“For several years a number of agencies concerned with medical education, including the Federation, have cooperated with the [AMA] Council on Medical Education and Hospitals…in preparing a list of foreign medical schools in which the curriculum of studies was comparable to that of approved medical schools in the United States and Canada….

At a Conference on Graduates of Foreign Medical Schools held in Washington, D.C., April 30, 1954, twenty-two interested organizations gathered at the invitation of the Council on Medical Education and Hospitals to discuss problems raised by the graduates of foreign medical schools who are seeking training and licensure in this country.

The problem created by the presence of these foreign educated physicians was considered serious because of their large number, the fact that a high proportion intend to practice in this country and because the adequacy of their medical school training which has been received by many of them was open to question.

It was agreed that in the final analysis this problem was in the province of state boards of licensure as represented by the Federation of State Medical Boards, and must be met by evaluation of the individual candidate through a central screening agency, regarding credentials, properly constituted examinations, backed up by adequate hospital internship and residency training.

It was recognized that knowledge and experience in the investigation of candidates' credentials are essential, and that most state boards do not have personnel trained for this task.

The conference ended with a general agreement that these two ends could best be accomplished through some central agency which would first evaluate credentials and hold preliminary examinations which would entitle these physicians to acceptance for examination for licensure by the states after completion of satisfactory hospital training.”

Walter Bierring, MD

Federation Bulletin, December 1954

The eventual outcome of the deliberations of the 1954 Conference on Graduates of Foreign Medical Schools, described by Dr. Bierring in the Federation Bulletin, was the creation of the Educational Commission for Foreign Medical Graduates (ECFMG) — an important development in the evolution of organized medicine in the United States.

Today, the ECFMG serves as the “central screening agency” conference attendees envisioned back in 1954 — taking on the complex task of ensuring equivalences in training and competency as International Medical Graduates (IMGs) trained in today's huge global medical education infrastructure seek training and licensure in the United States.

Almost 60 years later, the dynamics and questions remain the same: Does our system of evaluating IMGs ensure patient safety? Do we have the right mechanisms in place to help us stay ahead of the rapid pace of educational change in other countries? Is our process fair to all concerned — most importantly, to those seeking licensure in the United States?

In an increasingly connected global community, the task of evaluation is more complex than ever — but these fundamental questions are still at the heart of our work as an organization today.

Since 1956, the ECFMG (initially established as the Evaluation Service for Foreign Medical Graduates (ESFMG) and almost immediately renamed the Educational Council for Foreign Medical Graduates), a private, nonprofit organization, has been “promoting quality health care for the public by certifying international medical graduates for entry into United States (U.S.) graduate medical education.”1 

While our basic mandate has remained the same since 1956, ECFMG's scope of responsibilities has broadened — largely because we learned early on that success in our efforts would require strong, ongoing relationships and information exchange within the international medical community. In the process of broadening our view in this way, ECFMG has considerably enlarged its impact: today it can be argued that our presence has contributed to the advancement and improvement of medical schools worldwide.

Our impact grew significantly in 1974 when ECFMG merged with the Commission on Foreign Medical Graduates and became responsible for the visa sponsorship of Exchange Visitor physicians participating in U.S. graduate medical education (GME) programs. Since then, ECFMG has become increasingly involved in conducting research on IMGs and in fostering interactions with the global medical community, a trend that continues to this day.

ECFMG's responsibilities have expanded in other ways in recent years, primarily in the assessment of clinical skills of candidates for U.S. licensure; and in assisting international regulatory bodies with primary source credentials verification of applicants for graduate medical training or licensure in their countries of jurisdiction.

While remaining committed to our primary mission, noted above, ECFMG now “promotes quality health care for the public by participating in the evaluation and certification of other physicians and health care professionals nationally and internationally.” Furthermore, and “in conjunction with its Foundation for Advancement of International Medical Education and Research (FAIMER), and other partners, it actively seeks opportunities to promote medical education through programmatic and research activities.”2 

Although ECFMG has been focused on the quality and preparedness of IMGs for entry into U.S. Graduate Medical Education, as recommended by Dr. Bierring and his colleagues, and notwithstanding the challenges involved, interest in assessing the quality of international medical schools has not disappeared.

In fact, discussion about our system of evaluating international medical training has intensified in recent years.

Some educators argue that by the time IMGs have passed the United States Medical Licensing Examination®, completed an internship, residency and often fellowship, and met requirements for licensure in the United States, the quality of their undergraduate medical education becomes immaterial. And at least one study shows that no difference exists in cardiovascular clinical outcomes between U.S. medical school graduates and IMGs practicing in the state of Pennsylvania.3 

Nevertheless, many educators and regulatory agencies remain concerned about the lack of adequate data concerning the quality of international medical schools. The two medical school directories in primary use today throughout the world, the International Medical Education Directory maintained by our foundation, FAIMER, and the Avicenna directories, maintained by the World Federation for Medical Education (WFME), require that schools be recognized by the appropriate authority in their country before they can be listed in the directories. But both organizations that maintain these directories have no way of assessing the quality of the schools or the criteria that each country uses in “recognizing” medical schools.

Some state licensing boards have, accordingly, established programs for assessing, on their own, the quality of international medical schools, but their efforts are of necessity hampered by the limited resources available to them for this purpose. A general consensus exists that the best way to assess schools is through accreditation which, ideally, would be regional or local, albeit based on recognized global standards. Accreditation is not, unfortunately, utilized throughout the world; and where it is, standards can vary considerably. In an effort to promote accreditation globally and to provide an additional safeguard for the U.S. public, our board decided in 2010 to add a new requirement for ECFMG certification, effective in 2023: Graduation from an accredited medical school. Our board further specified that accreditation should be carried out in a manner and on the basis of standards similar to those of the Liaison Committee for Medical Education (LCME) that accredits allopathic schools in the United States; or on the basis of established international standards and procedures such as those published by WFME.4 

Following the announcement of ECFMG's new requirement, WFME initiated a new program to evaluate accrediting agencies worldwide, assess whether they meet WFME standards and officially recognize those that do. With support from ECFMG, and collaboration from FAIMER, WFME conducted an initial pilot of this program focusing on the Caribbean Accreditation Authority for Medicine and the Health Professions; and, in May of 2012, officially recognized the authority as meeting its requirements.

Other accrediting agencies have since applied to WFME for recognition; both the LCME and the Committee on Accreditation of Canadian Medical Schools have been scheduled for review in the first half of 2013. ECFMG enthusiastically supports WFME's recognition initiative which became possible, in part, through logistical support by FAIMER.

And so, we come full circle. ECFMG, which was created through the efforts and initiative of Dr. Bierring and other medical educators, regulators and leaders concerned about the quality of international medical schools and international medical graduates in the 1950s, has met and is continuing to meet the challenge assigned to it in 2013: Evaluating international medical graduates to ensure their readiness for entry into U.S. graduate medical education. But through our foundation, FAIMER, and through our recently announced accreditation requirement, it is also contributing to Dr. Bierring's and many educators' other concern: Evaluating and contributing to the improvement of medical school quality worldwide.

Evaluating the Quality of Care Provided by Graduates of International Medical Schools
Health Affairs

Author notes

“Past and Present” couples an excerpt from an article that appeared previously in the pages of the Journal or its predecessor, the Federation Bulletin, with a companion essay authored by an invited commentator. Here, Emmanuel Cassimatis, MD, President and CEO of the Educational Commission for Foreign Medical Graduates, offers his reflections on an article by long-time Journal editor Walter Bierring, MD, on the topic of the evaluation of international medical graduates. The article appeared in the December 1954 issue of the Federation Bulletin.

About the author

Emmanuel Cassimatis, MD, is President and CEO of the Educational Commission for Foreign Medical Graduates.