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Globalization of Medical Education: Continuing the Dialogue

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We want to thank all the 200+ attendeees who joined us at the 2012 Annual Meeting: Globalized Medical Education. We also sincerely appreciate all our esteemed speakers and moderator who presented at the session and participated in the lively panel today.

Please come back to this blog at the end of the week as we will have a summary of session highlights, a list of the questions that were sent to us during the session as well as updates to share with you. The AAMC will be posting all speaker presentations on their website and we will post the link to these presentations when they become available.

We look forward to continuing the dialogue!  Thank you.

Bob Crone, Strategy Implemented and Jenny Samaan, AAMC 

Globalization of Medical Education

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I am excited to announce a program that I will be co-hosting at at the 2012 AAMC Annual Meeting with my AAMC colleague, Dr. Jenny Samaan. We have organized a 3-hour discussion on the globalization of medical education.  We have invited prominent leaders in international medical education and from the US House of Medicine now involved internationally, to give us their insight on what globalization means for undergraduate and graduate medical education.  The future of US medical education and the US healthcare workforce may be impacted significantly by trends occurring beyond our shores. This 2-part session includes dialogue with the speakers and an opportunity for the audience to join in this lively debate.  [Read More]

Robert K. Crone, MD

President & CEO

Strategy Implemented, Inc.

Global Healthcare: From Russia with Love

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I just returned from a week’s visit to Moscow, a city I had not visited in 18 years.  During my time as a volunteer, and subsequently Medical Director for Project HOPE, a Virginia-based international medical educational foundation that was famous for the white hospital ship SS HOPE, I had witnessed the dissolution of the Soviet Bloc and with it, their healthcare infrastructure.  Under central planning in the USSR, all pharmaceuticals and medical supplies were manufactured in Eastern Europe for consumption in the Republics of the Soviet Union, from the Baltics to Central Asia and the Soviet Far East.  When the Soviet Union dissolved, so did the healthcare supply chain.  In the late 80’s Project HOPE was designated the lead agency by USAID for distribution of pharmaceuticals and medical supplies donated by the US healthcare industry.  As the Medical Director I traveled to virtually all of the Republics of the USSR during this time when things looked pretty dire.  Virtually all measures of the health of the population were in decline. Hospitals were outdated and without supplies of any kind.  Professionals were treated poorly with low salaries, long hours and no real direction. Clinical management was frozen in time from the Stalin era.  A visit this many years later to explore the feasibility of supporting healthcare privatization was an opportunity for me to have a Rip Van Winkle moment and to assess what progress had taken place.

My plane landed into a brand new terminal on a quiet Sunday morning at Sheremetyevo Airport, and I breezed through immigration and customs with efficiency that could have only been dreamed of in the 80’s. Highways were new and modern, the city was considerably cleaner with new skyscrapers, Red Square and other famous sights were sparkling and inviting.  The city was bustling with many local and visiting tourists enjoying a particularly lovely weekend in what now looked like a modern European city. The weather during this June week was something one could only expect to experience once in a lifetime.

Although it was clear that the hard infrastructure had changed quite considerably, as my colleagues and I visited healthcare facilities and met healthcare professionals, it was clear there was still a way to go with regard to the evolution of systems and attitudes toward health despite the fact that health statistics are beginning to turn around with increasing life expectancy and growth of the population for the first time in a long time.  We heard many stories of the distrust that the public still harbors regarding the public system of care and the challenges of providing patient focused, customer oriented care in the nascent private system.  There is a hope for the future and there appears to be an effort to transition some of the public hospitals into a new privatized healthcare model financed through medical insurance vehicles, but there appears to be a long way to go in this regard. Insurance companies are still looking for modern facilities to refer their customers and patients yearn to be cared for in a way they have experienced in the West.  Private investors see the opportunity but understand the system cannot and will not be transformed overnight.  Several healthcare leaders indicated medical education and healthcare regulation will need to be overhauled before real change can be realized and institutionalized. We talked to many who felt that knowledge and systems developed and practiced in the West would need to be adapted for, and embraced by Russia over the next generation if real change was to take place.  This, of course, is not really surprising. We have learned that we can build new facilities in a year or two, but it takes at least a generation if not two, to implement new systems and incentives that encourage changes in culture that will translate to better health and health care.

There is still a long way to go, but there clearly has been a start and hopefully they will to see it through.  I look forward to seeing if my colleagues and I can play some small role in supporting its advance, as it would be a privilege to be part of that process 20 years later.

Robert K. Crone, MD

President & CEO

Strategy Implemented, Inc.

Establishing Global Standards in Postgraduate Medical Education in Singapore: Are We on Our Way to a Flatter Medical World?

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Recently, the Ministry of Health of Singapore announced that it has partnered with the Chicago-based American Board of Medical Specialties, Inc. (ABMS) and some of its member boards to develop a US-based board certification process. The partnership will begin with the specialties of internal medicine, pediatrics and pathology starting in 2013 and extending to other key medical and surgical specialties by 2015[i]. The Ministry already has a partnership with the Accreditation Council for Graduate Medical Education (ACGME) to establish an accreditation process for residency training in Singapore. This is a major departure for a previously UK-centric country that traditionally has used the British “fellowship” system for specialty designation of its practitioners. Singapore decided several years ago to establish a new process in accreditation and certification that was deemed more objective, evidence-based and which aligned more closely with the US system of postgraduate specialty education.

At the same time the move toward an American-style system that aims to quantify performance may be an important first step in our ability to create multi-sited specialty-based residency training programs. Imagine that a graduate from an internationally accredited medical school anywhere in the world, who has passed a common set of assessment tools such as the USMLE, could enter a residency in general surgery where he or she would spend 2 years in surgical training in the US, 2 years in Singapore and 2 years in, India, Japan, Qatar or Iceland to become fully trained in a universally accredited program and be eligible for certification in one universally accepted specialty board program recognized as equivalent by a regional or national board such as the American Board of Surgery. Such a graduate specialist could then apply for and be accepted for medical licensure and practice medicine in any one of a number of licensing jurisdictions that recognized such a pathway.

This may sound like fantasy today, but I believe this is the direction in which world medicine is heading and I am convinced it will provide greater opportunities for our trainees to access high quality education, to learn about geographically important diseases and to experience health care in multiple settings, while enhancing our ability to provide a more uniform standard of medical care to our patients irrespective of where they may be located. Additionally, this approach may be viewed positively by licensing jurisdictions where workforce shortages are particularly acute, as it could provide access to a larger pool of well-trained providers for the community it serves.

Although there is still a long way to go in this process, there are a number of initiatives that are contributing to globalizing standards for medical education and training. These include establishing:

  • Regional or global accreditation processes for medical schools (recently mandated by the Educational Commission for Foreign Medical Graduates (ECFMG) in 2023[ii];
  • Common tools for assessing the competence of medical graduates such as the International Foundations of Medicine Exam (iFOM) offered in the US and internationally to medical students by the National Board of Medical Examiners, universal standards for accrediting graduate residency training programs;
  • Agreement on the core international requirements for specialty certification in each medical and surgical specialty.

The task of agreeing common standards is quite daunting, but small steps are being taken in the right direction and I applaud the effort.

Robert K. Crone, MD

President & CEO

Strategy Implemented, Inc.

Are Global Partnerships Right For Your Institution?

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I read with interest the article entitled American Colleges’ Missteps Raise Questions About Overseas Partnerships in the February 19, 2012 on-line edition of the Chronicle of Higher Education which sites several important examples of where American institutions of higher education had suffered badly from failed international partnerships.  As the article focuses exclusively on failed relationships, it is not surprising that it does not mention any of the potential benefits that can be derived from partnerships that have been thoroughly thought through and done well.

As in any circumstance where an institution considers entering into a new venture an objective analysis of risks and potential benefits must be conducted.  All too often, an opportunity presents itself to the leadership of an institution, and steps in the risk benefit analysis and risk mitigation strategies are overlooked in the enthusiasm of the day.

Ideally, an international strategy should be considered well before an opportunity presents itself.  It begins with an examination and determination of whether international expansion is compatible and consistent with the organization’s articulated mission, vision and values.    Next it is important to understand what programs, products and services are potentially exportable to another location, and what programmatic, financial or other institutional benefits can be derived compared to the cost and potential risks associated with international expansion.  Identifying the right partner who shares your goals, mission vision and values is critical as well.

Costs must include not only the actual costs associated with setting up an appropriate infrastructure to deliver internationally, it also includes an assessment of the opportunity cost of conducting this program versus what might be done at the home institution.  Similarly, an analysis of risk must include that associated with an organization’s reputation as well as the financial risk related to the undertaking.

As is well known – risk and reward are often related; increased potential risk as well as reward is generally associated with higher levels of international program involvement and complexity, for example being responsible for the actual delivery of care and education in a foreign environment.   We recommend that initial strategies be used to build relationships from which all participants can learn using products and services that are well within the capacity of the organization. When sufficient experience is gained in a given environment new assessments can be made.

Whether home or abroad, risk is inherent in any new venture – risk identification and putting in place proper risk mitigation strategies is where many institutions fail to devote sufficient attention. First and foremost is the risk of failure for whatever reason, so addressing this unfortunate prospect right up front contractually and with exit strategies is necessary.  The most common reason for failure is associated with mismatched expectations between the parties aptly described in the Houston Community College in Doha example in the Chronicle article.  The second most common reason for failure is insufficient attention paid to communication between all key constituencies related to the success and sustainability of the program, at all levels of the organization.

I am a strong believer in initiatives that lead to improved healthcare and educational quality and accessibility for citizens around the world.  Multi-national partnerships are an important contributor to improving the standards of care worldwide. With careful selection of the right partner, adequate planning, innovative and cost-effective programs, adequate human and financial resources, a robust delivery infrastructure at each site, strong institutional will and leadership, and adequate communication and risk mitigation strategies, international partnerships can add real value at home and abroad.

Robert K. Crone, MD

President & CEO

Strategy Implemented, Inc.

Composite Committee of the United States Licensing Examination

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I recently returned from the first meeting in 2012 of the Composite Committee of the United States Licensing Examination (USMLE), where I completed a 6-year term as a member and a 2-year term as Chairperson. As all US medical students and many international medical graduates know, USMLE is the series of examinations they must take and pass if they want to practice allopathic medicine in the United States and its Territories.  More than 30,000 medical students and international medical graduates enter the USMLE examination process each year.  The Composite Committee is responsible for overseeing the content and format of the USMLE examination process. The membership of the Committee is comprised of a dedicated group of leaders in various fields inside and outside of medicine whose entire purpose on serving the Committee is to protect the public.

 

At some point all 300 million people in the US are impacted by the competence of their medical practitioner.  The baseline used to judge competency is determined by decisions emerging from the Composite Committee.  Therefore individual Committee members volunteer their time to engage in and oversee a process designed to assure the public that their medical practitioners have achieved a minimum level of competency by developing and implementing standards for those entering the practice of medicine in the United States.  Competency embraces not only medical knowledge, but clinical and communication skills, professionalism, patient care, systems based practice, and practice-based learning and improvement.  This is currently accomplished through a set of 4 examinations interspersed through the medical educational continuum before graduates are fully licensed as independent practitioners.

 

The USMLE was established about 20 years ago by the National Board of Medical Examiners (NBME) and the Federation of State Medical Licensing Boards (FSMB) to serve as a unified set of examinations that all graduates of US medical schools would need to pass in order to be eligible for state medical licensure.  With the incorporation of the Educational Commission for Foreign Medical Graduates (ECFMG) into a trilateral arrangement, both US and international medical graduates were then required to take and pass the same set of examinations under a single standard used by all States and Territories in the United States for the first time in history. Now, all candidates applying for one of the approximately 24,000 residency slots available in US hospitals are expected to have passed the first three parts of  USMLE prior to acceptance into residency training and the supervised practice of medicine.  This is one of the important steps employed to protect the American public.
 
After 20 years, the USMLE is undergoing a comprehensive review of what it does and how it does it.  A set of recommendations have been developed which, over the next several years will lead to an evolution of the USMLE examination system that the Committee hopes will further enhance the performance of the tools used to evaluate the competencies of the next generation of medical practitioners in the United States.  It has been an honor and privilege to participate in this very important process and I look forward to seeing the implementation of the recommendations approved during my tenure on the Committee.