IAMSE Winter 2024 Webcast Audio Series – Week 3 Highlights

Presenter: Ahmed Rashid MD, Professor of Medical Education, Vice Dean (International) of Medical Sciences, Director of Faculty Development for Medical Education Collaborations, University College of London’s Medical School (UCL)

[The following notes were generated by Michele Haight]

Global Approaches to Medical Education: Who Wins?

This presentation examines the intersection of globalization, global health, and medical school regulation. It poses the question about who wins when we move to a global regulation process for medical schools.

At UCL, disruptive thinking has been the status quo since 1826. It was the first university in London to welcome women and students of any religion or social background. This progressive, egalitarian approach continues at UCL to this day. UCL is London’s global university.

The team at the UCL Centre for Medical Education Collaborations (CIMEC) is involved in supporting the development of new medical schools across the world. This includes developing tailored medical education programs and designing contemporary administrative and learning environments. This work is mostly concentrated in the Global South.

The World Federation for Medical Education (WFME) is an organization that exemplifies the different issues, challenges, and priorities that faculty members and medical education leaders face in different parts of the world. There is a mismatch between the priority and recognition of this agency across the world. Those in the Global North are not necessarily aware of the existence of the WFME, whereas those in the Global South are preoccupied with its existence.

The WFME is a tiny organization with virtually no staff. The decision-making body of the WFME appears to be its Executive Council. The voting members on the Executive Council include the six presidents of the representative medical education groups for each continent (AMEE, AMSA, PAFAMS, SEARAME, AMEEMR, WPAME), two founding members (WHO, WMA), and three executive members (IFMSA, JDN, ECFMG). The structure of the WFME makes sense, but the inclusion of the ECFMG, which represents a single country (US), is problematic.

ECFMG is the gatekeeper for physicians who train outside the US and wish to do a residency in the US. Completion of residency training in the US is considered prestigious and highly desirable around the world. 

In 2010,¬†ECFMG created a policy that as of 2023 (now 2024 due to the pandemic), all medical students wishing to train in the US had to graduate from a medical school accredited¬†by an agency that uses globally accepted criteria such as those put forth by the WFME. The additional requirement that¬†a medical school can only be certified by ECFMG if that school is accredited by an agency that is recognized by the WFME launched the WFME into the global consciousness. To be clear, WFME does not confer accreditation. Rather it recognizes certain¬†accreditation agencies, and schools that are accredited by those agencies meet the requirement. This policy decision had a tremendous global impact that has been likened to the “butterfly effect” (Lorenz, E.N., 1972).

The predominant issue is that a single agency from the US (ECFMG) developed this policy, and another US organization (FAIMER) developed the mechanics for implementing the policy. Essentially, the US has singularly developed the conceptual framework and the technical infrastructure for a policy that has a worldwide impact. The following three articles provide a closer examination of the issues associated with this policy.

Altruism or Nationalism: Exploring Global Discourse in Medical Education (Rashid M.A., 2023) This article provides a critical discourse analysis of 250 papers. The analysis revealed two contrasting discursive positions: altruism and nationalism. Altruism is informed by endorsement and modernization discourses. Each of these discourses contributes to a policy narrative that aligns with key global principles for modernizing and improving medical education across the world.

The second position is nationalism (referring to American interests), which is informed by discourses of protection and control. Protection is described as twofold. It refers to protecting the American public\ from the threat of foreign doctors, and it also refers to protecting American citizens who train outside of the US from poor quality medical schools. Control refers to the need for the US to monitor and manage the quality of all medical training. 

The article proposes that both discourses are present in the policy, each one appealing to a different audience. The article concludes that it is important to highlight the tension between the WFME, a global facing agency and the ECFMG, a single country-facing agency.

Examining the WFME Recognition Programme at 10 years (Tackett et al., 2023)
This research paper produced the following observations. 

  • Most of the countries that supply the most international medical graduates (IMGs) have agencies that have applied to the WFME program. So far, only 41 out of over 150 agencies around the world have applied to WFME.
  • There is no formal or informal evaluation of the WFME program.
  • The motivation for agencies to apply or not is unclear.
  • A global market for accreditation has emerged and perhaps this is the most troubling observation. There are no rules to stop accreditation¬†agencies from operating in multiple countries, and there are no rules for multiple accreditation agencies to operate in a single country. As a result, accreditation can become a highly political and commercial endeavor.
  • There is a lack of transparency and no research.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?
(Rashid, et al., 2023a)
This article postulates that the world deserves a different model for medical education.
The article points out that six white male presidents have helmed the model, even though the majority of medical schools are in the Global South. It further points out that the agency’s offices are mostly located in Western Europe and North America, not the Global South. The policies promoted by this agency legitimize standardization and westernization, and promote the values, priorities and policies of the Global North. Finally, there is a lack of transparency, democracy and evaluation in the current model.

Envisaging an alternative model might include the following characteristics, “‚Ķlocal rather than global, contextual rather than general, cooperative rather than hierarchical, supportive rather than judgmental, flexible rather than rigid, and developmental rather than a single snapshot‚Ķ‚ÄĚ(Rashid et al. 2023b).