Academic medicine has erected a new hurdle for foreign medical school graduates who want to train in the U.S.: a clinical skills assessment.
Starting July 1, international medical graduates must pass a test showing they can communicate effectively with patients. Those who flunk won't be eligible for residencies and fellowships in the U.S.
It's unclear what impact the exam will have on the number of foreign-educated doctors who train in the U.S.
The test already is being called discriminatory because graduates of American medical schools are not uniformly tested on their bedside manner, although there's a movement to change that. Moreover, the five-hour exam is being offered only in Philadelphia, making it a major inconvenience and expense.
The exam is likely to come under fire at the American Medical Association House of Delegates annual meeting in June in Chicago.
Concern about physician oversupply has prompted actions to stem the tide of foreign-educated doctors into the U.S. (Feb. 24, 1997, p. 16). But the Philadelphia-based Educational Commission for Foreign Medical Graduates, which developed the exam, claims that was not its intent.
The ECFMG certifies about 6,000 foreign medical school graduates for eligibility to apply to U.S. residency and fellowship programs each year.
The AMA is one of six organizations that sponsor the ECFMG. Others are the American Board of Medical Specialties, the Association of American Medical Colleges, the Association for Hospital Medical Education, the Federation of State Medical Boards of the United States and the National Medical Association.
The ECFMG's vice president for clinical skills assessment, Gerald Whelan, M.D., said the test is a response to increasing emphasis on clinical skills in medical education. In recent years U.S. medical schools have been required to teach and assess clinical skills.
"We have no idea whether it's being taught in foreign medical schools," Whelan said. "It's meant to level the playing field a little bit."
Whelan said the test was authorized by the ECFMG board about six years ago, but it wasn't until mid-1996 that development began in earnest.
Busharat Ahmad, M.D., chair of the AMA's international medical graduates section, said all candidates for medical training should be tested, not just those educated at foreign medical schools.
Ahmad said foreign schools always have focused on clinical skills because they have less technology. He conceded that the exam could do some good by encouraging foreign students to learn more about American culture before their training.
But he said: "Let's be fair. Let's apply (the test) to everybody."
Another issue is cost. Foreign-educated students will pay $1,200 apiece to take the test. That compares with $1,030 they pay for the U.S. Medical Licensing Examination, which tests scientific knowledge, and an English language comprehension test. Both are offered at many sites.
According to Whelan, the ECFMG spent several million dollars to develop the test and build an exam center, complete with 24 mock physician offices and audiovisual equipment to record encounters between examinees and actors, called "standardized patients."
Whelan said the ECFMG was sensitive to the cost. "We've done everything we can to keep it reasonable," he said, "which is not to say they're low, but they're justifiable."
Examinees are measured on their proficiency in obtaining medical histories, performing physical exams, using interpersonal skills, composing written records and communicating in English.
Except for the English language requirement, the exam is like one used since 1989 at many medical schools. That exam was developed by the National Board of Medical Examiners, which has made clinical skills assessment its top research priority.
The NBME and the Federation of State Medical Boards are expected to decide next year whether to require U.S. medical school graduates to pass a standardized clinical skills assessment.
Daniel Klass, M.D., director of the standardized patient project at NBME, said opposition is likely to come from medical students. Although the NBME is prepared to offer its exam at multiple sites, it's likely to be expensive. Klass said it might be possible to combine the ECFMG and NBME exams in the future.
He said pressure for clinical skills improvement comes from the medical profession itself, which is sensitive to the public's perception that many physicians are arrogant and communicate poorly.