The outcomes of global minimum essential requirements (GMER) pilot implementation in China.

Defining global standards for medical education in the form of competencies and the methods to evaluate whether an individual student possesses these competencies at graduation has long been a dream of some medical educators. The development of such standards, the methods to assess their presence and the pilot test study of the standards in graduating students at eight medical schools in China, as well as the process for establishing student and school performance "cut points", has been previously described. This paper reports on the performance of a single student who went through the assessment process, the performance of all students at one of the eight medical schools and the collective performance of all students at all eight medical schools. The actual quantitative data is presented, as is the conclusion of where the student, the school and all schools had strengths, where they were borderline in performance and/or where they need improvement. The results are serving as a blueprint for medical education reform in China. Implications of the pilot test and the entire process are discussed, as is the potential for global adoption of outcome based assessments.

Setting school-level outcome standards.

BACKGROUND: To establish international standards for medical schools, an appropriate panel of experts must decide on performance standards. A pilot test of such standards was set in the context of a multidimensional (multiple-choice question examination, objective structured clinical examination, faculty observation) examination at 8 leading schools in China. METHODS: A group of 16 medical education leaders from a broad array of countries met over a 3-day period. These individuals considered competency domains, examination items, and the percentage of students who could fall below a cut-off score if the school was still to be considered as meeting competencies. This 2-step process started with a discussion of the borderline school and the relative difficulty of a borderline school in achieving acceptable standards in a given competency domain. Committee members then estimated the percentage of students falling below the standard that is tolerable at a borderline school and were allowed to revise their ratings after viewing pilot data. RESULTS: Tolerable failure rates ranged from 10% to 26% across competency domains and examination types. As with other standard-setting exercises, standard deviations from initial to final estimates of the tolerable failure rates fell, but the cut-off scores did not change significantly. Final, but not initial cut-off scores were correlated with student failure rates (r = 0.59, P = 0.03). DISCUSSION: This paper describes a method to set school-level outcome standards at an international level based on prior established standard-setting methods. Further refinement of this process and validation using other examinations in other countries will be needed to achieve accurate international standards.

Ensuring global standards for medical graduates: a pilot study of international standard-setting.

Increasing physician and patient mobility has led to a move toward internationalization of standards for physician competence. The Institute for International Medical Education proposed a set of outcome-based standards for student performance, which were then measured using three assessment tools in eight leading schools in China: a 150-item multiple-choice examination, a 15-station OSCE and a 16-item faculty observation form. The purpose of this study was to empanel a group of experts to determine whether international student-level performance standards could be set. The IIME convened an international panel of experts in student education with specialty and geographic diversity. The group was split into two, with each sub-group establishing standards independently. After a discussion of the borderline student, the sub-groups established minimally acceptable cut-off scores for performance on the multiple-choice examination (Angoff and Hofstee methods), the OSCE station and global rating performance (modified Angoff method and holistic criterion reference), and faculty observation domains (holistic criterion reference). Panelists within each group set very similar standards for performance. In addition, the two independent parallel panels generated nearly identical performance standards. Cut-off scores changed little before and after being shown pilot data but standard deviations diminished. International experts agreed on a minimum set of competences for medical student performance. In addition, they were able to set consistent performance standards with multiple examination types. This provides an initial basis against which to compare physician performance internationally.

The WAMI Program: 25 years later.

The Washington, Alaska, Montana and Idaho (WAMI) Program is a four-state decentralized medical education program initiated at the University of Washington School of Medicine (UWSM) in 1972 with the goals of: (1) admitting more students to medical school from all states, (2) training more primary care physicians, (3) bringing the UWSM's resources to needy communities, (4) redressing the maldistribution of physicians by placing more MDs in predominantly rural states and (5) avoiding new construction costs. The program consists of a University Phase and a Community Phase, the latter extending to residency/postgraduate medical training. Thirty-three years on, and now renamed WWAMI (with the inclusion of the State of Wyoming), nearly 1200 students have been admitted to the program, with 5947 clerkship experiences and 2282 resident rotations, and the original goals of this experiment in decentralized medical education have been largely met. Almost half of all residents supported by the program return home to practice, and of graduates who underwent a part of their training in Alaska, Montana and Idaho, 64.7% returned home to practice. This paper reports on some lessons learned and speculates whether the WAMI program can keep pace with the rapid changes in medical education.

Medical education in China's leading medical schools.

This article gives a general overview of the evolution and present state of the undergraduate medical education system, programs, evaluation methods and conferred degrees in contemporary China. The publication is based on the information collected from on-site visits to the eight (8) leading medical universities, medical education conferences, visits to Ministries of Health and Education and their staff, and the contribution of Chinese medical education experts. As the Ministry of Education of the People's Republic of China (PRC) approves all tracks and strives for uniformity of educational programs as a cornerstone of quality, this overview reflects the general content of all five- and seven-year medical education programs that have provided the great majority of physicians since the founding of the People's Republic of China.

The assessment of Global Minimum Essential Requirements in medical education.

Using an international network of experts in medical education, the Institute for International Medical Education (IIME) developed the Global Minimum Essential Requirements (GMER) as a set of competence-based outcomes for graduating students. To establish a set of tools to evaluate these competences, the IIME then convened a Task Force of international experts on assessment that reviewed the GMER. After screening 75 potential assessment tools, they identified three that could be used most effectively. Of the 60 competences envisaged in the GMER, 36 can be assessed using a 150-item multiple-choice question (MCQ) examination, 15 by using a 15-station objective structured clinical examination (OSCE), and 17 by using a 15-item faculty observation form. In cooperation with eight leading medical schools in China, the MCQ, OSCE and Faculty Observation Form were developed to be used in an assessment program that is scheduled to be given to all seven-year students in October 2003.

Global minimum essential requirements: a road towards competence-oriented medical education.

With the growing globalization of medicine and the emerging concept of a 'global profession of physicians', the issue of the essential competences that all physicians must possess becomes sharply focused. If defined, these competences would help indicate what teachers are supposed to teach, what students are expected to learn and what educational experiences all physicians must have. The 'minimum essential competences' that all graduates must have if they wish to be called physicians were identified by the Institute for International Medical Education (IIME), sponsored by the China Medical Board of New York, through working groups of educational and health policy experts and representatives of major international medical education organizations. In the first phase of the project, seven domains have been identified that define the knowledge, skills, professional behavior and ethics that all physicians must have, regardless of where they received their general medical training. Appropriate tools to assess each of the domains have been identified. In the second phase of the project the 'global minimum essential requirements' (GMER) will be implemented experimentally in a number of Chinese medical schools. The aim of the third phase will be to share the outcomes of this educational experiment, aimed at improving the quality of medical education, with the global education community.