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Accreditation of foreign medical schools-good idea, or not?

The Educational Commission for Foreign Medical Graduates has announced that it will require accreditation of medical schools attended by all international medical graduates (IMGs) who seek ECFMG certification beginning in 2023.

The ECFMG believes this requirement will improve international medical education, leading to higher quality health care and enhanced protection of the public. The long time frame for implementation of this new requirement allows time for one or more entities to undertake the process of accrediting the world's 2,000 international medical schools.

Currently, IMGs must pass the USMLE to receive an ECFMG certificate and enter US GME programs.
We asked the readers of the AMA’s GME e-Letter their opinions on this new requirement and received the following feedback.

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I think it's "about time," and it's unfortunate it's not effective until 2023.

In addition, the English portion of the ECFMG test needs to be more stringent. Some IMGs can't speak English very well. There are also interpersonal communications issues with patients, secretaries, and desk personnel.

Put the lack of language/interpersonal skills together with cultural concerns, and mix that with lack of English medical terminology, and we're asking for mistakes in dictation, etc. It's so much more than just an exam score.

I believe that this decision was made entirely with the goal of improving the quality of applicants for US GME.

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I think this is a very good idea and long overdue. It makes it much easier for all of us recruiters to give the candidate concrete reasons why they may not fit the criteria.

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I am concerned that this requirement will only serve to further limit the ability of IMGs to come to the US and will also unduly punish the strong individual candidate that may come from a "non-accredited" school. Those schools that accept a large number of American citizens will probably be motivated to obtain the required accreditation, but what would be the motivation for other schools/countries? Schools without American students might just as well not want their graduates to leave the country for the US and would balk at additional regulations being imposed on them (regulations that are essentially being dictated by the US and that, if implemented, would continue to allow the best and brightest of their medical graduates to leave the country). So, this new regulation has the potential side effect of limiting the diversity of IMGs coming to this country.
 
I also think it is curious that this new regulation is being rolled out shortly after publication of one of the very first studies showing no difference in patient outcomes between US graduates and IMGs (Norcini JJ, et al. Evaluating the quality of care provided by graduates of international medical schools. Health Affairs 2010;29:1461-68).
 
Instead of increased regulatory oversight of foreign medical schools, perhaps what is needed are better programs to assimilate IMGs into the US system of health care (e.g., the IMG Acculturation Network, or IAN, of the ECFMG). Structured one-year, pass/fail observerships and clerkships can also be useful. Such programs put the burden of proof on the individual IMG rather than assuming that all graduates of an "accredited" school are worthy of entering US GME.
 
The US has a long history of welcoming IMGs to this country—and from all countries—and we should not be putting up barriers that medical schools in other countries may find paternalistic, intrusive, or exclusionary.
 
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This is a laudable idea but will have unintended consequences. The only medical schools that would seek such accreditation would be those that have been established as commercial for-profit entities—many of which are in the Caribbean. The schools that are generally good have no reason to seek accreditation, as their governments would prefer that their graduates stay in their country. So we will be left with substandard schools that will use this accreditation status to recruit students. In balance, it will be harmful.

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I think this is a great idea. I’d also suggest that ECFMG limit the number of examination attempts for IMGs and not make ECFMG certification available for those who graduated more than 10 years prior.

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I believe that this is not necessary, it will be a cost burden—and, who is "subpar?" Maybe "subpar" by American standards, but not by other schools’ standards. This also assumes that the US will continue to be a haven for medical migration, but the world is evolving quickly and soon IMGS may prefer to stay and practice in their own countries.

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Why wait till 2023? To solve problems of incompetence and inadequate training of international graduates, the ECFMG may have to request that foreign medical schools be accredited right away,

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I am in favor of the approach, and the long-term implementation plan will allow the accrediting body time to develop standards.

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This requirement is long overdue and needs to be moved forward expeditiously. Waiting until 2023 for this requirement to become operational seems unnecessary. I would suggest that the ECFMG consider moving the deadline up to permit a five-year window of opportunity for accreditation, beginning in 2012, with an appeals process that can grant waivers of extension for an additional two to three years, based on compelling evidence of extenuating circumstances.

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As someone who has been working to help US medical students and international students and graduates prepare for the USMLE examinations for nearly 30 years, I can appreciate the intent behind this new requirement.

It seems likely, however, that this will merely add to the difficulty of many IMGs whose medical schools will refuse to undergo the new ECFMG accreditation process. Medical schools in the Caribbean may be willing because they are profit-motivated and realize that if they don't pass muster they will soon attract fewer students. But many medical schools around the world will have little motivation to submit to this process and will probably resent it, seeing it as one more instance of a US attitude that our way is the only way.

For those whose schools refuse, the hope of obtaining residency training or of ultimately being able to practice in the US will be gone. This policy seems very short-sighted to me as well, given the frighteningly large estimates of the physician shortage the US is facing within the coming decades. What might make more sense is to impose the proposed accreditation process on foreign medical schools only when the USMLE passing rates of their students falls below a certain value. This would limit the potentially negative impact on the licensing and residency training opportunities of non-Caribbean medical graduates while still incentivizing the institutions with a poor track record to improve their curricula.
 
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This doesn't make sense. The data show the examination is a good screen, regardless of the applicant’s medical school. The system works. Accreditation of foreign schools sounds like a huge expense and an unnecessary bureaucracy.

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Accreditation for foreign medical schools? Sounds imperialistic to me.

Who are we to say that one or another medical school is or should be accredited? The University of Montpelier, or Bologna, for instance, have had medical schools for centuries. It is inappropriate for the US to demand their accreditation, by American standards. The individual medical student, soon-to-be doctor, must have the responsibility of showing that he knows his stuff.

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This will be a great help to all of us in training programs who have difficulty assessing the viability of international medical school graduates.
 
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Long overdue!

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I believe having all foreign medical schools accredited will be extremely beneficial to all residency programs and ultimately the future of medical care.
Having screened IMGs for years, I have come to learn that USMLE scores do not always tell the true story of the resident and their academic knowledge. I believe this process will truly weed out the subpar medical students and allow entrance to those who have the ability to be great students and physicians.