In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that as of 2023, physicians applying to train and practice in the United States will be required to graduate from a medical school that has been accredited using criteria such as those developed by the World Federation for Medical Education. This study analyzed posts on the Student Doctor Network (SDN) online forum that refer to this accreditation requirement to investigate how it has been perceived and understood by current and prospective medical students. A keyword search of relevant terms was used to identify posts discussing the accreditation requirement on the SDN online forum, which were subjected to thematic analysis. There were a total of 83 posts from 49 distinct user accounts between May 2012 and January 2020. Seven themes were identified in total; four whose overall purpose was to seek or offer advice and three whose overall purpose was commentary. Themes relating to advice included applications and admissions, future career planning, personal circumstances, and country-specific issues. Themes relating to commentary included the accreditation requirement policy itself, the potential implications of the requirement, and the educational quality of non-U.S. medical schools. Only half of web links on these posts were to the ECFMG website for official information about the requirement. Although a variety of different perspectives about the ECFMG accreditation requirement were expressed on an online forum for student doctors, the overall number of posts was low, which suggests that the requirement has not been a frequent topic of discussion on this platform. The insights gained from posts suggest personal opinions about the requirement and consequences for individual student application and career choices were the main areas of interest. Signposting to official information channels may help to raise awareness about the requirement and tackle areas of uncertainty and confusion about its implementation.
The Educational Commission for Foreign Medical Graduates (ECFMG) plays a key role in ensuring equivalences in training and competency as International Medical Graduates (IMGs) seek licensure in the U.S.1 Certification by ECFMG is required for IMGs to obtain a position in a U.S. residency training program, as well as to acquire an unrestricted state medical license. As the gatekeeper for IMGs to enter the U.S. health care system, ECFMG seeks to ensure these physicians have satisfactorily completed their undergraduate medical education.2 Since it began credentialing IMGs in 1958, ECFMG has had systems for assessing applicants’ medical schools.3 Notably, ECFMG requires applicants to have graduated from a school listed in its official database, including schools that have been approved by an appropriate local authority, such as an accrediting agency or government ministry.3
On September 21, 2010, ECFMG announced that “effective in 2023, physicians applying for ECFMG Certification will be required to graduate from a medical school that has been appropriately accredited.”4 ECFMG went on to clarify that this means only graduates from schools that achieved accreditation by an authority that follows standards and procedures comparable to those used by the Liaison Committee on Medical Education (LCME), the World Federation for Medical Education (WFME), or other globally accepted criteria would be eligible for ECFMG certification.5 In response, the WFME established a Recognition Programme in 2012 to formally recognize accrediting authorities.6 Graduates from medical schools accredited by WFME-recognized accrediting authorities would thus meet ECFMG requirements and be eligible to apply for ECFMG certification.1 The key implication of this policy change for state medical boards is that the WFME recognition process will provide a level of standardization, providing additional reassurance that the medical schools of all physicians who receive certification after this point will be accredited in a robust manner, and reducing the need for state boards to maintain specific unapproved lists, such as is the case with the Medical Board of California.7
As of June 2020, 23 of approximately 120 existing agencies had received recognition status by WFME. It has been noted that this low coverage means that the 2023 requirement has the potential to restrict the diversity of the ECFMG applicant pool, which could in turn have an impact on the U.S. physician workforce.8 It has also been noted that although workforce modeling is not ECFMG’s primary function, ECFMG is nested within a network of professional organizations in the health care industry and has a role in guiding relevant policy in this area.9 ECFMG has noted that notwithstanding potential future disruptions to national residency training recruitment, the initiative has had considerable influence on medical education internationally. ECFMG states, for example, that the “ultimate beneficiaries are, of course, the world’s patients.”10
In response to the unprecedented global disruption to health care and higher education caused by the COVID-19 pandemic, ECFMG announced in May 2020 that the deadline of this requirement will be shifted to 2024.11 Regardless of the eventual implementation of this requirement, it is fairly clear that it has already made a sizeable impact. Some consequences have been direct and intended, such as the renewed focus on accreditation and quality management of schools in a number of engaged countries.12 Other consequences, however, such as regulatory burden on under-resourced schools, limitations on physician shortages in the United States, and shifting migration patterns, are less clear and may take time to become apparent.
To date, the main focus when considering the accreditation requirement has been at the macro level. In other words, the debate and analysis has largely centered around the impact that this will have on health care and health care training at a national level, as most regulatory agencies are national organizations. However, given that applying for and completing medical training is a long process that can take several years, it is likely that many students and trainees already in the medical education system will have their postgraduate training options determined by this ruling. Some prospective medical students may select a medical school to increase their chances of entering a U.S. residency program. There has, though, been less focus on this at the micro level, with no published studies examining whether potential and current medical school applicants may be aware of the ECFMG 2023 initiative, and what their responses and reactions may be. Although choices made by medical school applicants have been shown to be influenced by a wide range of factors,13 a subset of students have clear ideas about their future professional career choices even prior to commencing medical school.14
Internet forums represent views of people communicating freely without the constraints of time or distance in a way that might not be captured by traditional research studies.15 Studies within health care have examined the views and experiences of a wide range of groups through analyzing online forum posts, including stroke,16 asthma,17 dementia18 and placentophagy.19 A recent analysis demonstrated that between 2007 and 2016, ECFMG certified individuals from 1,834 medical schools across 157 countries.20 An online forum therefore captures a sample of views that wouldn’t be feasible through direct methods at school or country level. We analyzed posts on a popular medical student online forum to understand whether, and how, the ECFMG 2023 initiative is influencing current and prospective medical students.
We conducted a thematic analysis of posts on the online forum Student Doctor Network (SDN), a non-profit website that aims to help build a diverse doctor workforce by providing free resources, tools and peer-support discussion platforms.21 We opted for a qualitative study design, recognizing the limits this places on generalizability, but also the opportunities it provides to attain richer insights into the perspectives of those writing posts.
The SDN has almost 700,000 members, spanning from high-school students to physicians, and is one of the largest online health and pre-health student communities.17 The forum was chosen after an initial scoping search, which highlighted discussion posts on the ECFMG requirement.
Only SDN members can post online. Each post was accompanied by a summary of the user’s profile, which can include the year that the user became a member, the user’s status (e.g., medical student, attending physician), the number of messages and likes the user has sent, and the user’s location. However, not all user profiles share all of these details, and the degree to which these were available varied.
The search strategy was piloted and refined prior to formal data extraction. The terms ”WFME,” ”ECFMG” and ”Educational Commission for Foreign Medical Graduates” were each separately searched, with the keyword ”2023.” All four key terms were also searched together. Searches were not restricted by thread title, number of replies or the user. Posts up until January 31, 2020, were included in the study.
There is consensus that internet data that are freely and publicly accessible can be used for research.22 This analysis is considered of low intrusiveness, and details on ethical issues related to analyzing online patients’ forums have been described previously.23 This study was approved by the UCL Research Ethics Committee (15443/003).
Data was managed in a Microsoft Excel spreadsheet. One author (Smith) extracted the data from SDN initially and another (Mughal) undertook a random check of 20% of extracted posts to ensure consistency in data collection. Uncertainties in data extraction were resolved through discussion between three authors (Smith, Mughal and Rashid). Information on user profiles was extracted where available.
A flexible inductive thematic analysis of open free-text posts using principles of constant comparison was undertaken in an attempt to obtain an in-depth insight into users’ posts.24,25 Smith, Mughal and Rashid read through all the posts extracted to become familiar with the data.
A coding framework was generated on the basis of preliminary codes. The data were revisited, repeat codes informed wider categories, and posts were mapped to this framework. Within the team, higher-level recurring themes were agreed upon. Where there were differences in agreeing themes, these were resolved through discussion to achieve consensus on final themes. The research team has backgrounds in medical education, applied health research, and social science. Smith is a current medical student and the remaining authors are practicing physicians. Conducting analysis with researchers from different backgrounds increases the trustworthiness of the findings.26
Eighty-three individual posts were included in the analysis. Included posts were from 49 different user accounts, including 10 (20%) physician accounts, 14 (29%) medical student accounts, 12 (24%) prospective medical student accounts, two (4%) unspecified student accounts, and one (2%) pharmacist account. The remaining 10 (20%) users had no information about their background available on their account. Thirty-four users (70%) posted once, seven users (14%) posted twice, three (6%) users posted three times, and the remaining five users (10%) posted up to a maximum eight posts. The posts ranged in date from May 2012 to January 2020. Figure 1 shows the chronological distribution of posts during this time, with notable increases in 2018 and 2019 compared to previous years. Nineteen of the 83 posts included links to websites, with a total of 36 links shared in total across all posts. Eighteen (50%) of the links directed to the ECFMG webpage, and the remaining links were to a variety of other webpages, including national accreditation agencies.
Each post fit into one of two groups with regard to its perceived general purpose: advice or commentary. Forty-eight (58%) posts were seeking or offering advice with regard to specific circumstances related to the accreditation requirement and were categorized into four themes. Thirty-five (42%) posts contained broader commentary and opinions about the requirement and were categorized into three themes. Figure 2 shows this classification of themes, along with example paraphrased quotes for each theme.
The first theme in this group relates to applications and admissions. Posts in this theme focused on how the accreditation requirement may influence decisions about choice of medical school applications or offer acceptance. A number of posts addressed the timing and implementation of the requirement and considered what the impact would be depending on year of graduation of individual students. Posts also shared information from the ECFMG webpage, direct quotes from ECFMG documents, and contact details for the ECFMG.
The second theme relates to career planning and advice that is longer term in nature than medical school admission, typically covering postgraduate training options in light of the accreditation requirement. Some of these posts convey uncertainty about how to interpret the requirement, and whether or not it should influence career plans. A subset of posts on career planning relate to exams, and in particular, whether the accreditation requirement should impact individual decision-making about taking the United States Medical Licensing Examination.
The third theme is about personal circumstances, and reflects a group of posts seeking and offering advice about individuals’ concerns and dilemmas. The situations described in these posts are often highly complex, including decisions about transferring schools, and financial predicaments. A number of posts within this theme address the anxieties associated with these decisions, and others offer supportive comments and suggestions.
The final theme relates to advice about specific circumstances in an individual country, including the United States, Ireland, Poland and the Caribbean.
Although posts in this theme had a primary focus of advice relating to these specific countries, a number of other countries were mentioned infrequently in posts in other themes: United Kingdom, Italy, Sweden, Croatia, Israel, Turkey, Egypt, Russia, India, Pakistan, Australia and Canada.
The first theme in this group is about the accreditation requirement itself and observations about it as a policy decision. These posts were largely neutral and descriptive in their tone and offered no strong opinions either in favor of, or critical of, the requirement. Some posts suggested possible rationales for the requirement, including standardizing international medical graduate competence, and bringing “real reform” to medical schools of low quality.
The second theme relates to the implications and consequences of the accreditation requirement as a policy decision. Many of these posts offer forecasts about the prospects for international medical graduates in the United States after 2023, which are largely pessimistic in tone, including the possibility of “physician shortages.” Other posts predicted the possible impacts on non-U.S. medical schools and are more optimistic.
The final theme in the group relates to posts commenting specifically on the educational quality of non-U.S. medical schools. These posts tend to be in favor of the accreditation requirement and see it as a way of raising global standards in medical education. Some language in these posts is particularly striking, referring to the ruling as a type of “crackdown,” to some non-U.S. medical schools as “diploma mills,” and to some countries as “Borat-like.”
This study demonstrates that in the decade after the ECFMG announced the 2023 accreditation requirement, there was a gradual increase in the number of posts about it on the SDN forum, although the overall numbers remained low throughout, indicating that it was not widely discussed on this platform. The purpose of the posts that did mention it was either to share advice on matters related to the requirement, or to provide commentary on the requirement itself and its possible implications. The advice offered was sought by, and directed at, prospective and current medical students, who expressed confusion and anxiety about its potential implications on their admissions, careers and personal circumstances. The low number of posts in this study means that these findings cannot be generalized to all forum users or prospective and current medical students, but our findings uncover a range of new perspectives and topics of discussions among those that posted.
Our findings reaffirm previous studies that have found that online forums are a useful medium to gather spontaneous and candid data, including in medical education.2 When we used the search strategy used in this study with the term “USMLE Step 1”, we found 10,520 posts, and when we used the term “IMG” we found 47,697 posts. This suggests that the accreditation requirement was discussed proportionately less than might be expected and comparatively much less than other topics of relevance to physician migration.
An article co-authored by the ECFMG president states that the accreditation requirement is designed to “provide greater reassurance to medical students,” and highlights the challenges faced by aspiring medical students, although it attributes this to the expansion of medical schools in the world rather than the requirement itself.3 The paper also highlights a new ECFMG web resource that was launched to help students make better decisions on medical school selection. As this resource was published toward the end of the data collection period, it is unsurprising that it was not mentioned or linked in any posts included in this study.
To our knowledge, this is the first study to explore the potential influence of the accreditation requirement on prospective and current medical students. Studies have examined its impact on individual medical schools, including Khyber Medical University in Pakistan,29 Kathmandu Medical College in Nepal,30 and Caribbean offshore medical schools.31 In each of these contexts, the emphasis is on the importance of adhering to international standards in a timely way in light of the requirement. We found a degree of uncertainty and anxiety relating to the requirement, particularly around admissions and future career planning. These were not raised or discussed in previous studies, which had a focus on institutional readiness for the requirement rather than students’ responses to it.27,28,29
Strengths and Limitations
A key strength of this study lies in the spontaneous nature of the data provided by online forums. Such data are less likely to be affected by self-presentation, reactivity and recollection biases and by the influence of the researcher’s agenda.13 Online forums are easily accessible by prospective and current medical students from all parts of the world, and their anonymous nature allows for honest, authentic voices. The diversity of the study team, which included a medical student and physicians, from both the United Kingdom and the United States, permitted varying perspectives to inform the analysis.
Limitations of this approach are potential biases in the participant sample (users of the SDN forum), the limited information about participant backgrounds and the inability to ask follow-up or clarifying questions to participants. The reliance on a single forum that is predominantly for English language users mean our findings may not be applicable of those writing in other languages, and those who do not have the necessary resources for regular online engagement. Furthermore, it is not possible to ascertain how many individuals read the forum and were influenced without themselves writing posts.
Implications for Medical Education and Policy
Much of the commentary and analysis emerging about the accreditation requirement has focused on the responses of national agencies and medical schools. Yet medical students, especially those who plan to do postgraduate training or practice in the United States, may be the most affected and vulnerable to this policy change. Although the ECFMG webpage provides detailed information about the ruling, the findings from this study suggest that awareness is low and confusion and misunderstanding persists, particularly relating to the impact on the future careers of individuals. Some of the language used in posts commenting on the ruling and its implications suggest that some xenophobic views are being linked to the ruling, despite the fact that these do not align with the formal ECFMG position.
The four-phase implementation plan (2018–2023) outlined by ECFMG may resolve some confusion seen in posts in this study. As students become aware of these resources, an ongoing focus on clear communication of policy will be important.32 Those involved in providing admissions and careers support to prospective and current medical students outside of the United States should recognize the potential uncertainties associated with the accreditation requirement and direct individuals to formal information channels. National accreditation agencies could also improve communication with medical schools and students in their countries about their progress with meeting the requirement. Further research in this area could focus on triangulating the findings from this study with analyses of other online forums and social media, as well as in-depth interviews with key stakeholders, including medical school applicants, medical students and those involved with medical school admissions.
Our findings highlight that although a wide variety of topics about the ECFMG accreditation requirement have been discussed in a popular online forum, it has overall received little attention in terms of number of posts. The posts analyzed in this study suggest there has been some confusion and anxiety about the requirement, particularly among those considering medical school and postgraduate training applications, who have grappled with questions about how it applies to their personal and career circumstances. Forum posts offering commentary vary in their perspectives, from those forecasting the potential impacts of the ruling on future U.S. workforce numbers and residency training applications, to those using the ruling to question the quality of non-U.S. medical schools. Given the lack of discussion about this potentially impactful requirement, and the confusion about its implementation from those who have discussed it, further efforts to raise awareness and signpost to official information sources should be prioritized as 2024 draws closer.
Funding: Dr. Mughal is funded by a National Institute for Health Research (NIHR) Doctoral Fellowship (NIHR300957). The views in this manuscript are those of the authors, and not necessarily those of the National Health Service, NIHR, or the Department for Health and Social Care.
About the Authors
Mohammed Ahmed Rashid, MBChB, MSc, MRCGP, is an Associate Professor in Medical Education at UCL Medical School, London, UK.
Victoria Smith is a medical student at the University of Birmingham, UK.
Sean Tackett, MD, MPH, is an Associate Professor of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Zakia Arfeen, BSc, MBBS, DRCOG, MRCGP, is a Lecturer in Medical Education at UCL Medical School, London, UK.
Faraz Mughal, MBChB, DCH, MRCGP, MPhil, is an NIHR Doctoral Fellow, School of Medicine, Keele University, Keele, UK.