ECFMG assessment of clinical competence of graduates of foreign medical schools. Educational Commission for Foreign Medical Graduates.

OBJECTIVE: To develop an assessment of clinical competence of graduates of foreign medical schools and to determine the reliability and validity of the assessment and the feasibility of large-scale administration. DESIGN: The Educational Commission for Foreign Medical Graduates (ECFMG) clinical competence study included (1) clinical encounters with standardized patients to assess history taking, physical examination, and communication skills; (2) laser videodisk pictorials to assess identification and interpretation of diagnostic procedures; (3) written clinical vignettes to assess diagnosis and management skills; and (4) assessment of spoken English. A uniform method of operating the test centers and of training the standardized patients was developed. SETTING: Medical schools and their primary teaching hospitals and affiliated hospitals. PARTICIPANTS: Six hundred twenty-four first-year residents, of whom 525 are graduates of foreign medical schools. MAIN OUTCOME MEASURES: Scores, reliability coefficients, validity measures, feasibility of multisite administration, trends of scores over time, and acceptability by examinees. RESULTS: The ECFMG clinical competence assessment was conducted at four geographically separate test centers. Reliability coefficients were high (.85) for the integrated clinical encounter and were in a reasonable range (.71 to .82) for all test components. The assessment adds to the predictability of the residents' performance in the hospital over that of current ECFMG certification examinations. Test security was addressed by demonstrating no consistent pattern of change in scores over testing dates. Virtually all examinees thought the assessment was appropriate. Standardized patients were able to assess spoken English accurately. CONCLUSION: The feasibility of conducting a reliable and valid test of clinical competence for graduates of foreign medical schools was demonstrated for this test population.

Metabolites of estradiol in serum, bile, intestine and feces of the domestic cat (Felis catus ).

We wished to develop an efficient, noninvasive method for monitoring ovarian function in domestic and nondomestic Felidae. We hypothesized that the method could be based on measurement of one of the major excreted estrogen metabolites. To identify and characterize the major excreted metabolites, a bolus of (14)C-estradiol was administered into the femoral vein of adult female cats. We measured the amounts of total radioactivity per unit time contained in unconjugated and conjugated estradiol metabolites, in conjugated metabolites that were hydrolyzable, and in those not hydrolyzable by beta Glucuronidase / aryl sulfatase (the enzyme). Radionuclide levels were determined in voided feces and urine, in jugular vein plasma, bile, contents of the duodenum, and in the small intestine. Metabolites of (14)C-estradiol were voided preferentially in feces and in equal amounts either as unconjugated estradiol or as conjugates not hydrolyzable by the enzyme. In plasma, conjugated estrogens comprised an increasing proportion of the total radioactivity during the first 40 min after administration. Plasma pools of samples from 0.5 to 30 min and 40 to 360 min contained a monoconjugate and a diconjugate, respectively; both were hydrolyzable by the enzyme. Bile and intestinal samples were collected at 360 min after administration. In the bile, 99% of the total radioactivity was in conjugated compounds, only 20% of which were not hydrolysable by the enzyme. The proportion of unconjugated metabolites increased to 18% in the duodenum and to 45% in the small intestine. The major conjugates contained in voided feces not hydrolyzable by the enzyme were estradiol sulfate (m/z = 351.6836), distributed as the 3-sulfate (20%) and 17-sulfate (80%); of the latter, 70% were 17alpha- and 30% 17beta-estradiol sulfates. These data document the fate of estradiol in the circulation of the cat, they demonstrate that a large portion of the voided estradiol metabolites are not hydrolyzable by the enzyme, and account for those conjugates previously termed nonhydrolyzable.

Excretion of estrone, estradiol, and progesterone in the urine and feces of the female cotton-top tamarin (Saguinus oedipus oedipus).

The excretion of three gonadal steroids was studied in the urine and feces of female cotton-top tamarins (Saguinus oedipus oedipus). Each steroid, 14C-estrone, 14C-estradiol, and 14C-progesterone, was injected into a separate female cotton-top tamarin. Urine and feces were collected at 8 hr intervals for 5 days on the three tamarins. Samples were analyzed to determine the proportion of free and conjugated steroids. Steroid excretion patterns were determined by sequential ether extraction, enzyme hydrolysis, and chromatography. Labeled estrone was excreted in a slow and continuous manner into the urine (57%) and feces (43%) with 90% of the steroid conjugated. The nonconjugated form had an elution profile identical to 3H estrone, but the conjugated portion was not completely hydrolyzed by enzyme. Labeled estradiol was excreted primarily in the urine (87%) and was released rapidly. Over 90% of the injected 14C-estradiol was excreted in urine as a conjugate, of which 41% was converted to an estrone conjugate and the remaining 59% was excreted as a polar estradiol conjugate. Labeled progesterone was excreted primarily in the feces (95%), 61% of which was free steroid. Four to six individual peaks of radioactivity were found when using celite chromatography and high performance liquid chromatography (HPLC), indicating that progesterone is metabolized into several urinary and fecal metabolites. One of these peaks matched 3H-progesterone and others may be pregnanediols, pregnanetriols, and 17-hydroxyprogesterone. These steroidal excretion patterns help explain the atypical hormonal patterns seen during the tamarin ovarian cycle.