Should ECFMG Be Concerned with Accreditation Practices in the Caribbean? Five Effective Ways to Streamline the Process

International Medical Graduates (IMGs) comprise one-fourth of the US physician workforce.¹ Certification by the Educational Commission for Foreign Medical Graduates (ECFMG) serves as the benchmark for assessing the qualifications of these physicians before they enter US graduate medical education (GME).² The requirements for ECFMG certification applying through pathways include completing the United States Medical Licensing Examination (USMLE) Step 1, USMLE Step 2 Clinical Knowledge (Step 2 CK), attestation of clinical skills, a diploma/transcript from the medical school, and passing the Occupational English Test (OET).³ According to the Federation of State Medical Boards (FSMB), most IMGs come from India, the Caribbean islands, Pakistan, the Philippines, Mexico, etc. There are more than 100 medical schools in the Caribbean region, and approximately 50% of graduates from the Caribbean region enter the primary care fields of the US healthcare workforce.⁴

In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that, beginning in 2023, ECFMG certification would require applicants to have graduated from an accredited medical school.⁵ However, the accreditation policy officially changed in 2024, representing a major development. Under this policy, “recognized accreditation policy” refers to an external quality assurance organization, such as the World Federation for Medical Education (WFME) or the National Committee on Foreign Medical Education and Accreditation (NCFMEA), that has evaluated and approved a medical school’s accrediting agency.⁶ However, many argue that ECFMG should not be concerned with the accreditation of medical schools, as any graduate from an international medical school should pass the USMLE Step 1 and Step 2 CK examinations, which should ensure the quality of a medical graduate. The author argues that the accreditation and accreditation practices should concern ECFMG in the absence of the Step 2 Clinical Skills (CS) examination.

USMLE Step 2 CS was an exam administered to medical students/graduates who wish to receive an ECFMG certificate or become licensed physicians in the US However, this exam was discontinued in January 2021. The components that were assessed in Step 2 CS are Communication and Interpersonal Skills (CIS), Spoken English Proficiency (SEP), and Integrated Clinical Encounter (ICE). Given the cancellation of the Step 2 CS exam, the OET examination and ECFMG pathways play a crucial role in the ECFMG certification process. According to Pathway 3, the applicant’s medical school is accredited by an agency recognized by WFME.⁷ As accredited medical schools are attesting their medical students/graduates under pathway three, it is imperative that accreditation practices and clinical training are ensured qualitatively. The author discussed three examples in this editorial and explained why accreditation practices are crucial, as well as the ways to streamline these practices.

One of the schools on the island of Grenada is accredited by the Grenada Medical and Dental Council (GMDC). The Grenada Ministry of Health appoints Council members to carry out GMDC’s responsibilities,⁸ organized into the Registration and Licensure Secretariat and the Accreditation Secretariat. A good regulatory or accreditation body should be independent of the government. This school, accredited by GMDC, contributes 20% of the country’s gross domestic product (GDP). In this context, how can anyone ensure that accreditation practices are fair, transparent, and provide equal educational experiences across the 80 clinical sites of this school, especially if the local government is more concerned with economic impact than quality?

The other school in Dominica was accredited for five years by the Independent Agency for Accreditation and Rating (IAAR) from Kazakhstan in 2023. However, no students were admitted, and there was no student cohort at the time of accreditation. It is evident from the report published by IAAR on its website that no meetings were conducted with students during the site visit to gather their opinions.⁹ The author was unable to find any visits conducted by IAAR to the clinical affiliates of this medical school during this site visit. In another four years, students might graduate and apply for ECFMG certification through Pathway 3. How can the quality of clinical training at this school be guaranteed, considering the absence of students/clinical students and clinical training at the time of the accreditation site visit? IAAR should have considered granting provisional/preliminary accreditation rather than five-year accreditation.

Another school on the island of Curacao was granted accreditation by the Agency for Accreditation of Educational Programs and Organizations (AAEPO)¹⁰ from Kyrgyzstan for a period of five years in 2023, despite not visiting the school’s clinical affiliates in the USA. The site visit report was not published on the AAEPO website.¹¹ It just listed the accreditation status of the medical school. Still, this accreditation body has not visited the clinical sites of this medical school. How can the quality of clinical training at this medical school be guaranteed without external review and quality assurance?

Drawing on these examples, the author urges the ECFMG to introspect and examine the accreditation practices in the Caribbean region, especially the accreditation site visits conducted by any accreditation agencies other than the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP) and Accreditation Commission on Colleges of Medicine (ACCM). CAAM-HP was legally constituted by CARICOM countries in 2003 to carry out accreditation activities in the Caribbean region. It offers initial candidacy, provisional accreditation, accreditation with conditions, and accreditation for schools that meet the established standards. Graduates from such accredited medical schools are eligible for ECFMG certification through Pathway 3. This is vital as it directly impacts public health, and the trust of stakeholders is at stake. The author would like to propose five steps to be incorporated by WFME in scrutinizing the accreditation practices, especially if an accreditation organization is involved in accrediting educational organizations operating in countries other than the home country of the accreditation organization since WFME is placed in a position as a policeman for accreditation bodies in ECFMG’s recognized accreditation policy:

Tripartite Agreement

Any accreditation agency operating in a country other than its home country’s accreditation body should have a tripartite agreement with the local government, the accreditation body, and the school. However, WFME has already implemented this policy in its framework.

Publishing Positive and Negative Decisions on Accreditation Organizations’ Websites

Some accreditation organizations publish only positive decisions. One best practice for maintaining transparency is to publish both positive and negative decisions on the website. This is essential for all stakeholders, including prospective students, parents, the public, and regulatory bodies, to be aware of accreditation decisions.

Availability of the Entire Report or Summary of the Report

Some accreditation bodies list only the institutions/schools they have accredited on their website.¹¹ Then, it is hard to find any details about the site visits. It is recommended that the external reviewer’s report, or at least a summary of the report, be published on their website.

Site Visits to Clinical Affiliates

It should be mandatory to visit clinical affiliates attached to the medical school. This ensures the quality of clinical training at clinical sites and the quality of education offered at these medical schools.

Contextualizing the Standards

Accreditation bodies from other continents applying their original, unmodified standards to the Caribbean context could have serious, potentially harmful consequences, especially for offshore medical schools in the Caribbean region with dual campuses and clinical affiliates in the USA. Adopt a tailored approach rather than a one-size-fits-all approach and adjust their standards to suit the local context effectively.

These are some good practices that WFME can incorporate to establish transparency in accreditation practices in the Caribbean region.

In conclusion, the ECFMG should indeed remain vigilant about accreditation practices in the Caribbean, as the integrity of these processes directly affects the quality of IMGs entering the US healthcare system. Strengthening transparency, accountability, and contextual relevance in accreditation is vital to maintaining public trust and safeguarding patient care. By implementing the five proposed strategies, WFME can play a pivotal role in elevating accreditation standards. These measures will not only enhance the credibility of Caribbean medical schools but also ensure that graduates are well-prepared for clinical practice. Ultimately, robust and transparent accreditation practices are essential for upholding the standards of medical education and protecting public health.

Disclosure

Dr Sateesh B. Arja has received personal fees from CAAM-HP and WFME as honorary compensation for site visits. He is also a dean at Avalon University School of Medicine, one of the leading medical schools in the Caribbean. Additionally, Dr. Arja is an Associate Editor-in-Chief for the Journal of Advances in Medical Education and Practice. The author declares no other conflict of interest and confirms that no funding was involved in this work.