Introduction
The global healthcare market is massive and expanding and is having an unprecedented
influence on medical education around the world.
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Increased demand for healthcare has created demand for physicians over and above the
global shortage of physicians that has been well-recognized. This heightened demand
for physicians has led to a number of trends, such as an exponential increase in the
number of medical schools and medical students and migration for medical education
and training.
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This new global medical education system, marked by its growing size and complexity,
has led to greater concerns about quality assurance of individual graduates and their
educational programs. The purpose of this article is to describe current trends in
international medical education and how this has motivated others to act to assure
the quality of individual graduates and educational programs.
International medical schools and migration of medical students
The number of medical schools around the world has been increasing dramatically over
the last several decades, particularly in emerging economies, in response to legacies
of physician shortages and the increased demand for healthcare. In some locations,
such as India, Pakistan, China, and Brazil, this rapid growth is potentially beneficial
to scaling up physician training and meeting population needs. However, in other
locations, notably the Caribbean, there are far more medical schools than are needed
to serve the local population. This asymmetric growth in medical schools is likely
fostered by an increased willingness of individuals to travel for their medical education.
While the “brain drain” of trained physicians from low income to high-income settings
has been well-recognized, migration for undergraduate medical education is a growing
trend. Medical education programs that are taught entirely in English have developed
in non-English speaking countries, including those in Eastern Europe, Russia, Ukraine,
and China, to attract international students and allow graduates greater mobility
across European borders and entrance to practice in English-speaking areas.
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With the language barrier removed, students often seek these international medical
schools as admission may be less competitive or tuition costs lower than schools in
their home countries. Additionally, some schools, such as several in the Caribbean,
have modeled and developed their admissions processes and curricula after US medical
schools to attract international students.
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These different driving forces - the urge to seek medical education at lower cost
and at institutions that have less competitive admissions processes have ushered in
more complex patterns of migration than those of traditional “brain drain”. Generally,
there has been a decrease in the number of international students opting to study
in “resource-rich” countries,
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although many students still migrate from areas where medical education may not be
possible. Currently, North America, South Asia, and Africa are the largest sending
regions, and the Americas, Eastern Europe, China, and Russia are the most common receiving
regions of international medical students worldwide.
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China provides an example of how student flows are taking new patterns. There, health
professional students are currently the third largest group among all international
students, with the largest influxes coming from South Asian and African countries.
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Quality assurance of individuals and educational programs
The increases in new and non-traditional medical schools and medical student migration
have been drawing greater attention to assuring the quality of individual graduates
and medical education programs.
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Many new medical schools are starting in areas with limited quality assurance mechanisms,
leading to concerns about for-profit and predatory schools that capitalize on a student’s
desire to become a physician and on their ability to pay tuition. For example, reports
of some private medical schools have drawn attention to their lack of formal testing
or exams, and unconventional practices for granting credit hours.
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How quality is assured in medical education varies considerably from country to country,
as do training models. However, traditionally there have been two ways to assure quality,
assessment of the individual practitioner (e.g., licensure examinations) and accreditation
of a school or educational program. The globalization of the medical workforce and
evidence that suggests that foreign medical graduates perform more poorly on standardized
exams than graduates from local schools is leading to interest in more uniform ways
to conduct each quality assurance process.
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The National Board of Medical Examiners, which administers the series of licensing
exams in the US has partnered with international groups for decades and has created
the International Foundation of Medicine exams, which are being increasingly used
for assessment throughout the world. Some have advocated for uniform assessments and
licensure processes that allow individuals to cross borders to practice medicine and
would create a genuinely global physician workforce. Still, whether a country should
have a national licensing exam is hotly debated due to limitations in the evidence
available to show that these exams improve clinical practice and protect public safety.
Driven primarily by the rapid growth in schools, accreditation of medical education
programs or schools is drawing considerable interest from the international community.
The first set of global standards was published by the World Federation for Medical
Education (WFME) in 2003.
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In 2010, the Educational Commission for Foreign Medical Graduates announced that by
2023 all applicants would need to have graduated from a program accredited by an authority
that met WFME or other global criteria for an accrediting body.
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Since then accreditation for all health training programs by 2020 was recommended
as part of the World Health Organization’s Global Strategy on Human Resources for
Health: Workforce 2030 and was endorsed by the World Medical Association.
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While it seems unlikely that all areas with medical schools will have a WFME-recognized
accrediting authority by 2023, that a growing number of agencies are applying for
recognition, and completing the recognition process, suggests that the enthusiasm
of international organizations for accreditation is being taken up by local authorities.
Indeed, the growth in medical schools shows no signs of slowing, so that some mechanism
of formal external peer review of medical schools is likely to benefit medical education
internationally.
Conclusions
Globalization has dramatically impacted medical education and the development of physicians,
and the international landscape is likely to become ever more complex. Recognizing
the emerging trends in medical school growth and student migration will be critical
to directing the evolution of regulatory and quality assurance mechanisms to ensure
all physicians received a high-quality education that will permit the medical education
community to meet population health needs and maintain public trust.
Conflict of Interest
The authors declare that they have no conflict of interest.