This paper discusses the information needs of regulators in the face of increasing globalization in medical education and practice, the history of information resources cataloging the world's medical education institutions, and the development of a tool that can fill an information gap concerning where and how physicians around the world are educated — the World Directory of Medical Schools. The World Directory was developed to meet the needs of medical regulators and other stakeholders who rely on specific data about medical schools and their educational programs. Its data model captures information about schools and programs as separate entities, allowing for greater flexibility and utility in the areas of regulation and workforce research.
Since 1953, a number of organizations have developed global medical school directories, available both in print and electronically.1 These resources have been used by medical regulatory authorities (MRAs) to assess the qualifications of physicians trained in other jurisdictions and by researchers tracking changes in the physician workforce supply. While the move from print to electronic media has made these resources more widely accessible, the format and structure of the data contained in these directories has limited their usefulness. Meanwhile, increasing globalization in health education and professional practice has made the need for current, well-structured data more necessary. In this paper, we describe the development of the data model for the World Directory of Medical Schools (commonly referred to as the World Directory) and how the schema better serves the needs of regulatory authorities, researchers, and other stakeholders in an increasingly global health care context.
Context: The Challenge of Globalization in Medical Education and Practice
Increases in both the globalization and mobility of health professionals has magnified concerns about the evaluation of medical qualifications obtained in countries with differing systems of education, health care, and professional regulation. These questions are of particular urgency in countries where international medical graduates (IMGs) represent a large proportion of applicants for registration or licensure. For example, IMGs make up approximately one quarter of licensed physicians in the United States,2 one third of hospital medical staff in the United Kingdom3 and over 40% of the physician workforce in New Zealand.4 Mobility also includes temporary migration of health professionals providing humanitarian aid, which can put additional pressures on overburdened regulators who must weigh the patient safety concerns of verifying physician qualifications with providing care that is urgently needed. The growth in use of telemedicine has raised concerns about health professionals providing care outside the jurisdictions in which they are licensed.5–7 Similarly, medical tourism raises a number of ethical and regulatory concerns for MRAs, both in establishing policies within their jurisdiction and in advising members of their communities who seek treatment outside their borders.8,9
All of these global trends, combined with the ever-increasing number of medical schools and physicians worldwide,10,11 highlight the need for improvements in information collection and sharing among MRAs and educational institutions. Drawing attention to this need are groups such as the International Association of Medical Regulatory Authorities (IAMRA), which advocates the “efficient and effective exchange of information between medical regulatory authorities about the physicians that they register, in the interests of the public.”12 Until recently, there has been little research on information systems for tracking human resources in health.13,14 As a growing number of MRAs begin to implement and extend such systems for tracking health professionals, the standardization of information collection and data formatting should be a priority. Standardized formatting of the data describing health professions education institutions will encourage a flow of data among regulators and will support efforts to gather health workforce statistics that are configured consistently across jurisdictions.
...INCREASING GLOBALIZATION IN HEALTH EDUCATION AND PROFESSIONAL PRACTICE HAS MADE THE NEED FOR CURRENT, WELL-STRUCTURED DATA MORE NECESSARY.
Context: The Challenges of Defining Medical Education
Though the field of health informatics is bringing attention to the area of human resource information systems for health,14 for such information systems to be useful on an international scale, we must understand the different systems in which physicians are educated and trained in different countries, the systems of licensure/registration, and the meaning of documents and underlying data used to provide evidence of competence or ability. Fundamental to an MRA's decision to grant access to the profession is evidence of completion of medical education.
Documents and Academic Titles
Documents such as diplomas and licenses can be used as evidence of completion of medical education, but provide little to no detail about the actual content of physicians' education, experience, or competencies. A medical school transcript may provide more information, but some institutions do not produce such documents. These documents may differ widely in format from country to country, making interpretation and comparison difficult or impossible.
The title of an academic qualification may have little meaning outside its national context. Depending on the country of origin and year in which it was issued, the primary medical qualification could be expected to be a bachelor's degree, a master's degree, a doctoral degree, or documentation of success on a national or state examination. Further, the same degree title may represent different levels and types of training in different countries. For example, a Doctor of Medicine degree is a primary qualification in the United States, but may be awarded to physicians upon completion of postgraduate clinical training in India or postgraduate research in the United Kingdom.15 The Bachelor of Medicine degree awarded in China may represent three to five years of education depending on when it was issued, and it may be awarded upon completion of an educational program in a discipline other than clinical medicine.16,17
...DIPLOMAS AND LICENSES CAN BE USED AS EVIDENCE OF COMPLETION OF MEDICAL EDUCATION, BUT PROVIDE LITTLE TO NO DETAIL ABOUT THE ACTUAL CONTENT OF PHYSICIANS' EDUCATION, EXPERIENCE, OR COMPETENCIES.
Diversity of Medical Education Models
The models and systems of medical education and entry to practice vary from place to place.18 The duration of a medical degree program may be between three and nine years in length, with entry at the post-secondary level or after award of a bachelor's degree. The proportion of the program spent training in a clinical setting may also vary, with some countries requiring variable periods of internship and/or social service either prior to the award of the medical degree or after. In some jurisdictions, the primary medical qualification may be awarded in a specific discipline (e.g., pediatrics) that is a postgraduate medical specialty in other parts of the world. Without an understanding of such international differences and changes over time, an academic degree document is insufficient means of determining whether an IMG's training is equivalent to that within an MRA's jurisdiction.
Background: History of Medical School Directories
In 1953, the World Health Organization (WHO) published the first edition of its World Directory of Medical Schools. This publication listed 567 medical schools, including bilingual (English and French) information about their location, date of foundation, admission requirements, language of instruction, duration of study, annual number of graduates, and tuition.1 Full details were available for schools in many countries, but only names and locations were available for most schools in countries such as China and the Union of Soviet Socialist Republics. Six subsequent and more comprehensive editions of the WHO directory were published, with the last edition in 2000 containing 1,642 schools in 157 countries and territories.19 After 2000, WHO provided occasional updates on their website when new information was received from United Nations member states, but there were no further systematic surveys conducted or complete editions of the directory published.
Around the time of the WHO's decision to discontinue the WHO directory, a number of other organizations took up the task of cataloging the world's medical schools. In 1999, the China Medical Board established the Institute for International Medical Education (IIME), which conducted a survey in 2000 and published an online global medical school directory. The IIME Database of Medical Schools contained contact information for over 1,800 schools, but is no longer available online.
The Geneva Foundation for Medical Education and Research (GFMER), established in 2002, also publishes an online directory of medical schools.20 Unlike other resources, the GFMER directory includes listings for national medical associations and related government agencies, and it provides country-level maps showing the location of each institution. However, the only detail given for each institution is a link to the school's or agency's website. Individual country pages of the GFMER directory are marked as having been last updated as recently as November 2016.
...MANY NATIONAL GOVERNMENT AGENCIES AND COUNCILS MAINTAIN THEIR OWN DIRECTORIES OF MEDICAL SCHOOLS, AND THESE VARY CONSIDERABLY IN THE TYPE OF INFORMATION GATHERED AND THEIR COVERAGE.
In 2002, the Foundation for Advancement of International Medical Education and Research (FAIMER) published its own online directory of medical schools — the International Medical Education Directory (IMED). This directory included details such as current and historical school names, location, language of instruction, curriculum duration, degree title awarded, and links to the websites for more than 2,500 schools. In 2008, the World Federation for Medical Education (WFME), in collaboration with WHO and the University of Copenhagen, published the Avicenna Directory of medical schools. The Avicenna Directory was intended as a continuation of the WHO Directory. It contained listings for over 2,000 schools, a portion of which included extensive information about affiliations, admission requirements, curriculum, facilities, faculty, enrollment, and other topics, collected through a detailed questionnaire distributed by WFME.
In 2012, WFME and FAIMER agreed to combine their resources and collaborate on a single directory, the World Directory of Medical Schools. The World Directory was first published online in April 2014 (at www.wdoms.org) and has replaced its predecessor directories, Avicenna and IMED. It is financed by international agencies — the directory's “sponsors” — that have roles in their countries' medical regulation or accreditation processes: the Australian Medical Council, the Educational Commission for Foreign Medical Graduates, the Medical Council of Canada, the Danish Health and Medicines Authority, and the Korean Institute of Medical Education and Evaluation. At the time of its launch, the World Directory contained records for 2,567 medical schools, and as of December 2017 contains 3,140 current and historical schools and 3,358 associated medical programs in 185 countries and territories.
In addition to these international efforts, many national government agencies and councils maintain their own directories of medical schools, and these vary considerably in the type of information gathered and their coverage. Several countries also have accrediting agencies or medical councils that provide accreditation review reports or lists of recognized schools online (examples include the Liaison Committee on Medical Education21 and the American Osteopathic Association's Committee on College Accreditation22 in the United States and the Medical Council of India23). In addition to offering minimal details about the medical programs' structure and content, such accrediting agencies may provide an incomplete accounting of medical schools in the country, omitting schools they have not had the opportunity to review, which may be a considerable number in countries where accreditation is not mandatory.24 Finally, there are some MRAs that publish lists of medical schools outside their jurisdiction which they find acceptable or unacceptable. Examples include the General Medical Council of the United Kingdom,25 the Malaysian Medical Council,26 and the Medical Board of California.27 These lists are notable in that they may provide evidence of external quality reviews; however, they rarely contain information about the schools in question, let alone the basis for the determination of acceptability or unacceptability.
...ACCREDITING AGENCIES MAY PROVIDE AN INCOMPLETE ACCOUNTING OF MEDICAL SCHOOLS IN THE COUNTRY, OMITTING SCHOOLS THEY HAVE NOT HAD THE OPPORTUNITY TO REVIEW...
Development of a New Information Resource
It is difficult to create a logical model that accurately represents educational institutions and their essential attributes in a structure that is useful to medical regulatory authorities and others who will use this information resource. Challenges include representing the diversity of educational models, academic titles, and documentation described above. A precise and representative data schema will support interoperability with other information resources, allowing for new research analyses and data-driven decision-making and fostering the free flow of information among international agencies.
What Information Should a Medical School Directory Contain?
In the development of any new information resource, it is necessary to identify the stakeholders who will use the resource and to understand each user group's needs. One of the primary groups whose needs were considered in the development of the World Directory of Medical Schools was the patient community that would be served by the schools' graduates. Both medical regulatory authorities and employers act, on behalf of patients, as gatekeepers to practice and have similar needs when vetting medical graduates. The assurance of physician competence is generally delegated to a community's regulatory authority as their primary function, and therefore, WFME and FAIMER met with representatives of several MRAs to discuss which information was most important to them.
First, a medical school directory must accurately identify, locate, and differentiate among institutions. Consequently, schools that are no longer operational must be retained in the directory, as prior graduates may still be in practice. Similarly, a history of names under which schools operated previously is necessary, as is information about any school mergers and divisions. Universities having more than one affiliated medical school need to have those affiliations shown clearly, allowing differentiation among affiliated schools. Details about the school's location and year of establishment also assist in differentiating among similarly named institutions.
Once a school is accurately identified, MRAs are particularly concerned about the legitimacy of the institution and its graduates. Therefore, the directory should only include those schools that are (or were) confirmed by the government or another appropriate agency in the country in which the school is located to have begun instruction in medicine. MRAs consider a variety of additional factors in determining whether a school's graduates should be eligible for licensure. Some may consider the length of time the school has been operational, the title of the degree awarded, the language of instruction, or the duration of study required.28,29 Consequently, all these elements must be captured in the directory.
A PRECISE AND REPRESENTATIVE DATA SCHEMA WILL SUPPORT INTEROPERABILITY WITH OTHER INFORMATION RESOURCES, ALLOWING FOR NEW RESEARCH ANALYSES AND DATA-DRIVEN DECISION-MAKING...
In addition to MRAs, other user communities' needs were considered in the development of the World Directory, including researchers engaged in assessing and projecting the health workforce. WHO and others researching the international health workforce have called for improvements in the collection and management of information about the supply of health professionals in support of ensuring an adequate supply of health professionals worldwide.30,31 While those responsible for the monitoring of the health workforce in many countries may have a deep understanding of, or even direct control over, local production of physicians, countries that are dependent on IMGs to meet health needs may have relatively little information about the international supply of physicians. To address these necessities, the directory must include all schools whose graduates might enter the workforce, regardless of the quality of the educational program, and must capture enrollment figures on an ongoing basis.
Another important group whose needs were considered in the development of the World Directory was prospective medical students and those who might be funding their education. Students and their sponsors need sufficient information to decide if the school will meet their requirements. Such information includes whether the school is recognized or accredited, its admission requirements, any non-academic (e.g., religious) affiliations, and fees for attendance. Medical schools themselves are also a directory user group. In addition to providing the directory with information about their own institutions, they are interested in the characteristics of peer institutions. Finally, we considered the needs of physician membership associations, providers of continuing medical education, publishers of medical journals, and developers of physician networking tools as potential users of the World Directory. The information needs of these groups overlap with the needs of the groups already discussed.
It is essential to correct a common misconception about the World Directory of Medical Schools. The inclusion in and of itself of an institution in the World Directory is not, and was never intended to be, a marker of quality. The goal of the directory is to include all schools educating future physicians, regardless of perceived or reported quality, with sufficient details about the institutions and their educational programs to serve the needs of all organizations and individuals who use this resource. This inclusivity 1) gives individual MRAs the flexibility to make independent, data-driven determinations about each school and its graduates' qualifications to practice in their unique settings; 2) serves researchers who require complete data on all institutions that contribute to the physician work-force supply; and 3) improves all users' ability to identify and differentiate among schools.
What is a Medical School?
The first challenge in the development of a school directory is to answer the question, “what is a medical school?”32 One problem is the representation of schools that offer more than one program or track to a medical qualification. A single school may offer two or more medical programs with differing admission requirements, curriculum durations, clinical focus, languages of instruction, or degree titles awarded. Common examples of this phenomenon are schools that offer both undergraduate- and graduate-entry programs and schools that offer parallel programs in different languages. Some medical schools also offer programs in other licensable health professions, which may be difficult to differentiate based on degree titles alone. For agencies or prospective medical students making decisions based on these factors, these differences could be substantial.
THE INCLUSION IN AND OF ITSELF OF AN INSTITUTION IN THE WORLD DIRECTORY IS NOT, AND WAS NEVER INTENDED TO BE, A MARKER OF QUALITY.
A similar problem is the issue of branch campuses. Large universities may have campuses in multiple cities with full or partial medical programs located at each.33 In some countries these different campuses may be separately accredited34 while in others all campuses are accredited together as a single program.35 In another variation, a medical school in one country may “franchise” their program or otherwise participate in the delivery of a medical program in a different country. More complicated still are cross-border medical programs. Some medical programs developed in partnership between medical schools in two countries deliver a single program across both countries, conducting basic medical training in one country and clinical training in the other. These programs may be accredited by agencies in one or both countries. For MRAs that make decisions based on the country in which a school is located and its accreditation status there, and for researchers counting medical schools or graduates by location, these multiple campuses and cross-border partnerships present analytical complications. As medical education becomes increasingly globalized, the complications of defining a medical school will only increase.
A SINGLE SCHOOL MAY OFFER TWO OR MORE MEDICAL PROGRAMS WITH DIFFERING ADMISSION REQUIREMENTS, CURRICULUM DURATIONS, CLINICAL FOCUS, LANGUAGES OF INSTRUCTION, OR DEGREE TITLES AWARDED.
A Data Model for Medical Education
Based on the needs and cases described above, it was determined that the primary unit of analysis for most stakeholder uses is the medical program rather than the school(s) delivering the program. However, there is still some very necessary information that applies to the school rather than individual programs, such as historical names, academic affiliations (parent universities), non-academic affiliations, and accreditation status. Any school in the directory may have one or more medical programs. This allows us to capture separately those elements that may be unique to different programs at the same school, such as program duration, degree title awarded, and associated student enrollment figures. A program may also be linked to more than one school, allowing us to map a single program with a single set of enrollment numbers to schools that may be in more than one country. Finally, as with schools, medical programs may be current or historical. This allows us to record major changes to a school's medical curricula over time, such as when institutions have moved from undergraduate entry to graduate entry. A medical school may have been in continuous operation for over 100 years, but the medical program offered today may bear little resemblance to the one offered 50 or even 15 years ago. These differences may be important to the analyses of regulators and researchers.
Another important feature of the World Directory is the representation of academic affiliations. In many areas of the world there is no distinction between the school offering the medical program and the institution awarding the resulting qualification, but in some countries these may be two differently named entities. In South Asia, it is common for one degree-awarding university to be affiliated with several medical schools at the same time. This presents a challenge for those who are attempting to determine which medical school a physician attended based on a document such as a diploma. Understanding relationships among parent and sibling institutions may also be relevant to those attempting to analyze the scholarly productivity of a school's medical faculty via journals' author affiliation metadata. To capture these relationships, the World Directory allows for mapping of parent and child schools. The data structure allows for a university with a unique school identifier to be linked to several World Directory listed schools while not being listed independently as a medical school itself in the directory. Here, too, relationships may be current or historical.
THERE IS CLEARLY A NEED FOR MORE INFORMATION FROM ACCREDITORS AND OTHER OVERSIGHT AGENCIES ABOUT THEIR DECISIONS WITH RESPECT TO INDIVIDUAL SCHOOLS AND MEDICAL EDUCATION PROGRAMS...
Based on our analysis of users' information needs and the considerations described above, a data model was created for the World Directory as shown in Figure 1.
The main entities represented in the World Directory are schools, programs, and accrediting/recognizing agencies. While the World Directory does not yet display information on accreditation, the current structure allows us to record accreditation actions taken with respect to schools or their programs. As a first step toward the representation of recognition data, school records in the directory now contain statements provided by two of the directory's sponsors regarding their acceptance of graduates from specific schools. There is clearly a need for more information from accreditors and other oversight agencies about their decisions with respect to individual schools and medical education programs over time.
The relationships between these main entities may be considered entities on their own, each having its own set of attributes. For example, an accreditation action (the relationship between a recognition authority and a school or program) has dates of effect and conveys one of a number of statuses, such as preliminary or full accreditation.
MEDICAL COUNCILS AND MINISTRIES OF HEALTH AND HIGHER EDUCATION ARE OFTEN SLOW TO RESPOND TO REQUESTS FOR INFORMATION ABOUT MEDICAL SCHOOLS IN THEIR COUNTRIES.
The Ongoing Challenge of Data Collection
Data collection remains an ongoing challenge to the maintenance of the World Directory. Medical councils and ministries of health and higher education are often slow to respond to requests for information about medical schools in their countries. Accuracy and currency of data are especially important when gathering recognition or accreditation actions. For school recognition data to be useful, they must be current and collected from the source organization directly. This will require the ongoing cooperation of accrediting/recognizing agencies to provide current information about their decisions with respect to individual schools and programs. We hope that medical regulatory authorities will encourage their local recognition authorities to share their information with us so that the outcomes of their important work can be accessible to all in this central location — the World Directory of Medical Schools.
The verification of the qualifications of applicants for licensure or registration is a fundamental activity of medical regulatory authorities. Part of ensuring patient safety requires timely and accurate verification that applicants have received the medical training needed to be competent physicians. For countries that rely on medical professionals educated abroad, verifying the qualifications of IMGs can be much more challenging than the evaluation of those who are educated locally. Language barriers and cultural variations in the way medical professionals are educated can make it difficult to interpret documentation of academic qualifications and summaries of training experience. The World Directory of Medical Schools is a developing resource that can assist MRAs and other organizations and individuals who rely on data about the institutions that train the world's physicians. The World Directory can also play an important role in the international health workforce planning by enabling more nuanced analyses of medical workforce supply on a global scale.
About the Authors
Amy Opalek, MS, is an Information Scientist at the Foundation for Advancement of International Medical Education and Research.
David Gordon, FRCP, FMedSci, is President of the World Federation for Medical Education.