THE CHALLENGE OF MEETING THE EDUCATIONAL NEEDS OF INTERNATIONAL MEDICAL STUDENTS AT SILESIA UNIVERSITY MEDICAL SCHOOL FOR THE CLINICAL FACULTY

A FORMIDABLE TASK!

WILLIAM H. HARVEY, PH.D.APRIL 29,2009

The Center of the Medical Educational Enterprise is:

THE MEDICAL STUDENT!

Primary purpose of any medical school:Educate the student to become a highly competent, well trained physician.Measure of that success for competency training here or abroad is medical student achievement.

Measure of that achievement:High pass on Step I and Step 2 of USMLESuccessful residency placementSuccessful achievement on Step 3 of USMLELicensure in the state of choiceThe medical school is less successful in its mission if it cannot provide the student the essential tools, resources or training to succeed in these activities

International Medical Schools have special challenges!IMS work with students in different cultural setting often with language challenges.Students may not has as strong academic skills as students in American medical schools.Some may not be as mature socially, academically or have poor time management or poor study skills.IMS may not have support systems to help students struggling academically, emotionally or socially.

Good IMS facilities will include:

Strong, committed facultyGood, up to date facilitiesGood library, with internet access to Medline and other relevant research sourcesAccess to financial aidComfortable, safe and affordable housingComprehensive and modern clinical exposure

My responsibility as a consultant to SILESIA is to evaluate:The living environment of SILESIA

The learning environment of SILESIA

The teaching environment of SILESIA

These inseparable elements all contribute to:

The total professional development of the medical students as measured by Board scores and residency placement. Consequently, these motivated students return to their homes, participate in post graduate training, become practicing physicians or engage in bio-medical research or a variety of other pursuits.

Assumptions for the medical student

IMS will provide an environment comparable as possible to American medical schoolAn attempt to create a learning, teaching, social environment that maximizes teaching and learning in the basic sciences and in the clinical rotationsThe outcome being competitive board scores and good residency placement

Good IMS will also include:Good student support servicesGood clinical placementGood residency placement

These latter two issues DEPEND UPON PERFORMANCE ON USMLE Step 1 + 2

Partnering between faculty and studentsIt is very important that faculty and administrators are aware of the changing nature of the USMLE exams!The medical student may have to take the initiative to remind the faculty how they can help students prepare for the USMLE!It is OK to teach the content of the USMLE exam!

The Ultimate responsibility is the students! You can try to work with the student and their peer group in preparing for these examinations, but ultimately they alone are responsible for being prepared. They cannot blame the faculty, school or administration for their lack of preparation.

The 500 kilo canary!!

IS STEP 1 AND 2 OF THE USMLE

http://www.usmle.org/Examinations/index.htmlQuick links

Step 1

Description

2009 USMLE Bulletin: Exam Contents

What does the USMLE do?The USMLE accesses a physicians ability to apply knowledge, concepts, and principles that are important in health and disease and that constitute the basis of safe and effective patient care.

Changes in the USMLEIn 2006, the USMLE completed its transition to FRED: FRED is a CBT format similar to the old CBT developed by Prometric, Inc.Dramatic increase in questions in broad based knowledge (more later)

Typical USMLE QuestionThe typical question screen in FRED has a question followed by a series of choices: you have a countdown timer, a review button: one clicks next to advance: screen will contain figures or color illustrations, typically to the right of question: gross photos, histo slides, radiographs, EMS etc.

Steps to complete ECFMG certificateGraduate from a medical school listed in the IMED. See www.ecfmg.orgPass Step 1 and 2 within a seven year periodPass Step 2 CK and CS exams (communication test)Have medical credentials verified by the ECFMGObtain an ECFMG certificate

IMGs in the USIn 2008, out of 902,053 physicians, 228, 665 IMGs received degrees from 127 countries accounting for 25.3% of the total physician count! In last 24 years non-IMG grew by 91.4%In last 24 years IMG grew by 170.2%The nation is projected to face a shortage of physicians between 85,000 and 96,000 in 2020! = more reliance on IMGs

Critical for the IMS Generally residency programs look for USMLE 1 scores above 200/82.

THE HIGHER THE BETTER!!

Median Step I scores for matches208 psychiatry and family medicine220 internal medicine and emergency med234 orthopedic surgery and radiology239 otolaryngology and dermatology243 plastic surgery

NGME

IMGs in the MatchApplicant200520062008U.S. IMG209124352694% U.S accept 55 51 50Non-U.S. 5554 6442 6992%Non accept 56 49 46U.S. Grads 14,719 15,008 15,206% U.S. accept 94 94 93

Council on Graduate Medical Education (COGME)

Changes in IMG populationNumbers of non-US IMGs are down: multiple issues here!More selective population of non-US IMGResidency placement of non-US IMG same as US IMG

USMLE ExamsStep 1 basic mechanisms and principles 336 questions/7 blocks 8hr passing score ~ 185(12/06/06)Step 2 Clinical diagnosis and pathogenesis:CK- 182/75-370 questions-9hCS - Pass/Fail - 12 stand. patients (test of communication skills etc.) (IMS may take Step 2 CK prior to Step 1) Step 3 Clinical management 500 questions/10 blocks 16 hr (2days) passing score ~ 184/75

USMLE Step I includesAnatomyPathologyPhysiologyGeneticsNeurologyBehavioral SciencesMicrobiologyPharmacologyCell BiologyImmunologyNutrition

USMLE Step 1 and the IMGUSMLE is computerized 336 multiple choice questions.Consists of seven~ 60 minute blocks each with 48 questions (total of 336 questions)Passing is minimum of ~ 185 where mean is ~ 220Passing is equivalent to answering 60-70% of questions correctlyIn 2008, 95% of NBME registrants passedIn 2008, 71% of ECFMG registrants passedNOTE: BETTER CHANCE OF PASSING OVER FAILING

www.ecfmg.org Accreditation Council for Graduate Medical Education (ACGME) www.acgme.org

HURRAH!

BETTER CHANCE OF PASSING EXAM THAN NOT PASSING EXAM!!

Additional factoids on Step 1

Over 3/4 of questions include clinical vignettes and begin with a description of a patientAbout 65% of questions are pathology basedStep 1 is required for both ECFMG certification and registration for CSAStep 1 is the only objective tool available to compare IMGs with U.S. graduates.THE LATTER IS A CRITICAL STATEMENT

Factoids continuedOfficial website: www.usmle.org/step1 and www.ecfmg.org/usmleEligibility: students and graduates of IMED listed schools (list at www.ecfmg.org)Students must have completed at least two years of medical school for eligibility.Eligibility period: a three month period of their choice

DETAILS OF THE BASIC SCIENCESWILL BE FOUND AT THE FOLLOWING WEBSITE:

http://www.usmle.org/examinations/step1/step1 content.html ALL THE BASIC SCIENCE CURRICULUM IS COVERED HERE!

THIS SITE INCLUDES:General description of USMLE 1 subject matter expectationsGeneral principles: All subject matter in basic science coursesSystems: Hematopoietic and LymphoreticularCentral and Peripheral NervousSkin and Related connective tissuesMusculoskeletal RespiratoryCardiovascularGastrointestinalRenal/UrinaryReproductiveEndocrine

DETAILS OF CLINICAL SCIENCES: STEP 2Are to be found at :

http://www.usmle.org/examinations/step2/step2.html

Please visit this site for details for Step 2, CS and CK exams

Master basic clinical skillsConduct competent medical interviewPerform competent physical examinationDO: start IV, draw blood, basic cardiopulmonary resuscitation, sterile technique, and othersDO: (minimally on models): spinal tap, childbirth, incision and drainage, othersWatch: GI endoscopy, bronchoscopy, joint taps, setting fractures, othersUse reports of: x-rays, EKGs, pap smears, blood chemistry, others

STEP 2: Diagnosis and PathogenesisClinical knowledge: 370 questions: 9h: pass of 182 (75%?)

Clinical skills: Pass/fail: 12 standardized patients: 11/12 communication skills

CS portion of Step 2 includes assessment of:ProfessionalismProblem solving abilityCommunication skillsLife long learningEthical/cultural/racial/gender sensitivity HumanismCommunity and public health awareness

CONNECTION BETWEEN STEP I AND 2?

YES!! STUDENTS WHO DO WELL BY STEP I WILL DO WELL ON STEP 2!!

Factoids continuedUSFMG students perform better than IMG on behavioral sciencesAbout 65% of questions are pathology basedGenerally, non-U.S. medical students perform worst in behavioral science and biochemistryBetter in gross and pathology

Standardization of examMean Step 1 score for U.S. medical students rose from 200 in 1991 to 215 in 2000 and have been relatively consistent since 2000.Related to exam design: profile of exam: doesnt change over the years, such that a 200 in 2008 is comparable to a 200 in 2000

What do these scores mean?Passing the CBT Step 1 corresponds to answering 60-70% of the questions correctly. This is a passing score of about 182-184.

Passing the CBT Step 2 corresponds to answering about 75% of the questions: 182

A CURSE AND A BLESSINGTHEY CANNOT RETAKE THE EXAM IF THEY PASS IT!!!!

WHAT ARE THE IMPLICATIONS OF THIS?

STEP 1+2 SCORES CRITICALTHESE ARE THE ONLY OBJECTIVE STANDARDS THAT ARE AVAILABLE FOR COMPARING THE EDUCATIONAL EXPERIENCE OF THE IMG WITH THE US TRAINED MEDICAL GRADUATE!

CONSEQUENCES! IN THE ABSENCE OF COMPETITIVE SCORES, THE IMG IS IS POORLY POSITIONED TO ATTAIN A RESIDENCY PROGRAM OF THEIR CHOICE OR MAY, WORST OF ALL, NOT BE ABLE TO OBTAIN A RESIDENCEY AT ALL!

CBSSACompetency Basic Science Self-AssessmentOffered by NBMETests in basic sciences: questions similar to USMLE200 questions (paced or non-paced)$45 for serviceAvailable at www.nbme.orgTHEY SHOULD DO THIS EXAM!!!

Some additional thoughtsStudents who tend to score well on NBME exams (shelf) tend to do well on Step 1Likewise with CBSSA practice exam!Likewise with GPA, MCAT, GRE scores correlate stronglyTypically 5-7 weeks of preparation is typical for Step 1Practice exams are shorter and less clinical than the real onesUse practice exams as diagnostic devices to evaluate strengths and weaknesses

Additional thought:BROAD BASED KNOWLEDGE IS MORE IMPORTANT THAN IT WAS IN EXAMS IN PREVIOUS YEARS. EXAM TESTS BASIC SCIENCE MATERIAL AND ITS APPLICATION TO CLINICAL SITUATIONS. AGAIN, 3/4 OF QUESTIONS ARE CLINICAL VIGNETTES!

Sources for clinical vignettes:Comprehensive: Pretest Clinical Vignettes for USMLE Step 1: McGraw-HillAnatomy: Underground Clinical Vignettes:Anatomy, Bhishan BlackwellBehavioral Sciences: Underground Clinical Vignettes: Behavior Sciences, BlackwellBiochemistry: Underground Clinical Vignettes: Biochemistry, BlackwellMicrobiology: Underground Clinical Vignettes: Microbiology, BlackwellPathophysiology: Underground Clinical Vignettes: Pathophysiology, Blackwell vol, 1,2,3Pharmacology: Underground clinical Vignettes: Pharmacology, BlackwellPhysiology: BRS Physiology Cases and Problems, Costanzo, LippincottGeneral: First Aid Cases for the USMLE Step 1 (250+ vignettes), McGraw Hill

Personal contact informationWilliam H. Harvey, Ph.D.Department of BiologyEarlham CollegeRichmond, IN 47374billh@earlham.edu765-983-1240Fax: 765-983-1497

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