EDUCATION
IMPACT OF THE NEW UNITED STATES MEDICAL LICENSING EXAMINATION ON THE CERTIEICATION PROCESS OF THE EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES ALTON I. SUTNICK, M.D., MARIE L. SHAFRON, AND MARJORIE P. WILSON, M.D.
The evolution of the United States of America from 13 separate colonies resulted in a distribution of the responsibility and authority between the state governments and the federal government in the United States constitution. Medical licensure is one of those functions that are designated to be under the authority of the state. Consequently, at one time, each state developed its own individual examination for qualifying for medical licensure in that state. An organization composed of all of the state medical licensure boards, the Federation of State Medical Boards, was founded in 1912' and ultimately developed a single examination (Federation Licensing Examination or FLEX), which was first administered in 1968 and was accepted by all state medical boards. The National Board of Medical Examiners (NBMF.) was founded in 1915^ to develop an examination, which was first administered in 1922. This became an acceptable examination in most states, and became the principal route of licensure of graduates of United States medical schools. Approximately 75% of United States medical graduates meet the examination requirements for licensure by successful completion of National Board examinations Parts I, II and III.' But even today, two states (Louisiana and Texas) do not accept the NBME certifying examinations for purposes of licensure within those states.''
ciency test. (4) Document completion of the educational requirements to practice medicine in the country in which they have received their medical education. The examination requirements have been met principally by taking the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS), which consist of a basic medical science component (Day 1) and a clinical science component (Day 2). The examination is given semiannually in January and July on two successive days in centers throughout the world.'' Graduates of foreign medical schools have not been eligible to take the NBME certifying examination, and that route to licensure was not open to them. If state law requires an unrestricted license to complete a residency in that state, or if a license is desired for some other purpose, it has been necessary to take FLEX. In 1989, responding to concerns of discrimination, NBME allowed the first administration of NISME Part 1 (basic medical science) and Part II (clinical science) for purposes of ECFMG certification.^ Graduates of foreign medical schools were still not eligible to take NBME Part III to complete the examination requirements for licensure. Part I was administered semiannually in June and September on two successive full days. Part II was administered in April and September on two successive full days. The distribution of subject matter of the test items is in the same proportion as that of FMGEMS, but Part I and Part II were double the length of their FMGEMS counterparts. That same year, an agreement was reached between the major organizations involved to support the concept of a single examination pathway for licensure acceptable to all of the state medical boards, academic institutions, and agencies. This resulted in the development of the United States Medical Licensing Examination (USMLE) of which Steps 1 and 2 are being administered for the first time in 1992, and Step 3 will be administered for the first time in 1994.-' With the development of USMLE, certification by ECFMG has become much more closely tied to the medical licensing process in the United States. After 1993, the only medical science examination administered for ECFMG certification will be USMLE Steps 1 and 1J In contrast to the previous policy, those who are successfully certified by EGFMG through Steps 1 and 2 of USMLE will be eligible to take Step 3, completing the examination requirements for licensure in all 54 licensure jurisdictions of the United States.^ Because the
ECFMG
The Educational Commission for Foreign Medical Graduates (ECI'MG), a nongovernmental, nonprofit organization, evolved from the Educational Council for Foreign Medical Graduates, which was established by the major medical service and educational organizations in the United States in 1956.' Through a program of certification, which began in 1958, ECFMG assesses the readiness of graduates of foreign medical schools to enter residency or fellowship programs in the United States. To earn ECFMG certification, graduates of foreign medical schools are required to: (1) Pass an examination in basic medical science. (2) Pass an examination in clinical science. (3) Pass an English language profiFrom the Educational Commission for Foreign Medical Graduates, Philadelphia, Pennsylvania. Address for correspondence: Alton I. Sutnick, M.D., E.C.F.M.G., 3624 Market Street, Philadelphia, PA 19104-2685. 798
Certification of Foreign Medical Graduates Sutnick. Shafron. and Wilson
medical science examination for ECFMC, certification will now represent two of the three steps of the medical licensing examination, they will be administered on the same schedule as administrations of USMLE for licensure purposes in the United States.
are geared to United States time schedules. Time and experience may cause the scheduling process to be modified. Also, while there will be approximately a 30% reduction in the number of test centers outside of the United States and Canada, from the 104 such centers currently administering FMGEMS, the distribution will be such as to maintain reasonable access.
TRANSITION PERIOD
During the transition period, graduates of foreign medical schools may take any of the following examinations for purposes of meeting the ECFMG medical science examination requirement: FMGEMS, NBME Parts I and II, and USMt^E Steps 1 and 2. Passing any of these examinations enables graduates of foreign medical schools to meet the medical science examination requirement for ECFMG certification,^ and for a visa to enter the United States. Only USMLE Steps 1 and 2 (or NUME Parts I and II) may fulfill part of the examination requirement for an unrestricted license to practice medicine.** IMGEMS has never been accepted for this purpose. The last FMGEMS will be administered in July, 1993, and the last regular administration of FLEX will be in December, 1993. Consequently, for those who have become certified by ECFMG by passing FMGEMS Days 1 and 2, the last opportunity for obtaining a medical license in the United States without taking all three steps of USMLE will be the FLEX administration in December, 1993. This has timing implications for graduates of foreign medical schools applying to residency programs in the United States, particularly if the program is located in a state that requires passing the medical licensure examination prior to completion of the residency. It is incumbent upon these applicants to inquire about the licensure examination requirements for residency in the states in which they seek graduate medical education. A number of states allow completion of a residency with a license restricted to practice within an educational system, a special certification for residency purposes, or even without any documentation from the State Medical Board. For those intending to return to their home countries after completion of a residency, there may be an adequate selection of highly qualified residency programs in states that have no requirement for an unrestricted license for residents.'' Other issues relate to the duration of the examination, its scheduling, and the number and distribution of test centers. The basic medical science and clinical science examinations of FMGEMS were each administered in a single day, and for those who must travel to a test center outside of their city of residence, or even to another country, the examinations were administered on two successive days, so the applicant would incur minimal travel expenses to become certified by ECFMG. USMLE Steps 1 and 2 are each two days in duration, which will limit the feasibility of taking Steps 1 and 2 during a single test administration. In scheduling examinations for medical licensure within the United States, the practicalities of administering and scoring those examinations
CONCLUSIONS
As the United States standardizes the examination for obtaining a license to practice medicine in all 54 of its licensure jurisdictions, the first two steps of the licensing examination will soon be the only medical science examination administered for ECFMG certification. Questions have arisen regarding the applicability of pre-existing EGFMG certifying examinations to the licensure process, the transition to the standardized examination system, the construction of the examination, the scheduling of its administration, and the distribution of test centers. All of these have an impact on those seeking graduate medical education in the United States, which they will have to consider in planning that stage of their academic careers.
REFERENCES
1.
2.
3. •
4. 5.
6.
7.
8.
799
FLEX and SPEX Information Bulletin 1992. Fort Worth: The Federation of State Medical Boards of the United States, Inc., 1992. Voile RL. The President's statement. National Board of Medical Examiners, 75th Anniversary. In: Service to medicine: a special review. Philadelphia: National Board of Medical Examiners, 1990. 1992 Information Booklet: l-.ciMG Certification and Application for Step 1 Examination, Basic Medical Sciences, Step 2 Examination, Clinical Sciences of the United States Medical Licensing Examination (uSMLE). Philadelphia: Educational Commission for Foreign Medical Graduates, 1992. Exchange 1989-1990. Fort Worth: The Federation of State Medical Boards of the United States, Inc., 1989. Educational Commission for Eoreign Medical Graduates Annual Report 1989. Philadelphia: Educational Commission for Foreign Medical Graduates, 1989. 1992 Information Booklet and Application: Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS) and L£CFMG English Test. Philadelphia: Educational Commission for Foreign Medical Graduates, 1992. HCFMG Information Booklet and Application for Part I Examination, Basic Medical Sciences, Part II Examination, Clinical Sciences of the National Board of Medical Examiners. Philadelphia: Educational Commission for Foreign Medical Graduates, 1992. USMLE United States Medical Licensing Examination, A Joint Program of The Federation of State Medical Boards of the U.S., Inc. and the National Board of Medical Examiners: 1992 Bulletin of Information. Fort Worth: The Federation of State Medical Boards of the United States, Inc., and Philadelphia: National Board of Medical Examiners, 1992.
IMPACT OF THE NEW UNITED STATES MEDICAL LICENSING EXAMINATION ON THE CERTIEICATION PROCESS OF THE EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES ALTON I. SUTNICK, M.D., MARIE L. SHAFRON, AND MARJORIE P. WILSON, M.D.
The evolution of the United States of America from 13 separate colonies resulted in a distribution of the responsibility and authority between the state governments and the federal government in the United States constitution. Medical licensure is one of those functions that are designated to be under the authority of the state. Consequently, at one time, each state developed its own individual examination for qualifying for medical licensure in that state. An organization composed of all of the state medical licensure boards, the Federation of State Medical Boards, was founded in 1912' and ultimately developed a single examination (Federation Licensing Examination or FLEX), which was first administered in 1968 and was accepted by all state medical boards. The National Board of Medical Examiners (NBMF.) was founded in 1915^ to develop an examination, which was first administered in 1922. This became an acceptable examination in most states, and became the principal route of licensure of graduates of United States medical schools. Approximately 75% of United States medical graduates meet the examination requirements for licensure by successful completion of National Board examinations Parts I, II and III.' But even today, two states (Louisiana and Texas) do not accept the NBME certifying examinations for purposes of licensure within those states.''
ciency test. (4) Document completion of the educational requirements to practice medicine in the country in which they have received their medical education. The examination requirements have been met principally by taking the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS), which consist of a basic medical science component (Day 1) and a clinical science component (Day 2). The examination is given semiannually in January and July on two successive days in centers throughout the world.'' Graduates of foreign medical schools have not been eligible to take the NBME certifying examination, and that route to licensure was not open to them. If state law requires an unrestricted license to complete a residency in that state, or if a license is desired for some other purpose, it has been necessary to take FLEX. In 1989, responding to concerns of discrimination, NBME allowed the first administration of NISME Part 1 (basic medical science) and Part II (clinical science) for purposes of ECFMG certification.^ Graduates of foreign medical schools were still not eligible to take NBME Part III to complete the examination requirements for licensure. Part I was administered semiannually in June and September on two successive full days. Part II was administered in April and September on two successive full days. The distribution of subject matter of the test items is in the same proportion as that of FMGEMS, but Part I and Part II were double the length of their FMGEMS counterparts. That same year, an agreement was reached between the major organizations involved to support the concept of a single examination pathway for licensure acceptable to all of the state medical boards, academic institutions, and agencies. This resulted in the development of the United States Medical Licensing Examination (USMLE) of which Steps 1 and 2 are being administered for the first time in 1992, and Step 3 will be administered for the first time in 1994.-' With the development of USMLE, certification by ECFMG has become much more closely tied to the medical licensing process in the United States. After 1993, the only medical science examination administered for ECFMG certification will be USMLE Steps 1 and 1J In contrast to the previous policy, those who are successfully certified by EGFMG through Steps 1 and 2 of USMLE will be eligible to take Step 3, completing the examination requirements for licensure in all 54 licensure jurisdictions of the United States.^ Because the
ECFMG
The Educational Commission for Foreign Medical Graduates (ECI'MG), a nongovernmental, nonprofit organization, evolved from the Educational Council for Foreign Medical Graduates, which was established by the major medical service and educational organizations in the United States in 1956.' Through a program of certification, which began in 1958, ECFMG assesses the readiness of graduates of foreign medical schools to enter residency or fellowship programs in the United States. To earn ECFMG certification, graduates of foreign medical schools are required to: (1) Pass an examination in basic medical science. (2) Pass an examination in clinical science. (3) Pass an English language profiFrom the Educational Commission for Foreign Medical Graduates, Philadelphia, Pennsylvania. Address for correspondence: Alton I. Sutnick, M.D., E.C.F.M.G., 3624 Market Street, Philadelphia, PA 19104-2685. 798
Certification of Foreign Medical Graduates Sutnick. Shafron. and Wilson
medical science examination for ECFMC, certification will now represent two of the three steps of the medical licensing examination, they will be administered on the same schedule as administrations of USMLE for licensure purposes in the United States.
are geared to United States time schedules. Time and experience may cause the scheduling process to be modified. Also, while there will be approximately a 30% reduction in the number of test centers outside of the United States and Canada, from the 104 such centers currently administering FMGEMS, the distribution will be such as to maintain reasonable access.
TRANSITION PERIOD
During the transition period, graduates of foreign medical schools may take any of the following examinations for purposes of meeting the ECFMG medical science examination requirement: FMGEMS, NBME Parts I and II, and USMt^E Steps 1 and 2. Passing any of these examinations enables graduates of foreign medical schools to meet the medical science examination requirement for ECFMG certification,^ and for a visa to enter the United States. Only USMLE Steps 1 and 2 (or NUME Parts I and II) may fulfill part of the examination requirement for an unrestricted license to practice medicine.** IMGEMS has never been accepted for this purpose. The last FMGEMS will be administered in July, 1993, and the last regular administration of FLEX will be in December, 1993. Consequently, for those who have become certified by ECFMG by passing FMGEMS Days 1 and 2, the last opportunity for obtaining a medical license in the United States without taking all three steps of USMLE will be the FLEX administration in December, 1993. This has timing implications for graduates of foreign medical schools applying to residency programs in the United States, particularly if the program is located in a state that requires passing the medical licensure examination prior to completion of the residency. It is incumbent upon these applicants to inquire about the licensure examination requirements for residency in the states in which they seek graduate medical education. A number of states allow completion of a residency with a license restricted to practice within an educational system, a special certification for residency purposes, or even without any documentation from the State Medical Board. For those intending to return to their home countries after completion of a residency, there may be an adequate selection of highly qualified residency programs in states that have no requirement for an unrestricted license for residents.'' Other issues relate to the duration of the examination, its scheduling, and the number and distribution of test centers. The basic medical science and clinical science examinations of FMGEMS were each administered in a single day, and for those who must travel to a test center outside of their city of residence, or even to another country, the examinations were administered on two successive days, so the applicant would incur minimal travel expenses to become certified by ECFMG. USMLE Steps 1 and 2 are each two days in duration, which will limit the feasibility of taking Steps 1 and 2 during a single test administration. In scheduling examinations for medical licensure within the United States, the practicalities of administering and scoring those examinations
CONCLUSIONS
As the United States standardizes the examination for obtaining a license to practice medicine in all 54 of its licensure jurisdictions, the first two steps of the licensing examination will soon be the only medical science examination administered for ECFMG certification. Questions have arisen regarding the applicability of pre-existing EGFMG certifying examinations to the licensure process, the transition to the standardized examination system, the construction of the examination, the scheduling of its administration, and the distribution of test centers. All of these have an impact on those seeking graduate medical education in the United States, which they will have to consider in planning that stage of their academic careers.
REFERENCES
1.
2.
3. •
4. 5.
6.
7.
8.
799
FLEX and SPEX Information Bulletin 1992. Fort Worth: The Federation of State Medical Boards of the United States, Inc., 1992. Voile RL. The President's statement. National Board of Medical Examiners, 75th Anniversary. In: Service to medicine: a special review. Philadelphia: National Board of Medical Examiners, 1990. 1992 Information Booklet: l-.ciMG Certification and Application for Step 1 Examination, Basic Medical Sciences, Step 2 Examination, Clinical Sciences of the United States Medical Licensing Examination (uSMLE). Philadelphia: Educational Commission for Foreign Medical Graduates, 1992. Exchange 1989-1990. Fort Worth: The Federation of State Medical Boards of the United States, Inc., 1989. Educational Commission for Eoreign Medical Graduates Annual Report 1989. Philadelphia: Educational Commission for Foreign Medical Graduates, 1989. 1992 Information Booklet and Application: Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS) and L£CFMG English Test. Philadelphia: Educational Commission for Foreign Medical Graduates, 1992. HCFMG Information Booklet and Application for Part I Examination, Basic Medical Sciences, Part II Examination, Clinical Sciences of the National Board of Medical Examiners. Philadelphia: Educational Commission for Foreign Medical Graduates, 1992. USMLE United States Medical Licensing Examination, A Joint Program of The Federation of State Medical Boards of the U.S., Inc. and the National Board of Medical Examiners: 1992 Bulletin of Information. Fort Worth: The Federation of State Medical Boards of the United States, Inc., and Philadelphia: National Board of Medical Examiners, 1992.
