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ISSN: Print -2349-0977, Online - 2349-4387

 Table of Contents  
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 21-24

Evaluation and certification of Foreign Medical Graduates: Roots, global practice, and methodology

1 Executive Director, National Board of Examinations, Vardhman Mahavir Medical College, New Delhi, India
2 Additional Director, National Board of Examinations, Vardhman Mahavir Medical College, New Delhi, India
3 Research Associate, National Board of Examinations, Vardhman Mahavir Medical College, New Delhi, India
4 Department of Radiodiagnosis, Vardhman Mahavir Medical College, New Delhi, India

Date of Web Publication26-Oct-2015

Correspondence Address:
Dr. Anurag Agarwal
National Board of Examinations, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2349-0977.168249

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Instituted by the Medical Council of India in 2002 through a duly vetted legal process, the Foreign Medical Graduates Examination conducted by the National Board of Examinations is a licensure exam, which aims to sift the charlatans from those who have acquired their medical degrees from another country, but are knowledgeable and skilled enough to bolster the country's physician workforce. Set up on the lines of similar screening exams held by countries across the world, the exam is an exercise in transparency, with a well-defined curriculum, which specifies the distribution and weightage of each subject, has no negative marking, and no limit on the number of attempts. Bereft of any competitive edge, the exam is extremely candidate-friendly, and yet, a positive step intent on preserving the piety and nobility of the medical profession.

Keywords: Computer based platform, Educational Council for Foreign Medical Graduates, Foreign Medical Graduates, General Medical Council, Medical Council of India, National Board of Examinations, Professional and Linguistic Assessments Board

How to cite this article:
Batra B, Agarwal A, Gupta A, Agarwal Y. Evaluation and certification of Foreign Medical Graduates: Roots, global practice, and methodology. Astrocyte 2015;2:21-4

How to cite this URL:
Batra B, Agarwal A, Gupta A, Agarwal Y. Evaluation and certification of Foreign Medical Graduates: Roots, global practice, and methodology. Astrocyte [serial online] 2015 [cited 2022 Jul 3];2:21-4. Available from: http://www.astrocyte.in/text.asp?2015/2/1/21/168249

  Introduction Top

Of the global human resource, physician workforce is a most precious wealth. Knowledgeable, clinically adroit physicians are the founding basis of quality healthcare services in a community. If a country's healthcare needs have to be met, a robust adequate taskforce of physicians, nurses, and paramedics is a must. With the demographic trends in developed countries favoring a burgeoning rise in aging population, a large majority of the global physician workforce must emanate from countries that enjoy the demographic dividend of a young population.

Slated to emerge as the world's most populous country by 2028, India requires to build its pool of medical doctors, who should be suitably equipped to handle the people's needs within its geographic borders and, simultaneously, be in such numbers as to fulfill the healthcare wants of other countries. The existing infrastructure of medical schools in the country, however, falls far short of meeting this goal. If the World Health Organization's (WHO's) standard physician: population norms have to be met, a critical mass of good, well-grounded medical schools is essential to breed a larger number of physicians. Conversely, the hiatus also can be filled by physicians who have imbibed medical education and training in other countries.

The big challenge, however, lies in ensuring that these Foreign Medical Graduates (FMGs), whatever be their seat of medical education and clinical training, are well-equipped to meet the healthcare needs of the people. While the Medical Council of India and other regulatory bodies act as a vigilant guardian for regulating medical education and clinical skill learning in the country, the same cannot necessarily be said about medical schools which operate in some of the other countries, where pecuniary gains, not standards, act as the singular thrust force. The admission norms, curricula, size and training of the faculty, quality of laboratories, and availability of medical equipment, and teaching and evaluation methods in these medical schools do not generally conform to regulations and values which nurture excellence in medical education.

Faced with this stark dichotomy—wherein FMGs must be imbibed into a perennially short-staffed healthcare system and, yet, the standards of healthcare must not suffer due to any inadequacy on the part of foreign-trained medical graduates—many countries have devised their own evaluation and certification program for FMGs. The system scrutinizes the credentials of the medical schools they graduate from and examines their medical knowledge and clinical skills before letting them cross the threshold into country's healthcare institution.

  Global Practice Top

Each country has an examining body, with its individual set of regulations, standards, and pattern of examination. Of the two such oldest international bodies, the Educational Council for Foreign Medical Graduates (ECFMG) conducts the exam in the United States while the General Medical Council (GMC) holds the Professional and Linguistic Assessments Board (PLAB) tests in the United Kingdom.

Established in 1956, the ECFMG is a nonprofit organization headquartered in Philadelphia, Pennsylvania. Responsible for a certification program which has endured well for now close to six decades, it has till date certified more than 320,000 international medical graduates.[1] Its robust three-step evaluation and certification program ensures that FMGs must meet the minimum standards in diverse patient care situations. The screening mechanism is rigorous: Beginning with a thorough scrutiny of documents relating to candidates' medical education, a proficiency test in English language, and a comprehensive exam in medical sciences. It conducts the Step 2 clinical skills test, which is in partnership with the National Board of Medical Examiners. Candidates passing this test are allowed to participate in patient care under supervision. However, if a candidate wishes to obtain an unrestricted license to practice medicine in the United States, he/she must qualify the Step 3 of the United States Medical Licensing Examination (USMLE).[2]

Each year, thousands of FMGs apply to ECFMG for USMLE. Only about one-half of them bite success. Between 1986 and 2005, a 20-year period, more than 267,000 International Medical Students/graduates applied to take theirfirst examination with ECFMG; of them, only 57.2% ultimately achieved certification despite repeated tries.[1]

The PLAB test held by the GMC, which allows FMGs to practice medicine in the UK under limited registration, has two parts. The Part 1, a 3-hour exam, has 200 extended matching questions and single best answer (SBA) questions. The Part 2, a 1-hour and 40 min exam, is, essentially, a 14-station objective structured clinical examination. The GMC requires the candidate to possess primary medical qualification from an institution listed in the WHO Directory of Medical Schools, qualify a skill test in English language, and must have 12 months' postgraduate clinical experience at a teaching hospital before being allowed to take the test. Between 2010 and 2014, a 5-year period, the pass percentage in the PLAB test has varied between 35% and 71%.[3]

Akin to these bodies, the Medical Council of Canada conducts a Qualifying Examination for FMGs who wish to work in Canada [4] while the Australian Medical Council does an analogous job in Australia. A host of other countries be it in Asia or Europe, observe a similar policy, although some consider the ECFMGE and PLAB tests as credible.

The sentient goal of these qualifying exams is to assess the clinical knowledge, skills and readiness of FMGs before being allowed to foray into country's healthcare mainstream—be it as a resident doctor in a clinical training program, a fellowship program, or as a primary health care physician.

  The Indian Landscape Top

In wake of mushrooming of exploitative medical schools in the former Soviet Union, Eastern European countries, China, Nepal, Philippines, and Caribbean countries, where entrance requirements were virtually nonexistent and standards of medical education and clinical training inconsistent and suboptimal, if not entirely dubious, the Medical Council of India incepted a licensure examination, a screening test for FMGs, in 2002.[5] Conducted by the National Board of Examinations (NBE), the qualifying exam has come to be known as the Foreign Medical Graduates Examination (FMGE). Any Indian citizen, who has taken a medical degree from a foreign medical school listed in the WHO Directory of Medical Schools,[6] is eligible to take the exam.

The screening test, which is based on the curriculum and standards of knowledge in a graduate degree program in medicine, must be cracked before an FMG is given a license to practice medicine in India. In the early years, the legality of the test was challenged in the Indian courts,[7] but a three-member bench of the Supreme Court of India upheld its necessity in 2009.[8],[9]

  The Methodology Top

Conducted twice at 6-monthly interval each year, the NBE-run FMGE comprises of 300 SBA questions, distributed in two parts of 150 questions each, and held on the same day. Each part is a 150-minute affair, allowing the candidate a minute for each item. A well-defined curriculum, specifying the distribution and weightage of each subject [Table 1], with no negative marking, and no limit on the number of attempts a candidate may take, makes the exam extremely candidate-friendly.
Table 1: Distribution and Weightage of Subjects in Foreign Medical Graduates Examination

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Each item, carefully picked from a bank of questions designed by subject experts who are faculty members in their respective disciplines and are actively involved in undergraduate teaching, training, and research, goes through a detailed review process. Three or more subject experts evaluate the item for its appropriateness, correctness, reliability, and validity in a rigorous item-validation workshop. Care is taken to ensure that each item follows the prescribed syllabus, falls well within the purview of standards of a graduate degree in medicine, and secrecy is not compromised at any stage. Each question paper is generated without human intervention with the help of a computer program from a large validated pool of questions.

Being a qualifying examination, and not a competitive examination, makes the task of passing the exam easier. Each item is a test of basic knowledge, is based out of vital and essential knowledge areas, and has a low difficulty and low discriminative score. All candidates scoring 150 or more items correctly make the grade.

With the exam having evolved from a paper-based testing (PBT) platform to a computer-based platform (CBT) since 2014, the process has become friendlier, more transparent, more clinical skill based, and with little or no possibility of error. A candidate can modify his/her response during the exam, which is not possible with PBT, where a candidate must darken a circle in the Optical Mark Reader sheet for the response. Since images, audiovisual clips, X-rays, electrocardiography, and the like can be used easily, a test of practical skills is simple to perform. Furthermore, as CBT keeps a digital record of the fingerprints of the candidate, impersonation is not possible. Care is also taken to record the entire process of examination, which precludes the use of unfair means. The robust CBT program even analyzes and determines the statistical difficulty and discriminatory indices of each item.

  Conclusion Top

Sir William Osler, the celebrated 19th and early 20th century Canadian physician, a founding professor of Johns Hopkins Hospital, the man who created the first residency program for specialty training of physicians, and the first teacher to bring medical students out of the lecture hall for bedside clinical training, is recorded to have once stated:

The higher the standard of education in a profession, the less marked will be the charlatanism.

The FMGE is powered by this simple yet powerful thought. If the once-prized medical profession has to live up to its piety and nobility, the charlatans and charlatanism must not gain ground. Work is the open sesame of every gateway, the great equalizer in the world, the true philosopher's stone which transmutes all the base metal of humanity into gold. A robust qualifying exam for a license to medical practice avers to this philosophy and cements the place of a doctor in the community.

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Conflicts of interest

There are no conflicts of interest.

  References Top

ECFMG. Educational Commission For Foreign Medical Graduates – Overview. Available from: http://www.ecfmg.org/about/. [Last cited on 2015 Aug 25].  Back to cited text no. 1
Brigham A, editor. Program Student Handbook – School of Medicine and Public Health. Madison: University Of Wisconsin; 2015. p. 109.  Back to cited text no. 2
General Medical Council. PLAB Pass Rates; 2015. Available from: http://www.gmc-uk.org/doctors/plab/23456.asp., [Last accessed on 2015 Aug 25].  Back to cited text no. 3
Medical Council of Canada. Medical Council of Canada Qualifying Examination. Available from: http://www.mcc.ca/examinations/mccqe-part-i/. [Last cited on 2015 Aug 25].  Back to cited text no. 4
Medical Council of India. Screening Test Regulations 2002; 13th February, 2002; [No. MCI-203 (9)/2001-Regn]. Available from: http://www.mciindia.org/RulesandRegulations/ScreeningTestRegulations2002.aspx. [Last cited on 2015 Aug 25].  Back to cited text no. 5
World Federation for Medical Education and the Foundation for Advancement of International Medical Education and Research. World Directory of Medical Schools, Available from: http://www.wdoms.org/. [Last cited on 2015 Aug 24].  Back to cited text no. 6
Bhatnagar R. Have Foreign Degree? Clear Screening TestFirst, in the Times of India; November 16, 2004, 06.37PM IST: New Delhi; 2004.  Back to cited text no. 7
Mahapatra D. Foreign Degree won't do to be a Doc in India, in The Times of India. New Delhi: 2009.  Back to cited text no. 8
Wikipedia, in Medical Council of India Screening Test. Available from: https://en.wikipedia.org/wiki/Medical_Council_of_India_Screening_Test. [Last modified on 2015 Jul 29].  Back to cited text no. 9


  [Table 1]


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