Educational Commission for Foreign Medical Graduates

The Educational Commission for Foreign Medical Graduates (ECFMG) has a distinguished history of providing high-quality, innovative 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 a continuing low rate of adoption will have on U.S. postgraduate medical education programs and workforce supply. The author of this Invited 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 according to evidence. As a publicly accountable authority, the ECFMG should debrief key stakeholders on current policies, track IMG practice patterns, and share the resulting data with stakeholders to inform their IMG-related planning decisions.

BackgroundTo describe the supply, distribution, and characteristics of international medical graduates (IMGs) in family medicine who provide patient care in the U.S.MethodsA cross-sectional study design, using descriptive statistics on combined data from the Educational Commission for Foreign Medical Graduates and the American Medical Association, including medical school attended, country of medical school, and citizenship when entering medical school.ResultsIn total, 118,817 physicians in family medicine were identified, with IMGs representing 23.8% (n = 28,227) of the U.S. patient care workforce. Of all 9579 residents in family medicine, 36.0% (n = 3452) are IMGS. In total, 35.9% of IMGs attended medical school in the Caribbean (n = 10,136); 19.9% in South-Central Asia (n = 5607) and 9.1% in South-Eastern Asia (n = 2565). The most common countries of medical school training were Dominica, Mexico, and Sint Maarten. Of all IMGs in family medicine who attended medical school in the Caribbean, 74.5% were U.S. citizens. In total, 40.5% of all IMGs in family medicine held U.S. citizenship at entry to medical school. IMGs comprise almost 40% of the family medicine workforce in Florida, New Jersey and New York.ConclusionsIMGs play an important role in the U.S. family medicine workforce. Many IMGs are U.S. citizens who studied abroad and then returned to the U.S. for graduate training. Given the shortage of family physicians, and the large number of IMGs in graduate training programs, IMGs will continue to play a role in the U.S. physician workforce for some time to come. Many factors, including the supply of residency training positions, could eventually restrict the number of IMGs entering the U.S., including those contributing to family practice.

Locomotion during ascent requires higher energy consumption than on flat terrain. Locomotion efficiency decreases in snowy terrain, with changes in the biomechanical pattern of walking. This study aims to evaluate differences in both cardiorespiratory responses and energy expenditure between locomotion over snowy terrain with an established footstep pathway (FP) and fresh snow (FS) that has not previously been compacted. Fifteen volunteers with experience in mountain activities at a competition level and a regular training schedule of up to 10 hours a week participated in the study. Estimated maximal theoretical oxygen consumption showed a mild increase (2.6%, 95% confidence interval: 0.9%-4.5%, t = 3.2, p = 0.005) when subjects followed the FP compared with FS. More time was necessary to complete locomotion in FS (256 ± 30 seconds) than FP (225 ± 29 seconds; p = 0.01). Uphill walking velocity increased by 0.43 ± 0.11 km/h (t = 4.2, p = 0.01) in FP compared with FS; and the FS respiratory rate was higher (by 2.3 ± 2.4 beats/min, t = 4.0, p = 0.001). For a same itinerary, locomotion in snow that has not been compacted before requires more time and represents a higher energetic cost, either at maximal or submaximal intensities. This should be considered in scheduling mountain ascents as part of the safety strategies. Climbing on virgin snow impedes developing maximal aerobic power, so athletes must regard the value of strength work of lower limbs to improve performance. Indirect calculation of maximal oxygen consumption based on time to complete locomotion in FP can have practical application as a field test.

Although the authors do not agree with medical students' bid to end the United States Medical Licensing Examination Step 2 Clinical Skills or Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation tests, they concur with Ecker and colleagues that conducting further research to support the validity argument, providing greater feedback on performance, and exploring options to reduce costs are important for addressing students' concerns. Evidence to support the validity of clinical skills exam scores and associated inferences already exists. What is lacking, and would help further justify the use of these examinations, is more evidence to support the "extrapolation" argument-that is, is performance on these examinations related to actual patient care? Enhanced feedback on exam performance should also be considered. While performance data from licensing examinations should be used judiciously given the primary purpose of these tests, additional data would be helpful to learners and their institutions. Centralized testing remains the least costly design, but efficiencies of standardized patient training, case development, and scoring can be reviewed. Scoring modifications made in the past several years at substantial cost should be evaluated to determine whether they have achieved desired goals. Testing organizations can and should embrace these essential elements of transparency and accountability to address concerns about the value of clinical skills examinations.

Previous studies on standardized patient (SP) exams reported score gains both across attempts when examinees failed and retook the exam and over multiple SP encounters within a single exam session. The authors analyzed the within-session score gains of examinees who repeated the United States Medical Licensing Examination Step 2 Clinical Skills to answer two questions: How much do scores increase within a session? Can the pattern of increasing first-attempt scores account for across-session score gains? Data included encounter-level scores for 2,165 U.S. and Canadian medical students and graduates who took Step 2 Clinical Skills twice between April 1, 2005 and December 31, 2010. The authors modeled examinees' score patterns using smoothing and regression techniques and applied statistical tests to determine whether the patterns were the same or different across attempts. In addition, they tested whether any across-session score gains could be explained by the first-attempt within-session score trajectory. For the first and second attempts, the authors attributed examinees' within-session score gains to a pattern of score increases over the first three to six SP encounters followed by a leveling off. Model predictions revealed that the authors could not attribute the across-session score gains to the first-attempt within-session score gains. The within-session score gains over the first three to six SP encounters of both attempts indicate that there is a temporary "warm-up" effect on performance that "resets" between attempts. Across-session gains are not due to this warm-up effect and likely reflect true improvement in performance.

Background: High stakes medical licensing programs are planning to augment and adapt current examinations to be relevant for a two-decision point model for licensure: entry into supervised practice and entry into unsupervised practice. Therefore, identifying which skills should be assessed at each decision point is critical for informing examination development, and gathering input from residency program directors is important.Methods: Using data from previously developed surveys and expert panels, a web-delivered survey was distributed to 3,443 residency program directors. For each of the 28 procedural and 18 advanced communication skills, program directors were asked which clinical skills should be assessed, by whom, when, and how. Descriptive statistics were collected, and Intraclass Correlations (ICC) were conducted to determine consistency across different specialties.Results: Among 347 respondents, program directors reported that all advanced communication and some procedural tasks are important to assess. The following procedures were considered ‘important’ or ‘extremely important’ to assess: sterile technique (93.8%), advanced cardiovascular life support (ACLS) (91.1%), basic life support (BLS) (90.0%), interpretation of electrocardiogram (89.4%) and blood gas (88.7%). Program directors reported that most clinical skills should be assessed at the end of the first year of residency (or later) and not before graduation from medical school. A minority were considered important to assess prior to the start of residency training: demonstration of respectfulness (64%), sterile technique (67.2%), BLS (68.9%), ACLS (65.9%) and phlebotomy (63.5%).Discussion: Results from this study support that assessing procedural skills such as cardiac resuscitation, sterile technique, and phlebotomy would be amenable to assessment at the end of medical school, but most procedural and advanced communications skills would be amenable to assessment at the end of the first year of residency training or later.Conclusions: Gathering data from residency program directors provides support for developing new assessment tools in high-stakes licensing examinations.To access the supplementary material to this article please see Supplementary Files under Article Tools online.

Background and Purpose: Questions remain about the congruence between students' written notes and checklists as summaries of encounters. Methods: Students examined standardized patients and summarized findings in postencounter notes. The patients completed checklists. A physician read the students' notes and completed parallel checklists to document the history and physical items performed. Rates of under- and overdocumentation were calculated. Results: Students documented findings for 71% of items performed—an underdocumentation rate of 29%. Approximately 94% of their documented findings were consistent with what they had done. Their rate of overdocumentation was 6%, in which they documented findings inconsistent with the checklists. About half the students had no instances of overdocumentation. Conclusion: Students' rate of underdocumentation was comparable to experienced clinicians. Although their overdocumentation rate was low overall, it was high for a few students. Evaluation of the congruence between checklists and postencounter notes provides useful information and informs checklist development.

Dieses Buch bietet einen allgemeinen Überblick über die verschiedenen Aspekte von Eigenschaften, Erzeugung, Speicherung und Anwendung von Wasserstoff auf Hochschulniveau. Schwerpunkte liegen auf der Thermodynamik der Speicherung von Wasserstoff sowie auf der Anwendung in der Verkehrstechnik und in der Energietechnik. Speziell wird die Anwendung in der Verbrennungskraftmaschine und in der Brennstoffzelle behandelt, wobei mit Bezug auf Forschungsvorhaben an der TU Graz und dem HyCentA der aktuelle Stand der Technik fundiert dargestellt wird. Neben einer technischen Vertiefung werden auch die geschichtliche und die mögliche künftige Entwicklung angesprochen.

Develop a scoring system that can assess the management of septic shock by individuals and teams. Retrospective review of videotapes of critical care house staff managing a standardized simulation of septic shock. Academic medical center; videotapes were made in a recreated intensive care unit environment using a high-fidelity patient simulator. Residents in medicine, surgery, and anesthesiology who had participated in the intensive care unit rotation. The septic patient was managed by the intensive care unit team in a graded manner with interns present for the first 10 mins and more senior-level help arriving after 10 mins. The intern was graded separately for the first 10 mins, and the team was graded for the entire 35-min performance. Both technical and nontechnical scoring systems were developed to rate the management of septic shock. Technical scores are based on guidelines and principles of managing septic shock. Team leadership, communication, contingency planning, and resource utilization were addressed by the nontechnical rating. Technical scores were calculated for both interns and teams; nontechnical scores applied only to the team. Of 16 technical checklist items, interns completed a mean of 7 with a range of 1.5-11. Team technical ratings had a mean of 9.3 with a range of 3.3-13. Nontechnical scores showed similar intergroup variability with a mean of 26 and a range of 10-35. Technical and nontechnical scores showed a modest correlation (r = .40, p = .05). Interrater reliabilities for intern and team technical scores were both r = .96 and for nontechnical scores r = .88. Objective measures of both knowledge-based and behavioral skills pertinent to the management of septic shock were made. Scores identified both adequate and poor levels of performance. Such assessments can be used to benchmark clinical skills of individuals and groups over time and may allow the identification of interventions that improve clinical effectiveness in sepsis management.