medical education for almost 10 million physicians and students.1,3
To make sure that competencies of doctors are globally accepted, it is necessary to have readily accessible and transparent documentation of the quality of educational institutions and their programmes.1 In this context, WFME Global Standards, both basic and quality improvement standards (which are a global expert consensus), cover all three phases of medical education.2 These are basic medical education (comprising of 106 basic standards, 90 quality development standards and 127 annotations); postgraduate medical education (comprising of 161 basic standards, 94 quality development standards and 123 annotations); and continuing professional development (comprising of 76 basic standards, 62 quality development standards and 80 annotations). 2 The focus of this editorial, however, will be basic medical education
Background:
National licensing examinations (NLEs) are large-scale examinations usually taken by medical doctors close to the point of graduation from medical school. Where NLEs are used, success is usually required to obtain a license for full practice. Approaches to national licensing, and the evidence that supports their use, varies significantly across the globe. This paper aims to develop a typology of NLEs, based on candidacy, to explore the implications of different examination types for workforce planning.
Methods:
A systematic review of the published literature and medical licensing body websites, an electronic survey of all medical licensing bodies in highly developed nations, and a survey of medical regulators.
Results:
The evidence gleaned through this systematic review highlights four approaches to NLEs: where graduating medical students wishing to practice in their national jurisdiction must pass a national licensing exam before they are granted a license to practice; where all prospective doctors, whether from the national jurisdiction or international medical graduates, are required to pass a national licensing exam in order to practice within that jurisdiction; where international medical graduates are required to pass a licensing exam if their qualifications are not acknowledged to be comparable with those students from the national jurisdiction; and where there are no NLEs in operation. This typology facilitates comparison across systems and highlights the implications of different licensing systems for workforce planning.
Conclusion:
The issue of national licensing cannot be viewed in isolation from workforce planning; future research on the efficacy of national licensing systems to drive up standards should be integrated with research on the implications of such systems for the mobility of doctors to cross borders.
The aim of this paper is to overview the concepts and global trends of quality assurance in medical educationthrough accreditation systems based on internationally embraced standards, the efforts to have an oversightprocess of quality at global level while maintaining a frm commitment to the position that accreditation is anational matter requiring adaptation of the generic global standards to the national context. It also providesan update on international registries of medical schoolsIt mainly targets the medical education community in Sudan and the decision-makers in medical educationto create awareness of the challenges of ensuring and sustaining quality in medical education in Sudan inthe face of expanding number of medical schools. Such efforts are empowered by the recognition of SudanMedical Council (SMC) by the World Federation for Medical Education (WFME) as a national accreditingbody after fulflling the WFME requirements in June 2018 .The overview is to alert the decision-makers and medical schools to the basic concepts on which they willbe held accountable to the community and the stakeholders and highlights the challenges to maintain thisglobal recognition.The paper is based on overviewing key publications addressing the concepts and updates of accreditationstandards and the global vision for a robust global oversight on quality of medical education (1-5 &10) andthe need for international registries in an increasingly expanding number of medical education institutionsand globally mobile medical and health task force.
Background
Medical school accreditation is recognized internationally as an important quality control process for programs that lead to the Medical Doctor (MD) degree. Accreditation standards govern the accreditation process which in turn drives educational objectives. Given the power of these standards to shape what becomes valued in the curricula, it is therefore imperative to ensure that core values and ideals of the profession are meaningfully incorporated. As the provision of compassionate care has long been a central medical value, this value should be clearly articulated in MD program accreditation standards.
Methods
We conducted a Critical Discourse Analysis of compassionate care within Undergraduate Medical Education (UME) Accreditation Standards governing North American medical schools since 1957. We explored how and to what extent the written language of the accreditation standards incorporated compassionate care.
Results
References to compassionate care in the UME Accreditation Standards were few and far between. Historically, a statement of “The Objectives of Undergraduate Medical Education” published by the Association of American Medical Colleges (AAMC) was referenced for the first and only time in the 1957 standards, describing the development of attributes such as the provision of compassionate care as a basic objective of UME. Thereafter, there was infrequent mention of this value. Terms that could potentially incorporate aspects of compassionate care were identified, yet these were explicated in ways that limited connection to compassion. Instead, the term “care” has increasingly been used instrumentally (i.e. acute care, chronic care).
Conclusion
The relative absence of language pertaining to compassionate care in accreditation standards is troubling as compassion is integral to good medical care. This absence is particularly important to attend to in the current era of competency‐based training where we must be explicit about all important curricular objectives lest essential values and practices be unintentionally lost.
Background:
Like many Chinese universities, Ningbo University (NBU) has two undergraduate medical courses - one taught in Mandarin for domestic students, and one taught in English for international students. This study examines the experiences of medical students who recently completed the English language program that has a particular focus on clinical placements.
Methods:
In-depth, face-to-face, semi-structured interviews were conducted with 10 final year medical students at NBU in April 2019. Transcripts were analyzed using inductive thematic analysis.
Results:
All medical student participants were non native English speakers and had a limited grasp of Chinese. Their clinical teachers were all fluent in Chinese and had variable command of English. The large majority of patients in the teaching hospitals where placements took place spoke only in Chinese. Despite the obvious challenges arising from this, students still had predominantly positive experiences of clinical placements. Although students recognized that their clinical teachers' English proficiency was variable, they felt that other attributes, such as enthusiasm, interactivity, and a desire to teach were more important factors to their learning experiences.
Discussion:
Despite challenging linguistic circumstances, non native English-speaking students were able to navigate the challenges of studying clinical medicine from teachers with limited English language skills and with patients who spoke virtually no English. Further studies should explore the perceptions of teachers of the program, and graduate outcomes when these students enter the workplace. Educators involved in supporting international medical students should note that non technical curricular areas such as professionalism may require greater attention where language barriers exist.
COVID‐19 has disrupted medical education on an international scale with clinical attachments cancelled, assessments and teaching moved online, and numerous universities graduating their final year medical students early to assist pressured health systems. As a result, several innovative educational projects and volunteering opportunities have been established to help care delivery and enhance remote medical education.
Certification by the Educational Commission for Foreign Medical Graduates (ECFMG®) is required for international medical graduates (IMGs) to enter U.S. graduate medical education (GME). As a gatekeeper to the U.S. health care system, ECFMG has a duty to verify that these individuals have met minimum standards for undergraduate medical education. Historically, ECFMG has focused on evaluating individual graduates, not medical schools. However, in response to the rapid growth of medical schools around the world and increasing physician migration, ECFMG decided in 2010 to institute medical school accreditation as a future requirement for ECFMG certification. More specifically, beginning in 2023, individuals applying for ECFMG certification will be required to be a student or graduate of a medical school that is accredited by an agency recognized by the World Federation for Medical Education (WFME). By requiring accreditation by an agency that has met WFME's standards, ECFMG seeks to improve the quality, consistency and transparency of undergraduate medical education worldwide. The 2023 Medical School Accreditation Requirement is intended to stimulate global accreditation efforts, increase the information publicly available about medical schools, and provide greater assurance to medical students, regulatory authorities, and the public that these future physicians will be appropriately educated.
Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 nonphysician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education and cannot mitigate the shortfall of 112,000 physicians expected in 2030.
To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents’, or there could be a token amount for this “internship.” Both models decrease the cost of medical education; the second financially unburdens the hospital.
Since the Flexner Report (when there was no formal postgraduate training), the end point of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors.
The 2010 announcement by the Education Commission for Foreign Medical Graduates, related to accreditation by the World Federation for Medical Education, accelerated medical education reform in Japan. This article reviews reports on reforms undertaken in undergraduate medical education in psychiatry in Japan after 2010, and discusses resulting implications. While Japanese medical education has made significant progress, achieving global standards in less than a decade, there remain issues related to utilisation of active learning – inclusion of self-directed learning, problem-based learning, team-based and small group learning, and clinical training – as well as the provision of opportunities for students to be involved in certain medical procedures, and the integration of behavioural and social sciences, including communication skills, decision making, medical ethics, medical psychology, and general health promotion perspectives. These issues imply considerable paradigm shifts for psychiatry in Japan. It remains to be seen whether these progressive perspectives in undergraduate education can be effectively incorporated into postgraduate training, as well. There is also an issue of balance with specific important areas. The question of how undergraduate education in psychiatry in Japan can assimilate issues relevant to the practice of psychiatry in Japan, while ensuring conformity with high-level global standards, remains a serious challenge.
Purpose:
To summarize the state of evidence related to undergraduate medical education (UME) accreditation internationally, describe from whom and where the evidence has come, and identify opportunities for further investigation.
Method:
The authors searched Embase, ERIC, PubMed, and Scopus from inception through January 31, 2018, without language restrictions to identify peer-reviewed articles on UME accreditation. Articles were classified as scholarship if all Glassick's criteria were met and non-scholarship if not all were met. Author, accrediting agency, and study characteristics were analyzed.
Results:
Database searching identified 1,379 non-duplicate citations, resulting in 203 unique, accessible articles for full text review. Of these and with articles from hand searching added, 36 articles were classified as scholarship (30 as research) and 85 as non-scholarship. Of the 36 scholarship and 85 non-scholarship articles, respectively, 21 (58%) and 44 (52%) had an author from the United States or Canada, 8 (22%) and 11 (13%) had an author from a low- or middle-income country, and 16 (44%) and 43 (51%) had an author affiliated with a regulatory authority. Agencies from high-income countries were featured most often (scholarship: 28/60, 47%; non-scholarship: 70/101, 69%). Six (17%) scholarship articles reported receiving funding. All 30 research studies were cross-sectional or retrospective, 12 (40%) reported only analysis of accreditation documents, and 5 (17%) attempted to link accreditation with educational outcomes.
Conclusions:
Limited evidence exists to support current UME accreditation practices or guide accreditation system creation or enhancement. More research is required to optimize UME accreditation systems' value for students, programs, and society.
The purpose of this qualitative study was to explore the role of online communities and the impact of educational social media on 14 Saudi female college students who were studying in the United States. The findings revealed that social media was important to the participants for maintaining relationships and seeking out information from others. Social media was also an important way for participants to remain close to their communities and keep in contact with Saudi friends and family; however, the use of social media to interact with their communities was often shaped by Saudi cultural expectations. Most of the participants enjoyed online education and interacting with others in an online educational setting because it promotes collaborative learning and cultural interaction. Overall, social media used for educational purposes was mostly seen by the participants as a positive and beneficial part of their educational experiences.
The purpose of this study was to investigate the performance of graduates of international medical schools who seek Educational Commission for Foreign Medical Graduates certification based on accreditation of their medical education programmes. For the self-selected population who took United States Medical Licensing Examinations during the study period (2006–2010), accreditation was associated with higher first-attempt pass rates on some examinations, especially for international medical graduates from schools located in the Caribbean region. In addition, certain essential accreditation standards were associated with better performance on all examinations. This study lends support to the value of medical education accreditation.
Building on the work of others, this article sketches out what a Foucauldian ‘education’ might look like in practice, considers some of the challenges, paradoxes and (im)possibilities with which such an ‘education’ would face us, and indicates some of the cherished conceits and reiterated necessities that we must give up if we take seriously the need for an education that fosters an orientation to critique and curiosity. Three elements of Foucault’s ‘philosophical ethos’ that might be translated into educational practices are addressed: first, fostering a learning environment that encourages experimentation; second, enabling the development of an awareness of one’s current condition as defined and constructed by the given culture and historical moment; and, third, encouraging an attitude or disposition to critique – a focus on the production of particular sorts of dispositions that would be valued and fostered. All of this raises issues about ‘the teacher’.
Background: In 2003, the World Federation for Medical Education (WFME) published the Trilogy of Global Standards for Quality Improvement of Medical Education, covering all three phases of education in medicine. The intention was to provide an instrument to be used by medical schools and responsible authorities in quality assurance and improvement of medical education. The standards were revised in 2015.
Results: This paper reviews 29 published articles dealing with the practical use and analysis of the standards. 21 papers deal with basic medical education, six with postgraduate medical education and two with CPD.
Conclusion: It is concluded that using the WFME standards can be a profitable endeavor with documented impact. Standards should be used as intended, i.e. as a template modified with local specifications.
The Educational Commission for Foreign Medical Graduates (ECFMG) has a distinguished history of providing innovative and high-quality products and services to international medical graduates (IMGs) seeking to study and practice medicine in the United States. In 2010, the ECFMG board introduced a policy stating that, starting in 2023, all IMGs applying to the ECFMG for credentialing must have graduated from a medical school that has been accredited by an internationally recognized accrediting body akin to the Liaison Committee on Medical Education in the United States or the World Federation for Medical Education. In this issue of Academic Medicine, Tackett reviews the reasons for the policy and its adoption worldwide. After eight years, the number of schools meeting the new standard is modest. He is concerned about the negative effect that a continuing low rate of adoption will have on U.S. post-graduate medical education programs and workforce supply. The author of this commentary offers three perspectives: an overview of the ECFMG's successes, alternative measurement tools to ensure the quality of IMGs entering the United States, and frameworks by which an organization like the ECFMG can refine its policy positions and processes for the future. Academia can expect the ECFMG, given its history of successful collaboration and public accountability, to continue using best practices and to adjust policies based on evidence. As a publicly accountable authority, the ECFMG should brief key stakeholders on current policies, track IMG practice patterns, and share the resulting data with stakeholders to inform their IMG-related planning decisions.
In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG, Philadelphia, Pennsylvania) announced that, beginning in 2023, graduation from a formally accredited medical school would be necessary for an international medical graduate (IMG) to be eligible for ECFMG certification. The announcement is notable since ECFMG certification is required for graduate medical training and practice in the United States. Graduating from a school accredited by an agency formally recognized by the World Federation for Medical Education (WFME), which has been formally evaluating and recognizing accrediting agencies since 2012, would fulfill the new ECFMG requirement. In 2015, ECFMG applicants came from 1,141 medical schools located in 139 countries or territories. As of December 2018, the WFME had formally recognized 14 accrediting agencies, which would cover only approximately a third of these recent ECFMG-certified IMGs. In this Perspective, the author compares the context of the original ECFMG announcement to the beginning of accreditation in the United States so as to provide insight into the challenges the WFME faces as it seeks to evaluate and recognize what could ultimately be over 100 more accrediting authorities. The author then explores the possible effects of the requirement-specifically its potential to restrict the ECFMG applicant pool-on the quantity and quality of the U.S. physician workforce. The author ends the Perspective by considering the implications of three broad policy options that the ECFMG could consider starting in 2023: implementation as announced, maintenance of the status quo, or a policy modified from the original announcement.
Objective: To borrow a public health concept, there has been a global outbreak, perhaps a pandemic, of new medical schools during the last 20 years, resulting in a diverse range of programs in many different contexts. The question posed was: how should the task of establishing a new medical program be approached in 2018?
Methods: Based on involvement with several new medical programs, this paper presents a highly idealistic commentary on what a new medical program might look like. The paper adopts the organizational structure of the World Federation of Medical Education Basic Medical Education standards as a scaffold, because accreditation both locally and globally is intended.
Results: The program design reflects both progress in learning technology and the challenges faced in a changing world, where disruption appears inevitable, and innovation may be necessary to produce the medical graduates needed to improve the health status of an expanding, ageing and ailing global population.
Conclusion: The program model described represents a combination of educational design, emerging technology and a focus on future health care needs.
Context
The tensions that emerge between the universal and the local in a global world require continuous negotiation. However, in medical education, standardization and contextual diversity tend to operate as separate philosophies, with little attention to the interplay between them.
Methods
The authors synthesise the literature related to the intersections and resulting tensions between standardization and contextual diversity in medical education. In doing so, the authors analyze the interplay between these competing concepts in two domains of medical education (admissions and competency‐based medical education), and provide concrete examples drawn from the literature.
Results
Standardization offers many rewards: its common articulations and assumptions promote patient safety, foster continuous quality improvement, and enable the spread of best practices. Standardization may also contribute to greater fairness, equity, reliability and validity in high stakes processes, and can provide stakeholders, including the public, with tangible reassurance and a sense of the stable and timeless. At the same time, contextual variation in medical education can afford myriad learning opportunities, and it can improve alignment between training and local workforce needs. The inevitable diversity of contexts for learning and practice renders any absolute standardization of programs, experiences, or outcomes an impossibility.
Conclusions
The authors propose a number of ways to examine the interplay of contextual diversity and standardization and suggest three ways to move beyond an either/or stance. In reconciling the laudable goals of standardization and the realities of the innumerable contexts in which we train and deliver care, we are better positioned to design and deliver a medical education system that is globally responsible and locally engaged.
Context
In recent years, point‐of‐care ultrasound (POCUS) has become a widely used clinical tool in a number of clinical specialties. In response, POCUS has been incorporated into medical curricula across the learning continuum, bolstered by enthusiastic appraisals of the technology's benefits for learners, clinicians and patients. In this project, we have sought to identify and understand the effects of dominant discourses influencing the integration of POCUS into medical education.
Methods
We conducted a Foucauldian critical discourse analysis (CDA) to identify and analyse discourses that legitimise and privilege the use of POCUS in medical education. We assembled an archive of 473 texts published between 1980 and 2017. Each article in the archive was analysed to identify frequently occurring truth statements (expressing concepts whose truths are unquestioned within particular discourses) that we used to characterise the major discourses that construct representations of POCUS in medical education.
Results
We identified three dominant discourses: (i) a visuo‐centric discourse prioritising the visual information as truth over other clinical data; (ii) a utilitarian discourse emphasising improvements in patient care; and (iii) a modernist discourse highlighting the current and future needs of clinicians in our technological world. These discourses overlap and converge; the core discursive effect makes the further elevation of POCUS in medical education, and the resulting attenuation of other curricular priorities, appear inevitable.
Conclusions
The three dominant discourses identified in this paper engender ideal conditions for the proliferation of POCUS in medical education through curricular guidelines, surveys of adherence to these guidelines and authoritative position statements. By identifying and analysing these dominant discourses, we can ask questions that do not take for granted the assumed truths underpinning the discourses, highlight potential pitfalls of proposed curricular changes and ensure these changes truly improve medical education.
Context:
Medical education has not been immune from forces for globalisation in the contemporary world. At the same time the social accountability of medical schools in addressing local health priorities has been emphasised. This paper explores the global-local tension in medical education through a careful selection of key overview papers.
Globalisation:
Globalisation in medical education has taken two main forms: economic and altruistic. The former includes licensing curricula, recruiting internationally and establishing 'offshore' schools or campuses. Altruistic collaborations focus on the spread of learning and educational innovations. Both forms bring benefits but have been subject to critique for their differential impact and focus on educational inputs rather than outputs.
Social accountability:
Social accountability requires medical schools to direct their activities to local priorities and to serving local health systems. Adoption of the principles of social accountability compels all medical schools to ask questions of their educational programmes and graduate outcomes. However, these are globally interdependent questions and are the intent of some well-known social accountability collaborations. It is naïve to think that adoption of a social accountability agenda by all medical schools would necessarily reduce global health inequity. A recent Australian example shows that workforce maldistribution, for example, is resistant to even high-level intervention.
Conclusions:
It is yet too early to fully accept that 'think global, act local can be turned on its head'. There is much research to be carried out, particularly on the outcomes and impacts of medical education. Establishing cause and effect is a challenge, as is determining whether globalisation or localisation can contribute to greater global health equity. If we are ever to resolve the global-local tension in medical education, we need more evidence on the outcomes of what we do, whether globally or locally inspired.
Context
Twitter is a social media platform on which users post very brief messages that can be rapidly communicated across wide geographical areas and audiences. Many doctors use Twitter for personal as well as professional communications and networking. The #TipsForNewDocs hashtag is used on Twitter to give advice to newly qualified doctors as they commence their careers. This study explores the nature and focus of such advice.
Methods
An analysis of Twitter activity containing the #TipsForNewDocs hashtag was performed using Symplur health care analytics software. Tweets sent during a peak 48‐hour period in 2016 (immediately preceding the first day of work for newly qualified UK doctors) were studied. The geographical locations and professional backgrounds of participants were categorised and the content of tweets was subjected to thematic analysis. During 1 and 2 August 2016, 661 unique #TipsForNewDocs tweets were posted. A total of 621 (94.0%) were posted by people in the UK; 522 (79.0%) were posted by doctors, and the remainder by allied health care professionals and patients.
Results
The majority of included tweets focused on aspects of professional development, improving personal or professional knowledge, particularly tacit knowledge, and developing ‘know‐how’. These aspects of professional knowledge have previously been described as fundamental to professional education and training. However, a significant subset of tweets focused on accelerating socialisation into the profession, an essential step in joining a professional community. The tweets relating to socialisation were often humorous and colloquial in nature.
Conclusions
Despite their brief and often jocular nature, #TipsForNewDocs tweets provided meaningful advice for newcomers to the profession, often focusing on tacit learning and professional socialisation. Hashtag‐driven enquiries can be a valuable and time‐efficient way of accessing and sharing tacitly held knowledge. Social media content analysis can provide valuable insights into key educational issues.