Medical education in the Caribbean has undergone significant change and growth in the past decades. Currently, approximately 60 medical schools in the Caribbean provide medical training to a combination of domestic and international students. External quality assurance of these institutions has varied in effectiveness and scope throughout the region. The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) was established by governments of the Caribbean Community as a way to fulfill regional and local needs for a governmentally recognized quality assurance agency. To examine efficient and effective options for maintaining and improving established accreditation systems such as CAAM-HP, the Invitational Conference on Accreditation of Medical Education Programs in the Caribbean took place in May 2007 in Jamaica. The conference was hosted by CAAM-HP and the World Federation for Medical Education, with assistance from the Educational Commission for Foreign Medical Graduates. The evaluation and monitoring of undergraduate medical education programs in the Caribbean by a regional accrediting system such as CAAM-HP can help ensure the quality of the education delivered at these diverse institutions.

To the Editor: We commend the efforts of Reynolds and colleagues1 to achieve “the reintegration of undergraduate and graduate medical education in psychiatry and neurology under the rubric of clinical neuroscience.” As supervisors and teachers of psychiatry residents, we also agree with those authors that “psychiatry is grounded in clinical neuroscience” and that our residents need a “deeper understanding of genetics, pathophysiology, functional neuroanatomy and neuropsychopharmacology.”

BACKGROUND:Global shortages of healthcare workers in both developed and developing countries are of great concern. Research on physician migration typically focuses on medical school graduates, most often those seeking postgraduate training opportunities elsewhere.DESCRIPTION:An overview of medical school migration patterns is presented in this paper. To put this phenomenon into the broader context of global physician migration, data is also presented on the distribution of medical schools, physician density, the flow of international medical graduates to the US, and the present composition of the US physician workforce.RESULTS:Results of the study indicate that many individuals leave their home country for undergraduate medical education.CONCLUSIONS:Given the movement of students and physicians, both for medical school and for advanced training opportunities, it is evident that some medical schools in the world are training doctors for their home country as well as for the international labor market. Overall, given the internationalization of medical education, collaborative efforts will be needed to develop an adequate, balanced, and well-trained global physician workforce.

As indicated in its mission statement, the Educational Commission for Foreign Medical Graduates (ECFMG), established in 1956, "promotes quality health care for the public by certifying IMGs for entry into U.S. graduate medical education, and by participating in the evaluation and certification of other physicians and health care professionals. In conjunction with its Foundation for Advancement of International Medical Education and Research, and other partners, it actively seeks opportunities to promote international medical education through programmatic and research activities." From 1958 through 2005, the ECFMG certified 287,382 international medical graduates (IMGs); the number per year has varied, depending on the world political situation and other factors. Currently, IMGs constitute 25% of practicing physicians in the United States. India, followed by the United States and the Philippines, has provided the largest number of certified IMGs. The ECFMG has developed extensive resources for verifying medical school diplomas and other credentials of applicants, and it provides credentials verification services to other organizations. Under the U.S. government J-1 Exchange Visitor Program, it also has played a major role in facilitating the entry of foreign physicians to the United States for clinical training and research experience. Over the years, testing of IMGs seeking ECFMG Certification has evolved; whereas initially applicants took examinations specifically for IMGs, they now take the same United States Medical Licensing Examination (USMLE) sequence of examinations as U.S. medical graduates. Passage of the USMLE is required for ECFMG Certification and licensure in all jurisdictions.

International medical graduates (IMGs) represent a large proportion of the population entering graduate medical education (GME) programs. Many of these internationally trained physicians go on to practice medicine in the United States. To be eligible for GME, IMGs must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). The number of certificates issued by the ECFMG has varied over time and historically has exceeded the number of available training positions. More detailed longitudinal analyses are required to better understand the interwoven issues of physician supply, consumers' needs, and the role of IMGs in the U.S. health care system.

In April 2002, the Foundation for Advancement of International Medical Education and Research (FAIMER) introduced the International Medical Education Directory (IMED). IMED is a Web-based resource on the world’s medical schools. As of Feb. 13, 2004, IMED contained information on 1,858 medical schools worldwide.FAIMER is a nonprofit foundation of the Educational Commission for Foreign Medical Graduates (ECFMG). The foundation was established in 2000 to support ECFMG’s aims and missions, thereby advancing ECFMG’s overall purpose of promoting excellence in international medical education.In addition to FAIMER’s charge of tracking medical education worldwide, most notably evidenced by its implementation and maintenance of IMED, FAIMER’s activities include the education of educators, i.e., providing educational programs for international medical school faculty that provide opportunities for the cross-cultural exchange of educational expertise and experiences. These programs allow faculty members to serve as local resources for educational improvements, which can enhance health outcomes. FAIMER’s educational programs fulfill ECFMG’s commitment to assist international medical schools and other organizations concerned with health professions education as they engage in program development, standard setting and evaluation.Additional FAIMER activities are concerned with the theme of discovering and disseminating knowledge. FAIMER is committed to understanding the impact of physician migration on the functioning of health care systems. It is also dedicated to studying which aspects of medical education lead to improved patient outcomes. To these ends, FAIMER will support research and collaborations that yield meaningful knowledge on medical education and international medical graduates, and will disseminate this information broadly.In developing IMED, FAIMER sought to build an accurate, objective informational resource on the world’s medical schools and share this resource with physicians, patients, students, researchers, medical schools and organizations concerned with credentialing and medical licensure.IMED is a Web-based directory of the world’s medical schools, available at no cost on the FAIMER website, www.faimer.org. The information in IMED is derived from the extensive and historical data developed by ECFMG throughout its history of verifying the medical education credentials of international medical graduates (IMGs), graduates of medical schools outside the United States and Canada. Using these data as a starting point, FAIMER initiated the development of IMED in 2001 and introduced the directory in April 2002.The medical schools listed in IMED are recognized by the government agencies in the countries where the schools are located, usually the ministry of health. The information listed for each medical school is provided by the appropriate government agency and by officials of the medical school. IMED’s Web-based format allows updated information to be incorporated as it is received by FAIMER, providing current information to its users. FAIMER updates IMED continuously as new information is received from these agencies concerning their recognition of medical schools and from officials of the medical schools that are listed in IMED. FAIMER itself is not an accrediting agency. The listing of a medical school in IMED does not denote recognition, accreditation or endorsement of the school by FAIMER.Since April 2002, ECFMG’s medical education credential policy has required that an international medical graduate’s medical school be listed in IMED. The individual’s year of graduation must be included in the medical school’s IMED listing. The medical education credential requirements for ECFMG Certification also require that the IMG must have had at least four credit years (academic years for which credit has been given toward completion of the medical curriculum) in attendance at a medical school that is listed in IMED.Prior to the introduction of IMED in April 2002, ECFMG required a graduate’s medical school be listed in the World Directory of Medical Schools published by the World Health Organization (WHO). The WHO listed medical schools and information on medical education in the World Directory of Medical Schools as provided to it by member states. As with FAIMER, the WHO does not accredit medical schools, and its listing of a medical school does not imply recognition or accreditation by the WHO.As stated previously, the information in IMED is updated continuously. As of Feb. 13, 2004, there were 1,858 medical schools listed in IMED. Of that number, 1,757 (95 percent) were medical schools that, based on the most recent information available, were currently in operation. These 1,757 medical schools were located in 165 different countries. The remaining 101 (5 percent) of the 1,858 medical schools listed in IMED are schools that are no longer in operation, whether due to closing or merger with another medical school. Since IMED seeks to be both historical and current, IMED maintains information on medical schools that no longer exist, such as the Universidad CETEC, Dominican Republic.Exhibit 1, which indicates the distribution of the 1,757 medical schools currently in operation, shows there are 120 medical schools in Africa (6.8 percent), 619 in Asia (35.2 percent), 71 in Central America and the Caribbean (4 percent), 418 in Europe (2.4 percent), 87 in the Middle East (5.5 percent), 225 in North America (12.8 percent), 19 in Oceania and the Pacific Islands (1 percent) and 198 in South America (11.3 percent).Of the 40 countries in Africa with one or more medical schools currently in operation, four countries have 10 or more medical schools: Algeria (11), Sudan (14), and Nigeria and Egypt (15 each). In Asia, India has the largest number of medical schools (156), followed by China (130), Japan (80) and South Korea (49). There are two countries in Central America and the Caribbean with 10 or more medical schools: Cuba (14) and the Dominican Republic (10). In Europe, the countries with the largest numbers of medical schools are Russia (60), France (45), Germany (38) and Italy and Turkey (34 each). Iran and Iraq have the largest numbers of medical schools in the Middle East, Iran with 46 and Iraq with 12. In North America, the United States has 145 medical schools, Mexico has 64 and Canada has 16. Australia has the largest number of medical schools in Oceania and the Pacific Islands, with 11 medical schools. In South America, Brazil has the largest number of medical schools (83), followed by Colombia (29) and Peru (20).The information that IMED currently contains on each country in which there is at least one IMED-listed medical school includes the name of the country, its capital, current population, the geographic region in which the country is located, the official language(s) and the number of medical schools that are listed in IMED.For each medical school, IMED provides the: Medical school nameName of the university with which the medical school is affiliated (if applicable)Medical school address, telephone/fax numbers and email addressMedical school website addressFormer official names of the medical school (if applicable)Degree title (title of the medical degree currently awarded by the medical school or university)Graduation years, which are calendar years for which the medical school has been recognized by the government agency in the country where the school is located. Graduation years for many schools begin in 1953, although individual medical schools may have been recognized prior to that date.The “Graduation years” listed for each medical school indicate the years for which the school is or was recognized by the government of the country. Medical schools that have “Graduation years” that are “current” are schools that are currently recognized by the government agency in the countries in which the medical schools are located.“Graduation years” that are not “current” indicate that the medical school is no longer recognized by the government or that the medical school was closed or no longer exists. Examples of medical schools that do not have “current” graduation years are Guy’s Hospital Medical School, St. Thomas’s Hospital Medical School, King’s College School of Medicine and United Medical and Dental Schools of Guy’s and St. Thomas’s, United Kingdom. These four medical schools no longer exist as individual medical schools due to mergers. IMED provides an explanation, indicating Guy’s Hospital Medical School and St. Thomas’s Hospital Medical School merged, forming United Medical and Dental Schools of Guy’s and St. Thomas’s. King’s College of Medicine merged with the United Medical and Dental Schools of Guy’s and St. Thomas’s, to form Guy’s, King’s and St. Thomas’s School of Medicine. The medical school that resulted from these mergers, and which is the one currently recognized in United Kingdom, the Guy’s, King’s and St. Thomas’s School of Medicine, has “Graduation years” that are “current.”IMED also includes such other historical information on medical schools as changes of medical school name. An example is Ross University School of Medicine, Dominica. IMED notes that former names of this medical school were the University of Dominica and Windward Islands University.Users of IMED have the ability to search the IMED database for a medical school in several ways, including geographic region, country, the name of the medical school or its affiliated university and the city in which the medical school is located.Because FAIMER’s goal for IMED is for the directory to be accurate and up-to-date as well as serve as a resource of detailed, objective information on medical schools, FAIMER is currently completing a survey of international ministries of health, ministries of education and medical councils. The survey asks about items not currently in IMED. These items include whether there is a national system of evaluation or accreditation of medical school programs and, if so, the name and contact information for the responsible evaluation or accrediting authority. The survey also requests information on whether there is a requirement in the country for medical schools to engage in periodic, comprehensive reviews of their educational programs, whether such review utilizes criteria established by an external body and, if so, what agency or agencies establish these criteria. Much of the information gathered in this survey will be reflected in IMED in the future.The current FAIMER survey also focuses on medical licensure, requesting the name of the authority responsible for physician licensure and contact information for that agency. The section of the survey on licensure also asks whether there is a period of internship and/or social/government service required for licensure, whether the internship and/or social/government service is required of both citizens and non-citizens, whether there is a licensing examination and if the government has agreements with other countries for mutual recognition of medical qualifications and, if so, to specify the country or countries. Finally, the survey asks that the agency provide for each medical school in the country currently listed in IMED updated information on the year each medical school was granted recognition in the country and to list any recognized medical schools that are not currently in IMED.FAIMER is also in the final stages of designing a survey to be completed by all the medical schools listed in IMED that are currently in operation. The survey will be a detailed cataloguing of objective information on each medical school, focusing on institutional characteristics (e.g., academic year, length of curriculum, sources of funding, admissions requirements, numbers of students and teaching staff), curriculum organization and process (e.g., number of hours of study in various subjects and percentages of curriculum time in preclinical and clinical phases) and facilities and equipment (e.g., research and teaching laboratories, computers, library facilities and holdings). The medical school survey also focuses on medical schools’ educational and assessment methods.FAIMER believes that by providing detailed, objective information on medical education and medical schools, IMED will be a model resource for the public, the international medical licensing community and others who seek and use such information.

Educational Commission for Foreign Medical Graduates, 3624 Market Street, Philadelphia, Pa. 19104-2685

This paper presents information from the Educational Commission for Foreign Medical Graduates (ECFMG) on the certification and practice of international medical graduates (IMGs). IMGs constitute 25 percent of the U.S. physician workforce, and there is a vigorous pipeline of highly qualified candidates seeking graduate training in the United States. When considering how to address the potential physician shortfall described by Richard Cooper, policymakers will need to consider U.S. health care needs in the context of the intense international debate regarding global physician migration and its implications for the developing world.

International medical graduates (IMGs) consistently represent approximately one fourth of both the physician workforce and the graduate medical education (GME) population of the United States. To enter into accredited US GME programs, IMGs must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). Changes in the number and characteristics of those seeking certification directly affect the GME population and the future physician workforce in the United States. In July 1998, in response to concerns that IMGs might be lacking in basic clinical skills (eg, history taking, physical examinations, communicating with patients in spoken English), the ECFMG initiated a requirement that IMGs pass a clinical skills assessment (CSA) to achieve ECFMG certification. In this study we examined the pool of IMGs seeking certification, using databases reporting on all individuals beginning the certification process from 1995 through 2001. For this period, we found that the number of IMG candidates taking the Step 1 examination decreased by 45.5% (36983 vs 16828), and the number of IMGs registered to take Step 2 decreased by 38.1 % (31751 vs 12 122). The number of ECFMG certificates issued annually decreased, from a range of 9000 to 12000 (1995-1998) to fewer than 6000 (1999-2001). Although the number of IMGs annually seeking and receiving certification has decreased, the quality of the applicants appears to have improved and the number of IMGs certified annually continues to adequately fill GME positions not taken by US medical graduates.

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The percentage of neutrophils forming erythrocyte-antibody-complement complex (EAC) and with erythrocyte-antibody complex (EAG) was determined for 30 normal newborns and 10 normal adults. The cord values ranged from 84-100% EAC binding cells with a mean of 95%. The adult values ranged from 89-100% EAG binding cells with a mean of 96% rosetted neutrophils. The mean percentage of EAG binding cells in the cord samples was 81%, whereas in the seven adult samples the mean was 87%.