Digest Standards Committee Hearing/Meeting Minutes
(Left) Dr. Jim Appleyard, Immediate Past President, World Medical
(Middle) IAOMC President Bernard Ferguson, J.D.,
(Right) Dr. Lynn Eckhert, Director, Harvard Medical International.
August 12, 2005
Grand Hyatt Hotel, 109 East 42nd St. New York, NY
The meeting opened with President Bernie Ferguson, JD, welcoming all in
attendance including representatives of: Mission of Sudan to United Nations
(UN); Permanent Bulgarian Mission to the UN; Dominican Medical Board; Medical
Board of Trinidad and Tobago, Medical Council of Ireland, Steve Seeling, JD, Vice
President, Education Commission Foreign Medical Graduates and Thomas
Monahan, Executive Secretary, New York State Board of Medicine, appearing as
an individual. Members of IAOMC committees and IAOMC Board Members were
also present. He then introduced the Immediate Past President of the World
Dr. Jim Appleyard
The practice of medicine respects but is not contained by national barriers because
suffering, disease and pestilence in one area of world impacts on others. And now the
explosion of knowledge and web communication in medicine that is accelerated
everybody into thinking globally
Historically, the European empire’s medical school grads had passport to ¼ of world.
The flow of physicians was from the developed to the undeveloped colonies of the world.
Then the empires dissolved, the new nations trained their own citizen medical students.
Licensure tests and processes are used for political purposes are adapted to meet the
perceived protectionism that some required.
Today there is a reverse flow of medical practitioners from the
undeveloped world to developed world. Recognition of overseas schools is an issue. There are difficulties
with the World Health Organization list of medical schools.
What is accreditation? Some claim it is a process that will gradually drive up standards
worldwide. Actually it is a process where you furnish credentials and you offer to
sanction schools. You are building on World Federation of Medical Education’s
minimum standards. Its purpose in adopting global standards was to safeguard the
practice of medicine, including manpower utilization, and its increasing
internationalization, by defining international standards for medical education. The
accreditation aim is to stimulate medical schools to formulate their own plans for change
and adopt quality improvement in association with these international regulations.
Standards must provide a broad base education with those three pillars of education;
skills, attitude, and behaviors. Put your ethical dimension as your top priority as a
standard. A well- established part of the accreditation process is self-evaluation. I think
your initiative to weight the standards is terribly important all
Kassabaum’s articles come to that conclusion. There must be adequate resources for clinical instructions. The top
standard is to encourage developing ethical principals caring for patients.
Now the fundamental requirements for an accreditation system are that it must be
trustworthy; based on academic competence, efficiency, transparency and fairness.
This is something that comes very clearly from reading the standards that you are
developing, and I warmly commend that.
Think global standards but apply them and act locally. Problems will start when
implementing global standards at local levels. Particularly true if the individual countries
and the countries you represent are too small to do it themselves. That means small
countries joining together with other countries.
The LCME accreditation did not consistently count for 45 percent of its standards.
Meaning they probably didn’t think them very important relative to others. You already
started on that journey to decide the weighting of the different standards.
I don’t think you should be ashamed at all of being for profit. Medicine has always
worked within the marketplace. We had to cope with market. The original contract, of
course, was between the patient and the physician and there had to be payment.
increasingly the concept was the public sector, therefore, was the particular custodian of
the medical conscious which all medical ethical principles.
Dr. Lynn Eckhert
– was then introduced by IAOMC Vice President Dr. Gordon Green.
She was the former Chair, ECFMG; Association of American Medical Colleges; and
appears here today as current Director, Academic programs at Harvard Medical
International (HMI); Harvard Macy Program.
Dr. Eckhert described the guiding philosophy of Harvard Medical International:
that every citizen of the world should have easy access to quality health care of a world
standard. Since 1994, HMI is the nonprofit subsidiary of Harvard University and of the
Medical School, providing an inner connecting board with Harvard Medical School and
Harvard University. Comprising 40 programs in 30 countries, with a staff of about 55,
HMI is committed to building an infrastructure related to either health care systems or
medical education, and interested in long-term partnerships.
Dr. Eckhert presented an overview of the undergraduate, post graduate, and
continuing education HM programs. Harvard Macy Programs are undergraduate
medical education programs headed by Liz Armstrong with a team that supports
hospitals and health care systems around the world. This team helps to improve policies
in building new hospitals and helping determine what staff is needed, re-educating
people, meeting the joint commission standards internationally, and providing education
regarding the management of these systems. Many areas around the world have asked
HMI to help develop basic research and ethics issues surrounding research, and how to
set up animal systems which may or may not exist in medical schools.
Dr. Eckhert spoke of the Harvard name recognition worldwide and of LCME aspiring
to a similar approach to standard development, and the current process for establishing
and meeting criteria for attaining those high levels. She said, “as citizens need access to
the highest quality health care systems, hospitals and physicians, it’s reasonable that
medical students should have access to high quality medical schools.”
She described the HMI health system’s division group that works with hospitals. HMI
does not accredit hospitals, but reviews them for the joint commission international
preparation; helps them with education for quality improvement; helps them do a selfstudy,
or does a study to determine which areas need improvement and how to move
toward that improvement; an educational program is then designed for the school with
the hospital in mind, using a format not dissimilar to the LCME. “There’s no joint
commission of international accreditation at this point; we’re not preparing people to
have an LCME accreditation, but we are looking at international standards and doing a
consultation saying we think you meet these kinds of standards, or we think that you
have these areas to address for improvement.”
Alluding to discussions with the Joint Commission of Hospitals regarding
the move from domestic accreditation to international accreditation, Dr. Eckhert said, “we share
the same history.” She described the process of setting up a consulting system where
they went to international hospitals, looked at the standards that they normally use for
domestic hospitals, determined areas needing improvement, taking part in an education
program to improve, and moving to the next level of actually having an accreditation
process. The commonalities were extraordinary: people from Brazil and India and the
Caribbean, the United States and the U.K., etc. agreed on most areas including patient
flow issues, operating room standards, and emergency room functions. The biggest
difference was in patient rights due to cultural differences; for example, counseling
services for students. You have to take into account what some of the differences are.
Zimbabwe had one of the most elaborate systems of community education; we
discovered we could apply some of those lessons here. An interesting ongoing
program is with one of the German schools. The medical students spend time at
Harvard; they design a new program of education for their own school. A group of eight
students from Germany put evidence-based medicine into their school curriculum.
Dr. Eckhert addressed the current LCME approach: First, defining the
standards and agreeing on them. Next, the process of reviewing the schools, and how to accomplish
self-assessment: what time does that take, how elaborate is it, who do you expect to do
it at which schools, who’s going to analyze the schools, what are their
credentials/ experience, and what do you expect of them?
Dr. Eckhert assumed that during testing some schools would look better than others.
If some things are added and/or some taken out, what are the results? And what are the
actions? Do you give accreditation for a long period of time or a short probation? With
many options it comes to redefining standards that the LCME is always adding or taking
away on a regular basis. She described possibilities for innovation with normal things at
the bottom — institution setting, educational programs, medical students, and faculty
issues. At the top were questions asking what contribution the school is really making to
either local, regional, national, international. What about the professionalism and social
responsibility? What do the public and patients think of your product?
In an ideal medical school, Dr. Eckhert said there are core competencies that all
graduates are expected to have. Those competencies are pretty much the same
worldwide. There are certain skills and knowledge, basic science, clinical science that
everyone needs to know, how we do it differs. Do evaluations include student
performance, long-term experience, doctors who are extraordinary, those that don’t do
so well? All schools: Canadian, American, U.K. should be doing those top items, but
that’s more innovative, and may be where you want to go.
She described some of the Macy educational programs, believing that may be where
any collaboration works best. Medical educational programs are created in institutions
that meet global, regional, and local needs. The interest is in both education and how it
interrelates with research and clinical, societal and academic missions, also
cost effective processes that support these goals. Macy works on creating educational
benchmarks to assure world-class quality and supports global networks; about 1,000
people have taken the Harvard/Macy Program. The approach is to look at the
assessment of the health care needs and the stakeholders, assess strengths and
weaknesses, do an analysis of medical schools; then establish priorities and time lines,
looking at their goals, their mission statements, their vision of success, how are they are
sustainable and the strategies involved.
Curriculum planning is the central area. If you decide what your curriculum is and put
it in the center, all other things follow: kinds of faculty needed, kinds of students to
recruit, the organizational structures. If you look at new medical schools around the
world, you find that the organizational structures of the usual anatomy, physiology,
biochemistry, etc. departments shift to fewer departments that are much more
integrated, much more amalgamated. Standards setting accreditation procedures must
allow for some of those changes. Facilities and technology are essential — particularly if
it’s going to be a new school and you design your curriculum mostly around lectures,
you’ll need great big lecture rooms. If curriculum has people moving away from lectures,
but towards small groups, facility design must meet those needs.
Dr. Eckhert proposed evaluation strategies moving schools away from the multiple
choice questions to using OSCIE’s, using simulated methods of assessment and
teaching. Policies have students involved in both designing and evaluating their
curriculum; an implementation plan for faculty prepared to make changes and to reach
standards being set.
Dr. Eckhert concluded with an overall description of Harvard Macy Programs as a
continuation of faculty development from information to transformation. Two major
programs are 1) physician educator and 2) a leadership program focused on negotiating
change and leading the new challenges in medical education. The benefits of
attendance: to practice improved teaching skills, learn about measuring education
outcomes, improve teaching skills, develop strategies for project development, develop
new perspectives to assist in working with teams, and an opportunity to network with
The Meeting/hearing of the Standards Committee followed.
Present: (Left to right)
St George’s University Joe Feldman, MD
American University of the Caribbean, . Fr. Jeff Hamblin, MD
Our Lady of Fatima University, Vic Santos, MD
St. George’s University Mary Jo Demilia, MD
St. Matthew’s University Andy Vaithilingham, PhD
Saba University Joe Chu, MD Committee Chair
Saba University Pat Huff, MD
Universities of Lubin and Selesia Shokat Fattah, MD Hope Medical Institute
Ross University Nancy Perri, MD
Joe Chu, M.D. committee chairman, opened the Standards Committee meeting. He said that everyone should have a copy of the proposed standards that were previously
published on the Internet and distributed. The document in hand is a draft, with no final
adoption expected during the meeting. He asked to have the committee people, as well
as audience members, comment on concerns for consideration. The following issues
Weighting of each of the different standards. Should certain things that we think
are more important be weighted more in terms of the evaluation and accreditation? Also perhaps develop a system to look at the way the standards
are applied by different individuals to institutions. How we evaluate specific sites
and how the faculty meet. Someone suggested a purpose of the weighting be some minimum set of standards that were absolute. There’s no possible way to
achieve accreditation if certain items were not met; other items could perhaps not
be met and yet represent some sort of partial accreditation.
Distance education, from being a virtual campus to having recognized
opportunities for student education. Distance learning involves teaching by
blocks rather than by weeks, and is based on whenever the student wants to
take the courses. Part of the discussion focused on the development and measure of a standard for competency. Whether it’s interactive or in CME you
check, and it gives you a result. The ultimate question for accreditation is
making sure that everyone can have access to a high standard or good level of
care, and can competency be measured only in the sense of a number of weeks?
American students who study at foreign medical schools, take licensing exams in the
various boards, or practice in the various state boards. Vic Santos said initial focus
should address minimum requirements of the state boards concerning their basic
sciences. The students must have a specific number of required hours and then
practice in the clinical area. Focus should be on the minimum requirements of the state
boards. Forty-seven states require 128 weeks for licensure, but other countries may not
require as many; to be global, we need to address them.
Most of our students are going to be taking the licensing exams in the United States;
therefore, the various state boards would have their own requirements. It’s essential that
we meet their minimum requirements. Whose responsibility is it to know what the
requirements are in the country that you want to practice in? Is it up to the student to
know what the requirement is and that School A meets the requirement, and School B
does not, or is it the school’s responsibility to meet the requirements for every country?
Should there be accreditation within this group that is categorized on different subsets of
standards? Hypothetically we have standards for students who want to come back to the
states. You’re accrediting medical schools, you have to have the flexibility and the
standards so that it will allow people to go through the process and ultimately practice
medicine wherever they want. When LCME goes out, they don’t worry about licensure,
they worry about getting people through an acceptable program of medical education.
Minimum number of weeks of education for curricula content: a breakdown of
how detailed we want to be in terms of how many weeks of basic science, how
many weeks of clinical experiences, and do we want to be even more proscriptive in what they should be? Joe Chu urged caution in terms of the
numbers of weeks of education and the number of months of education as it relates to licensure requirements. Not just the United States but various countries
around the world should be relatively general in the way that a standard is
Dr. Dorrian Shillingford, Dominican Medical Board makes a point,
Steve Seiling JD, looks on.
An audience member mentioned page 5 under Mission and Objectives, Objective
#2, General Design says, “the educational program must be at least 130 weeks in
duration. That includes the basic science as well as the clinical training.” There’s some
language that clarifies the MD degree because most countries around the world don’t
confer the MD degree. You might want to call it the MD or equivalent or comparable
degree for starters. That 130 weeks is directly or mostly from the LCME standards. In
New York it’s 32 months which works out to be 4 academic years, close to 130 weeks.
An audience member cited page 10-D of the document under Clinical Sciences Number
6 (VI) “Medical students shall participate in clinical courses and rotation not less than 72
weeks in duration.” So hypothetically, the 72 minus the 130, if you want to be minimal, is
a number that is 58 weeks of basic science. The question is do we want to be so
proscriptive the numbers mean you get very little basic science? Another member asked
if that list of clinical rotations is core-mandated?
Standards Committee member Fr. Jeff Hamblin, MD,
AUC provides input as Vic Santos, MD Our Lady of Fatima, looks on.
There are some places where you may not find all fields included in core rotations. An
example would be family practice. The concern is we should just mention about 72
weeks. European Union has a different set of standards that apply to certain schools in
Polish settings, where they don’t require family medicine as part of core locations. If you
become too specific, it may become an issue for many other medical schools. If you just
say 72 weeks of clinical training that would be very helpful. You also may not want to
designate the number of weeks in each course for clinical rotation because that will vary
from country to country. The concern with this issue is some might hear that a clinical
program should be at minimum 72 weeks in duration. Again we can address that as it
applies more globally.
Dr. Muris Fitzgerald, Irish Medical Council, states his opinion
Muris Fitzgerald, Irish Medical Council, said in Europe there’s an ethical focus within
a framework. He said standards that are prescriptive in terms of hours and subject
matter as were out of touch with reality when compared with the diversity of educational
activity that exists in reality out there.
Vic Santos agreed with diversity of curriculum across nations but said we should
emphasize a basic core of knowledge and the basic subject matter within a different
framework of time. He recommended not assessing a real figure but putting in a figure
as a recommended number. He said the committee should say this is a recommended
model time but it will have to boil down to the core teaching and core knowledge.
A proposal was made to not put in a number either for the number of weeks, for the
entire curriculum, or the number of weeks of clinical. In parentheses insert the LCME
standard is and give them an idea what the standard is. Let the site visit teams deal with
the fact; if they’re so far outside of what we’re considering, they’re going to have to justify
it somehow within their application. Rebuttal was if we don’t set a minimum number,
then our standards lose credibility. Others agreed there should be a minimum number of
weeks requirement, then leave it up to the institution. Two different systems were
mentioned: medical education may be five to eight years, yet people come with a
baccalaureate degree before they go to four years of medical school. If you’re going to
use our model you need to have one standard for people who have a baccalaureate
entering that kind of medical school and another standard for people who are coming out
of high school.
The discussion looked at accrediting institutions that would provide medical knowledge throughout a world with diverse needs. Someone suggested a modular idea
with different levels that an institution would seek to achieve. If you’re in a very
undeveloped nation or culture, perhaps you don’t need to be providing all of the various
levels of education that are required in more developed institutions, so we just provide
more latitude in ideas. Another suggestion was prescribing a number — we, as an
accrediting institution, stipulate our prescriptive norm; however, if you have an
explanation of how this content was covered within your curriculum, we would accept
that. We can explain that this is not a firm number, provided you can demonstrate
equivalent education. In other words, if you can explain the standard and how we will
apply it so everyone will know if there’s leeway here, all we’re looking for is the essence
of the education, not a particular number. Some felt it was better to always have higher
standards with some degree of flexibility than have some kind of low standard. You
never approve anybody with that low standard but everybody’s going to look at that and
use it as a benchmark.
Dr Neil Singh, Medical Board of Trinidad and Tobago talks as
Dr. Fredrick, Saba University listens
The question, ‘what do we think is acceptable medical education?’ Different major
points were made to determine what is driving this whole discussion — if we are talking
about standards for the world or standards just for the United States. Medical educators
believe that medical education should encompass certain minimal principles. The
strengths and weaknesses of potential approaches were discussed.
A deadline for rewrite was suggested. The five different sections within the
standards were discussed and assigned:
Programs for the MD Degree
The Medical Student - Jim and Andy
The Faculty - Shokat
Educational Resources – Victor
The Committee meeting was
called to a close.
Bulgaria’s Representatives; Anna Ruski and Dr. Elena Piperkova
Tom Monahan, NY, Steve Seeling, JD, ECFMG Dr. Lynn Eckhert
Drs. Jim Appleyard and Juliet Santos talk while her son listens
President Bernie Ferguson announced there had been some complaint that there
was insufficient notice of this meeting to discuss standards. He read the communication from the United Kingdom’s General Medical Counsel to that effect
and therefore extended the time for written comment to be certain everyone has
the opportunity to provide his or her opinion and/or recommendations.