Lessons learned from six years of international administrations of the ECFMG's SP-based clinical skills assessment.

PURPOSE: The Educational Commission on Foreign Medical Graduates (ECFMG) conducted international clinical skills assessments (CSAs) to evaluate the readiness of foreign medical graduates to enter U.S. residency programs, to validate national medical examinations in other countries, and to introduce other countries to new methods of evaluating medical students. METHOD: The ECFMG conducted CSA studies in the United States, Israel, Spain (Madrid and Barcelona), Ukraine, and Brazil between 1989 and 1995. ECFMG staff worked with local teams in following a seven-phase implementation process. The CSAs were conducted in each country's native language, and clinical cases were translated from English and culturally adapted. A total of 636 examinees took a ten-station standardized patient-based examination. RESULTS: A comparison of test results indicated stable psychometric properties and similar patterns of relationships among test components across all six countries. In every country, physical-examination and patient-note mean scores were lower than were history-taking scores, indicating the possibility of common skill deficiencies. CONCLUSION: The successful completion of international CSA projects in six countries suggests that high-quality standardized CSA projects are feasible and can be implemented from long distances.

Women in US medicine: the comparative roles of graduates of US and foreign medical schools.

The feminization of US medicine has occurred historically through two separate phenomena: the increase in the number of female graduates of US medical schools and the in-migration of female graduates of foreign medical schools. Reported here are the findings regarding gender on specialty choice, employment setting, and specialty board certification of 55,031 and 191,723 graduates of foreign medical schools and US medical schools, respectively. Graduates of foreign schools were subdivided into those who were foreign-national international medical graduates (IMGs), naturalized US citizen IMGs, and native-born US citizen IMGs at the time of entry into the US medical system. Statistically significant differences between women and men as well as among groups of medical graduates were found, with women in each medical graduate group proportionately overrepresented in primary care specialties, underrepresented in medical and surgical specialties, and underrepresented in both solo practice and group practice settings. Foreign-national IMG women were especially overrepresented in pathology, radiology, and anesthesiology, and in certain employment settings such as public hospitals and the Veterans Administration. The findings provide a basis for further study of the causes and consequences of the observed differences.

International medical graduates in rural America: the 1987 distribution of physicians who entered the U.S. medical system between 1969 and 1982.

This study examines the differential location on Dec. 31, 1987, in nonmetropolitan U.S. counties of a cohort of international medical graduates (IMGs) (n = 246,754) certified by the Educational Commission for Foreign Medical Graduates between 1969 and 1982, and a matched group of U.S. medical graduates (USMGs). Analysis of counties grouped into categories of population size revealed disparities across certain U.S. census divisions. IMGs were distributed disproportionately in the West North Central and East South Central census divisions. The implications of the IMG presence in numerous rural counties is discussed from the perspective of recent policy proposals to reduce the number of IMGs in the United States.

Numbers of physicians and medical students in Europe and the United States.

The authors compared data from the early 1990s for physicians and medical students in the United States with data for those in 14 members of the European Union and 15 other European countries within the European region as defined by the World Health Organization. With a total population twice that of the United States, the European countries had three times the numbers of physicians and first-year students, and five and one-half times the number of applicants to medical schools. Europe has a higher density of physicians (an average of one physician for every 335 people) than the United States (one physician for every 472 people). Numbers of medical schools per million people are similar (1.8 versus 2.0), but the average first-year class size is larger in Europe (184 versus 136 students). There is approximately on first-year medical student per 10,000 people in Europe, compared with one per 15,000 people in the United States. It is likely that these ratios will remain the same, since both the United States and Europe have approximately one first-year medical student for every 30 practicing physicians, and the student admission policies of the individual countries appear to mirror the physician-population ratios. There is one applicant for every 2,125 people in Europe; the United States has one applicant for every 5,174 people. Further, Europe has 4.6 applicants for every place in the class, while the United States has 2.6. Finally, the authors provide detailed information about physicians and students in the countries surveyed.

Use of ECFMG certifying examinations for national comparisons: performance of graduates of Israeli medical schools in basic and clinical science examinations.

Examinations were used for comparison of Israeli medical school graduates. The two schools with traditional curricula had higher pass rates for first takers of Day 1 (68% and 61%, mean scores 76.6 and 76.4) than the community-based school (44%, mean score 74.5) and the technologically oriented school (40%, mean score 72.5). There were similar pass rates for traditional school first takers of Day 2 (97% and 91%, mean scores 82.4 and 80.4) as for community-based school first takers (94%, mean score 80.1). The traditional schools and the community-based school demonstrated higher pass rates and mean scores for first takers of Day 2 than the technologically oriented school. Analysis of the time lapse between the basic science curriculum and taking the basic science examination reveals no trend in scores or pass rates. While the likelihood of better performance on Day 1 seems enhanced by traditional curricula, there is an equivalent performance on Day 2 by graduates of schools with traditional curricula.

Pilot study of the use of the ECFMG clinical competence assessment to provide profiles of clinical competencies of graduates of foreign medical schools for residency directors. Educational Commission for Foreign Medical Graduates.

PURPOSE: To conduct the first of a series of pilot projects of the clinical competence assessment (CCA) of the Educational Commission for Foreign Medical Graduates (ECFMG) in order to provide profiles of clinical competencies of graduates of foreign medical schools for residency directors in the United States and for governments and institutions in other countries. METHOD AND RESULTS: In September 1992 the first pilot project of the ECFMG CCA was conducted for a program director who wanted to evaluate ten first-year residents in a midwestern U.S. program. The CCA consists of integrated clinical encounters with ten standardized patients, 60 laser videodisc pictorials, and analysis of test items of previously completed ECFMG certification examinations. Profiles of the following clinical competencies were provided to the program director: data gathering (history and physical examination), interviewing and interpersonal skills, diagnosis and management skills, interpretation of diagnostic and laboratory procedures, written communication of information to the health care team, and spoken-English proficiency. The profiles were provided as individual scores compared with mean scores of a reference group of 525 first-year residents who took the CCA at four U.S. assessment centers, and as percentile scores with a range of one standard error of measurement. CONCLUSION: The individual performance data in this first pilot project were valuable to the program director, who used them to supplement scores on a written examination during the first residency year. The pilot project has shown the ECFMG CCA to be a useful tool for program directors to evaluate applicants and residents who are graduates of foreign medical schools.

ECFMG assessment of clinical competence of graduates of foreign medical schools. Educational Commission for Foreign Medical Graduates.

OBJECTIVE: To develop an assessment of clinical competence of graduates of foreign medical schools and to determine the reliability and validity of the assessment and the feasibility of large-scale administration. DESIGN: The Educational Commission for Foreign Medical Graduates (ECFMG) clinical competence study included (1) clinical encounters with standardized patients to assess history taking, physical examination, and communication skills; (2) laser videodisk pictorials to assess identification and interpretation of diagnostic procedures; (3) written clinical vignettes to assess diagnosis and management skills; and (4) assessment of spoken English. A uniform method of operating the test centers and of training the standardized patients was developed. SETTING: Medical schools and their primary teaching hospitals and affiliated hospitals. PARTICIPANTS: Six hundred twenty-four first-year residents, of whom 525 are graduates of foreign medical schools. MAIN OUTCOME MEASURES: Scores, reliability coefficients, validity measures, feasibility of multisite administration, trends of scores over time, and acceptability by examinees. RESULTS: The ECFMG clinical competence assessment was conducted at four geographically separate test centers. Reliability coefficients were high (.85) for the integrated clinical encounter and were in a reasonable range (.71 to .82) for all test components. The assessment adds to the predictability of the residents' performance in the hospital over that of current ECFMG certification examinations. Test security was addressed by demonstrating no consistent pattern of change in scores over testing dates. Virtually all examinees thought the assessment was appropriate. Standardized patients were able to assess spoken English accurately. CONCLUSION: The feasibility of conducting a reliable and valid test of clinical competence for graduates of foreign medical schools was demonstrated for this test population.

Influence of candidates' test selection on pass rates on examinations for certification by the Educational Commission for Foreign Medical Graduates.

BACKGROUND: Parts I and II of the National Board of Medical Examiners (NBME) examination were first offered to graduates of foreign medical schools in 1989 as an alternative to the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS). This study was designed to determine whether differences in pass rates and scores were related to differences in the populations selecting one or the other examination. METHOD: (1) Combined pass rates on the FMGEMS and NBME in 1989 and 1990 were compared with pass rates in previous years. (2) The proportion of NBME takers in 1989 was compared with the proportion in 1990. (3) Respective pass rates on the FMGEMS and NBME in the first NBME administration in 1989 were compared with pass rates in 1990. (4) The percentage of repeaters taking the FMGEMS was compared with the percentage taking the NBME in 1989 and 1990. (5) The distribution of repeaters by number of previous takes was compared between the FMGEMS and NBME in 1989 and 1990. RESULTS: (1) Combined pass rates were similar to the pass rates of previous years. (2) The proportion of NBME takers declined in 1990. (3) The pass rates for the FMGEMS were higher in both 1989 and 1990, but the difference in pass rates between the two examinations narrowed in 1990. (4) The percentage of repeaters taking the NBME was high in 1989 and declined in 1990. (5) The number of previous takes among repeaters was higher for the NBME than for the FMGEMS in 1989 and became equal in 1990. CONCLUSIONS: Some students probably opted to take the NBME in 1989 in the belief that it might be easier than the FMGEMS, resulting in lower pass rates for the NBME. The NBME pass rates rose in 1990 after the differential pass rates had become public.

Hepatitis and hepatocellular carcinoma in Southeast Asia.

Scientists of several countries in Southeast Asia are exchanging information on research efforts on hepatocellular carcinoma under the sponsorship of the World Health Organization. It was agreed to direct preventive measures to hepatitis B virus and aflatoxins, but research should be continued on viruses, parasites, hepatotoxins of plant organisms, food contaminants, and drugs. Preventive measures include 1) blood transfusion services, 2) other transmission controls, 3) food hygiene, and 5) the establishment of pilot projects for the study of the efficiency of control measures. International collaboration and adequate data exchange are necessary for the successful continued pursuit of knowledge in chronic liver diseases in the countries of Southeast Asia, with the goal of prevention of debilitating and fatal diseases among a large segment of the world's population.

Comparison of performances of transfer students and first-year acceptees.

Graduates of the Medical College of Pennsylvania during 1970-1977 were studied to determine the impact of three types of preclinical training on prelicensure clinical performance. The 586 students who comprised these groups consisted of 471 students admitted to the first year, 53 students admitted with advanced standing from U.S. medical or graduate programs, and 62 students admitted with advanced standing from foreign medical schools. Academic performances among the groups differed as measured by scores on the examinations of the National Board of Medical Examiners. However, perceived clinical performances of both transfer groups, as measured by honors awarded in year four and by first-year residency evaluation, were on a par with that of the original matriculants.