Educational Commission for Foreign Medical Graduates (ECFMG) Accreditation Policy Change: A Boon or Setback for Caribbean Medical Schools?

Abstract

According to the World Federation of Medical Education (WFME), “accreditation is the certification of the suitability of medical education programs and the competence of medical schools in the delivery of medical education.” There are more than 100 medical schools in the Caribbean. The educational programs and accreditation requirements of Caribbean medical schools vary from island to island. In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) in the USA mandated that graduates applying for ECFMG certificates must come from an accredited medical school starting in 2023. The accreditation agency must be recognized by the WFME. This motivated the Caribbean medical schools to go for accreditation and invest considerable financial resources. However, the ECFMG changed its stance and implemented a recognized accreditation policy in 2024, which does not require graduates from an accredited medical school. Is this a progressive or regressive change in Caribbean medical schools? The authors would like to explore this perspective based on current practices and available data, expectations of the future situation of the global healthcare systems, and perceptions of accreditation in the Caribbean, especially in undergraduate medical education programs.

Overview and Introduction

Accreditation has long been regarded as a cornerstone of quality assurance in medical education, ensuring that programs meet rigorous standards and prepare students for the complexities of modern healthcare. Van Zanten et al (2012, p.587) defined accreditation as a “review of an educational program conducted by a governmental organization or a private entity account` at the government level based on publicized standards and predetermined protocols”.¹

In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that starting from 2023, ECFMG certification would require graduates from accredited medical schools.² This policy aimed to stimulate meaningful global accreditation processes, pushing schools worldwide to adhere to internationally recognized standards.² Furthermore, accreditation agencies accrediting medical schools must be recognized by the World Federation of Medical Education (WFME). To support schools in adapting, the ECFMG provided ample time to implement changes and announced a policy over a decade in advance. This effort reflects a strong commitment to fostering quality improvement in medical education.

The policy was announced in 2010 and intended to be implemented in 2023. As per this old policy, any International Medical Graduates (IMGs) applying for licensure in the USA and seeking ECFMG certification must have graduated from an accredited medical school. Moreover, the accreditation body that accredits the medical school must be recognized by WFME. For this purpose, WFME implemented a recognition program for accreditation programs globally.

However, the recently implemented accreditation policy in 2024 marks a significant shift. “Recognized accreditation policy means that a medical school’s accrediting agency has been reviewed and recognized by an external quality assurance organization. This quality assurance/recognition organization, in turn, has been reviewed and approved by the Intealth. Only medical schools accredited by an agency that an organization approved by Intealth recognizes satisfy the requirements of the Recognized Accreditation Policy.³“ International Medical Graduates (IMGs) can continue to apply for and pursue ECFMG Certification even if their medical school does not meet the requirements of the Recognized Accreditation Policy. While this policy promotes transparency by recognizing accrediting agencies through external quality assurance organizations, it paradoxically allows graduates from non-accredited schools to apply for ECFMG certification,³ raising questions about whether this shift is progressive or regressive.

Comparison Between the Initial Policy and the New Policy

As per the old policy, the students/IMGs are required to be from an accredited medical school to sit for the United States Medical Licensing Examinations (USMLEs), get ECFMG certified, and ultimately enter residency programs (postgraduation programs) in the USA. This ultimately impacts IMG licensure in the United States. This motivated many medical schools to seek accreditation, including those in the Caribbean region. However, with the new policy, IMGs need not come from an accredited medical school to write USMLE examinations or to get ECFMG certified. Suppose a medical school complies with the requirements outlined in the Recognized Accreditation Policy. In that case, a corresponding note will be added under the Sponsor Notes tab in the school’s listing in the World Directory of Medical Schools.³ This information is valuable to current and prospective medical students, medical regulatory authorities, and other stakeholders worldwide. Additionally, it provides US program directors with a helpful data point when evaluating the educational background of IMGs applying for US graduate medical education (GME) programs.³ However, it does not stop the students and graduates from non-accredited medical schools from sitting for USMLE examinations, applying for ECFMG certification, or entering residency programs in the USA. This takes away the motivation or urgency for medical schools to seek accreditation. The policy change could be due to political or economic reasons or the pandemic in 2020, as IMGs contribute a significant workforce to the US healthcare system. During the pandemic, some accreditation bodies had backlogs in visiting medical schools. However, once the travel restrictions were lifted, the accreditation bodies addressed these issues appropriately and in a timely manner.

International Medical Graduates (IMGs) Contribution to the US Healthcare Workforce

Graduates from medical schools outside the USA accounted for 27% of residents in residential positions in the USA. According to the 2022 Federation of State Medical Boards Census of Licensed Physicians in the United States, India accounts for the highest percentage (21%) of licensed International Medical Graduates (IMGs) in the US, followed by the Caribbean (20%), Pakistan (6%), Philippines (5%), and Mexico (4%). The demand for primary care physicians is anticipated to increase due to demographic trends such as population growth, aging populations, and rising incidences of chronic diseases linked to modern lifestyles.^4,5

Caribbean Medical Schools

Many offshore medical schools in the Caribbean have dual-campus programs. The World Bank defines offshore medical schools as (2004) “a medical school that caters primarily to foreign (North American) students wishing to practice medicine in the US and Canada”. Students are required to do basic sciences in the Caribbean, and they conduct clinical clerkships in the USA, the UK, and Canada.⁶ There are some publicly funded schools, such as the University of West Indies, where the entire medical program is completed in the home country and focuses on serving the home country. Today, the Caribbean region hosts over 100 medical schools, contributing significantly to the US healthcare workforce.⁷

More than 75% of U.S.-born International Medical Graduates (IMGs) graduated from offshore Caribbean schools, and over 50% of graduates from these schools actively work in primary care roles in the US, addressing critical physician shortages.^4,5 Notably, the number of credentialed doctors from Caribbean schools has increased by 115% since 2010, with US citizen graduates experiencing growth from 48% in 2010 to 67% in 2022.⁸

Despite these contributions, the quality of education in Caribbean medical schools varies significantly⁹ due to inconsistent accreditation standards across the region. Some islands require mandatory accreditation; in others, it is voluntary. Some countries in the Caribbean region have national accreditation bodies, such as St Kitts, Barbados, etc., and some countries have no national accreditation requirements. However, the ECFMG policy² announced in 2010 motivated Caribbean medical schools to seek accreditation from the WFME-recognized accreditation bodies. The impact of the policy announced in 2010 by ECFMG was greater on Caribbean medical schools than on other regions since more than 50% of Caribbean graduates work in the primary healthcare workforce of the USA.^4,5 All of them require ECFMG certification to be licensed in the USA. However, some Caribbean schools are thriving in keeping up with academic standards and global accreditation. However, the motivation is not the same across Caribbean medical schools, and the problem is compounded by cross-border accreditation created by some of the accrediting agencies in the Caribbean region.

Impact of Accreditation on Medical Schools

Thus, the role of accreditation in enhancing the quality of medical education cannot be overstated. Accreditation has been the driving force behind progress in many schools, compelling them to adopt reforms to meet internationally recognized benchmarks. It harmonizes educational initiatives, ensures accountability, and fosters trust in the global healthcare workforce. ECFMG’s initial policy successfully encouraged Caribbean medical schools to adopt accreditation standards, substantially improving quality assurance.

The literature suggests that students perform better on-board examinations at accredited medical schools than non-accredited ones.^10,11 Graduates from accredited schools consistently demonstrate higher first-attempt pass rates on the United States Medical Licensing Examination (USMLE) and greater success in obtaining ECFMG certification than those from non-accredited institutions.^10,11 Additionally, students’ performance on licensing examinations is highest during and immediately after accreditation site visits, declining until the midpoint of the accreditation cycle before increasing again, demonstrating a direct correlation between the accreditation process and educational outcomes.¹²

Accreditation has driven improvements in educational processes, fostering curricular reforms, strategic planning, and continuous quality improvement (CQI) practices.^13,14 Accreditation and ECFMG requirements impacted the Caribbean medical schools’ educational processes and CQI practices.^14,15 Many Caribbean medical schools reactively adopt accreditation-driven changes, implementing reforms only during site visits rather than embedding quality assurance as a proactive ongoing practice.^14,15 Most of the change processes at Caribbean medical schools have been attributed to prior accreditation site visits, driven by areas of concern cited in the resulting reports, reinforcing the reactive rather than proactive approach to quality assurance.^14,15 Moreover, most of the change processes and quality improvement (QI) efforts at Caribbean medical schools are motivated by accreditation requirements, indicating that accreditation serves as the primary catalyst for fostering QI in these institutions.^14,15

Potential Threats Across the Caribbean Region

The Recognized Accreditation Policy, with recent changes in the ECFMG, necessitates a critical evaluation of their long-term implications. Over the past decade, many Caribbean schools have invested significant resources into achieving accreditation. This issue is further exacerbated by cross-border accreditation practices in which accrediting agencies operate outside their primary jurisdictions. Cross-border accreditation has created an uncontrolled marketplace, prioritizing business interests over educational integrity and undermining the core purpose of accreditation.⁷ A few examples of cross-border accreditations that occurred in the Caribbean region are the Agency for Accreditation of Educational Programs and Organizations (AAEPO) in Kyrgyzstan, which visited one of the medical schools in Curacao, and the Independent Agency for Accreditation and Rating (IAAR) in Kazakhstan, which visited a medical school in Dominica. The IAAR is now recognized by the government of Barbados. Cross-border accreditation practices often lead to lax standards and reduced credibility.⁷ In the author’s opinion, will the problems compounded by the ECFMG’s policy changes continue to drive progress, or will they regress into leniency, compromising the standards they aim to uphold? Is it a boon or setback for the Caribbean medical schools?

Conclusions and Recommendations

It’s important to note that the political framework of Caribbean medical schools may evolve in response to changes in accreditation standards, government regulations, and the broader landscape of medical education. There has been rapid growth in medical schools in the Caribbean. Only a charter and business license are needed to open an offshore medical school in the Caribbean.⁶ This contrasts with the rigorous review of standards by the Liaison Committee on Medical Education (LCME), which medical schools must comply with to meet the accreditation requirements. Local governments are encouraging Caribbean medical schools, as they are economic spinners. Local governments must sign the agreement for any accreditation body visiting the medical school in the Caribbean region. It is a tripartite agreement between the medical school, local government and the accreditation body. However, some local governments are not keen on standards, or the accreditation procedures employed by the accreditation bodies or the context in which medical schools operate compared to the home countries where these accreditation bodies originated as they are keen on sustaining these economic spinners: Caribbean medical schools. Many local governments are not concerned with the standards of these accreditation bodies, and such examples allow AAEPO and IAAR to conduct accreditation site visits in the Caribbean region.

Although continuous quality improvement (CQI) was promoted due to external motivations, such as accreditation requirements, rather than internal motivation,¹⁵ it was mainly due to the ECFMG policy announced in 2010. The literature suggests that accreditation affects the processes of Caribbean medical schools, such as governance, documentation (data collection and analysis), creation and revision of policies and procedures, CQI, curricular reforms, and faculty engagement in educational programs.¹⁴ However, recent changes in the ECFMG policy and its stance on accreditation raise concerns that the policy is still committed to fostering quality improvement in medical education globally. Cross-border accreditation practices across the Caribbean exacerbate these issues. Moreover, over the past decade, some Caribbean schools have invested significant resources into achieving accreditation. This necessitates the establishment of a standardized accreditation process for medical schools that is essential for maintaining educational quality.

Ensuring rigorous academic standards in Caribbean medical schools through ECFMG oversight is vital to preserving integrity and excellence. This requires clear guidelines, strict supervision, and regular review of accreditation standards to uphold academic credibility. This could lead to detrimental and adverse effects in Caribbean medical schools. One of the reasons for the introduction of the original policy of accreditation requirements is the mushrooming of medical schools in the Caribbean region and the variability in accreditation requirements from one island to another.¹⁶ The Caribbean region already faces issues with cross-border accreditation and accreditation teams in Kyrgyzstan and Kazakhstan. The changes in ECFMG’s policies of the ECFMG compound this problem, and ECFMG’s coming up with a recognized accreditation policy could be a setback idea for the Caribbean region and it is not a boon for Caribbean medical schools. A steadfast commitment to maintaining academic standards in Caribbean medical schools through ECFMG oversight can effectively ensure integrity and quality within the system. Establishing clear guidelines and advocating a review of accreditation standards are crucial for upholding academic excellence.

The recent changes in ECFMG’s accreditation policies, particularly introducing the “Recognized Accreditation Policy”, may pose setbacks for the Caribbean region rather than benefitting its medical schools. While intended to enhance global standards, this policy could inadvertently hinder the accreditation requirement. However, a strong commitment to maintaining academic standards through ECFMG oversight remains essential to preserving integrity and quality in medical education across Caribbean medical schools. This is especially vital in the context of Caribbean medical schools supplying physicians to the USA healthcare system, which is facing huge physician shortages. To support this goal, it is vital to establish clear, fair guidelines and promote a thoughtful review of accreditation standards, especially cross-border accreditation, that consider the unique context of Caribbean medical schools while still upholding academic excellence.

Funding Statement

The authors declare that there is no specific grant for this research from any public, commercial, or not-for-profit funding agency.

Disclosure

Dr Sateesh Arja reports personal fees from CAAM-HP and WFME as honorary fees for site visits. He is also an associate editor-in-chief for the Journal of Advances in Medical Education and Practice. The authors report no other conflicts of interest in this work.