The accreditation of medical education, i.e., the certification of the suitability
of medical education programs, and of the competence of medical schools in the delivery
of medical education, ensures patient safety and competent practicing doctors. Medical
knowledge advances at a very rapid speed. The international medical education systems'
changing rate was unable to cope with such rapid advances. Every human is a stakeholder
in this issue and prefer to remain healthy and productive, as patients prefer to have
a high degree of safety and care by qualified physicians. Naturally, the financiers
of health care and insurance companies as well as others are interested in such outcomes.
All stakeholders like to see more countries being accountable in having internationally
recognized medical schools and graduate safe physicians. Of course, this is an ideal
target that will require major resources and international cooperation to achieve
some steps. In the United States alone, approximately 25% of the working physicians
and residents are international graduates.[[1]]
With the increased level of globalization and open healthcare market, many international
medical graduates (IMGs) seek specialization training and work opportunities abroad.
The United States residency market is a very popular goal for many of them and is
known to employ the largest number of emigrating physicians.[[2]] Probably, stability, the internationally-recognized accreditation and the opportunities
for highly advanced subspecialty training are among the reasons for seeking this market.
The Education Commission for Foreign Medical Graduates (ECFMG) has been the gatekeeper
to protect the American public and assure the quality of the international physicians
seeking to train and work in the American health sector.[[2]] Over time, the ECFMG and the international community felt the gap and recognized
the wide variation in the quantity and quality of medical education and its outcome.
This stimulated the discussion about streamlining medical education internationally
to have similar outcome of competent doctors. In 2010, the ECFMG decided that IMGs
have to come from medical schools that are accredited by the World Federation of Medical
Education (WFME). The board decided that 2023 is the year of complete implementation
of the new policy and new accreditation requirements for medical schools to get their
graduates accepted for training in the USA.[[3]],[[4]]
For decades, the ECFMG has relied on individual certification as long as the graduate
came from a medical school that has been included in the WHO directory of medical
schools. Accreditation of medical education is normally carried out by national governments,
or by agencies receiving their authority from national governments in accordance to
the standards set by the WFME. That is not any longer adequate after 2023. The medical
schools themselves have to be accredited. Of course, there is no single international
agency that is capable of accrediting every medical school in the world. The WFME
has developed minimal criteria as standard guidelines for an acceptable medical school
with acceptable outcome.[[4]] The WFME prepared a document with the essential knowledge to graduate a safe physician.
The document included nine areas of needed reforms and focus. The following are the
areas as posted in the WFME website: mission and outcomes, educational program, assessment
of students, students, academic staff/faculty, educational resources, program evaluation,
governance and administration, and lastly continuous renewal. Each area has several
subheadings to strive for quality. All these areas need a lot of reviewing and quality
improvements over a long period of time. All medical schools which seek accreditation
will undergo self-assessment, internal and external evaluation, and reforms to comply
with the WFME and ECFMG guidelines. The ECFMG has published the phases of implementation
plan for the new policy.[[5]]
The implementation phases are described in [[Table 1]]. This requires that each country has to create or contract with an accreditation
body responsible and capable of accrediting such vital educational institutions. Such
authoritative body has to meet certain criteria and follow specific procedures and
policies to be accredited by the WFME. It is vital to have honest, credible local
accreditation bodies to help streamline the entire process to get a reasonable, homogenous
outcome of competent doctors. Tackett has reported that by December 2018, only 14
accrediting bodies have been certified.[[3]],[[6]] Many countries remained behind in creating the authoritative body. At this rate,
it may result in major delays of accrediting many countries, especially in Africa.
So far, Sudan is the only African country that has been accredited as far as I know
now. Dauphinee commented on Tackett's article and concerns and proposed three different
options that ECFMG may use to assure quality of care.[[7]] The delays in the creation of the required accrediting bodies can be attributed
to several factors. Many of these countries can be going through hardship, administrative
limitations, and even armed conflicts. On the other hand, some governments may not
view this accreditation as a matter of national priority. They may even see it as
a blessing in disguise, helping them to reduce brain drain by doctors emigrating from
home countries.[[8]],[[9]]
Table 1: The road map and its time scale as set by the Education Commission for Foreign Medical
Graduate[5]
Developing countries vary widely in the practices of accreditation of all main degrees
granted by medical schools. For instance, in the United Arab Emirates (UAE), all UAE
medical MBBCh programs are currently accredited by the Commission for Academic Accreditation
(CAA) under the Ministry of Education.[[10]] Indeed, all granted university degrees are meticulously stored in the ministry's
database. The authors are aware that CAA is undertaking the necessary steps to meet
the 2023 ECFMG requirements for all UAE medical schools. We have been informed that
work by the medical schools in Bahrain and Oman is in progress. However, this may
not be readily available in many countries in Asia and Africa. For instance, Libya,
as an example from Africa, is a country of 6 million people with 15 medical schools,
two of which are not functional currently.[[5]] In fact, only 11 Libyan medical schools are on the WHO list. Thus, there is one
medical school for every 400,000 people. This is at a much higher rate than what has
been published.[[11]] It is very difficult to gather credible data about the quality of education in
all these schools.[[6]],[[12]] The medical graduates exceed the capabilities of the local employment market. Over
the years, a fair number of them have traveled abroad for advanced training and some
remained for practice. There are no clear policies regarding the quality improvements
or accountability of graduates' outcome. Considering that 2023 is around the corner
and no evidence of major reforms and auditing, it is very concerning that some of
these colleges may not meet the needed standard criteria. Until recently, there was
no accreditation authority. However, in 2019, the government launched the National
Center for Accreditation of Medical Institutions (personal communication). Most of
the developing countries are in a similar situation. Add to these challenges, the
need to appoint qualified people to fulfill the duty-free of any political or corruption
issues. Such individuals can guide medical schools through self-evaluation as well
as site visits and accreditation process.
The process of creating accreditation bodies is very slow and full of obstacles. Once
that hurdle is overcome, it takes approximately 2 years to complete the accreditation
application with the WFME. The above challenges paint a relatively gloomy and critical
situation of medical education in many developing countries.
How the WFME can police such a process will be very challenging.[[3]] The training of new accreditation bodies is essential, which should be done through
a rigorous curriculum to assure honesty and effectiveness. The new policy will have
a major impact on many countries and certainly will be very challenging for the WFME
as well as international medical colleges and their graduates.
In conclusion, the year 2023 is around the corner. It is the responsibility of the
medical colleges as well as their countries to take the situation seriously and invest
in the reforms. Major resources are needed for the completion of the process before
2021 to give time to correct deficiencies and follow-up site visits. The resources
are needed now. Meeting the new requirements by 2023 by the colleges worldwide is
not only to get the accreditation by the WFME and ECFMG, but it should also be viewed
as a golden opportunity to enable them to graduate qualified physicians and to provide
quality care for their own citizens.
Authors' contributions
All three authors developed the concept, drafted and approved the final version of
the manuscript.
Compliance with ethical principles
Not Applicable.
Reviewers:
Not Applicable
Editors:
Elmahdi A Elkhammas (Columbus OH, USA)
Salem A Beshyah (Abu Dhabi, UAE)
