Meeting of the Board of Regents | December 2010

THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234

TO:	The Professional Practice Committee
FROM:	Frank Muñoz
SUBJECT:	Oversight of international medical schools approved for long-term clinical clerkship placements
DATE:	November 30, 2010
STRATEGIC GOAL:	3
AUTHORIZATION(S):

 

Summary

Issue for Discussion

The purpose of this item is to discuss with the Professional Practice Committee (PPC) recommendations for the continued oversight of the didactic and clinical education of international medical schools who seek to place their students in New York State hospitals for long-term clinical clerkships.  Having presented the background for proposed changes at the November meeting of the PPC, the discussion will now focus on the process that we think will bring structure, consistency, and transparency to the review and approval of the schools.  The process steps include the designation of either a subcommittee of the State board for medicine or other entity acceptable to the Regents that will undertake an informed, collaborative discussion of factors such as standards, demand for physician services, growth of dual campus schools, workforce trends, post-licensure performance, and many other factors that the Regents have studied when reviewing similar programs in other areas.

Reason(s) for Consideration

 

Review of Policy.      

           
Proposed Handling

This item is a continuation, at the request of the members of the Professional Practice Committee, of the discussion that was begun during the November 2010 meeting of the Professional Practice Committee.  

Procedural History

            At the November 2010 meeting of the Professional Practice Committee, Deputy Commissioner Muñoz and Roger M. Oskvig, M.D., Chair of the New York State Board for Medicine, presented background information to assist the Board of Regents in considering the need for amendments to the Regulations of the Commissioner of Education regarding the oversight of international medical schools.  The presentation before the Professional Practice Committee included information derived from a series of discussions held by the Study Group on International Medical Schools, which had been established by the Department to provide the Board of Regents with information, perspective, and recommendations for continued oversight over the didactic and clinical education of the international medical schools that have been approved for long-term clinical clerkships. The Study Group is comprised of representatives from the Department of Health, hospital associations, New York State medical schools, New York State hospitals, and international medical schools, and others.  Staff from the Legislature and the Governor’s Office has been invited to observe the discussions. Over several meetings, the Study Group identified key data points and topics for consideration and discussed proposed recommendations.  

Background Information

            The Board of Regents has broad authority to regulate medical education and licensure for the practice of medicine.  Exercise of that authority, including the evaluation and approval of the didactic and clinical medical education, is set out in Part 60 of the Commissioner’s Regulations.  Section 6524 of Education Law contains the licensing requirements for physicians.  Those requirements include passing the relevant licensing examination and obtaining education acceptable to the Department.  As part of the necessary education, medical students typically complete approximately 72 weeks of clinical clerkships to gain the total needed for licensure. 

            Domestic medical students usually pursue their clinical training in affiliated hospitals within the state in which the school is located. However, in the last 20 years, there has been a proliferation of “dual-campus” medical schools, commonly referred to as “offshore” medical schools.  A dual-campus medical school is one in which the first two years of didactic education are completed in a foreign country, typically the Caribbean. Generally, the final two years of clinical education are completed in affiliated hospitals in the United States, but not exclusively, in New York State.

            Part 60.2 of Commissioner’s Regulations require the evaluation and approval of “dual-campus” international medical schools who wish to place students in NYS hospitals for clinical clerkships for more than 12 weeks (long-term clinical clerkships).  Currently, to be “approved,” the school must submit an application to the Department, undergo a site visit and meet the requirements of Part 52 of the Commissioner’s Regulations.  The site visitors (Executive Secretary and four consulting physicians with experience in medical education) evaluate the physical plant, library, student support services, admissions criteria, curriculum, faculty, financial viability, etc.   The review also includes a visit to affiliated hospitals in New York State to ensure that there is adequate supervision of students from that dual-campus school and alignment of the clinical experience with the objectives of the school. 

            These “approved” schools enter into affiliation agreements with New York hospitals to secure clinical clerkship spaces for their students. The agreements provide that the school will pay a fee for each student who undertakes a clinical rotation.  Concerns from domestic medical schools that their students will be “squeezed out” of clinical training opportunities have been conveyed to the Department.

            Concern has also been expressed about the preparedness to undertake medical education of students admitted into dual-campus schools.  Students admitted into dual-campus schools tend to have lower GPAs and Medical College Admissions Test (MCAT) scores than their counterparts do in domestic medical schools; indeed, most international medical schools do not require students to take the MCAT. There is evidence, however, that the more mature dual-campus schools admit students with very competitive academic backgrounds.  It appears that many of these students were not granted admission to domestic schools because of the limited number of available seats.  Regardless of the point of entry criteria and issues related to determining student preparedness to undertake the study of medicine, aspiring physicians must ultimately satisfy all of the requirements for licensure to be able to practice in New York State.

            International Medical School graduates comprise approximately 36% of the New York State physician workforce. Many of these physicians were educated at “dual-campus” international medical schools. 

1. Currently, 14 international medical schools are approved for long-term clinical clerkships.  In recent years, many existing dual-campus schools have expanded their student population. NYSED continues to receive applications for the approval of new schools. The regulations for such clinical approval were developed in 1981, and have not been modified since 1985.  To keep current with medical education today, the regulations should be reviewed to determine if they are still appropriate to ensure fulfillment of the Regents responsibility for the general supervision of educational activities within the State. 

 

1. Section 6524 of the Education Law grants the Board of Regents broad authority to regulate medical education and the practice of medicine.  Exercise of that authority is reflected in Part 60 of the Commissioner’s Regulations. The following factors are addressed in those implementing regulations:

1. Pre-professional education
2. Length and curriculum content of professional education
3. Degree to be awarded
4. Examination requirements
5. Clinical training requirements including:
6. who may perform clinical training in NYS
7. the duration of such clinical training
8. where such clinical education may be conducted
9. Experience requirements
10. Post-graduate training requirements

 

            The Board of Regents has the authority to amend or waive any of the enumerated factors.

STUDY GROUP

            In response to expressed concerns and its commitment to continually review regulations for current relevancy, and with the Regents consent, the Office of the Professions convened a Study Group to provide the Board of Regents with information, perspective, and recommendations for continued oversight over the didactic and clinical education of the 14 dual-campus International Medical Schools that have been approved for long-term clinical clerkships.  Numerous meetings have taken place over the last several months, beginning with research and internal meetings in late spring.  Meetings with stakeholders were held throughout, including:

1. 7/2/10 – Discussion with the NYS Department of Health and Associated Medical Schools of New York State (AMSNY), Albany, to discuss their concerns related to the impact of the contracts and SED’s role in overseeing the quality of International Medical School education and clinical clerkships
2. 7/29/10 – Stakeholder meeting, NYC, to solicit suggestions and recommendations for the direction of the Study Group
3. 8/26/10 – SED, DOH, Greater New York and HANYS, to discuss stakeholder recommendations and next steps.
4. 9/21/10 – Briefing with Regent Norwood, SED and Dr. Oskvig, Chair, NYS Board for Medicine
5. 9/28/10 – Study Group Meeting #1, NYC, to discuss factors for evaluation (demographics and educational quality) and to reach preliminary recommendations for Regents action
6. 10/28/10 – Study Group Meeting #2, NYC, to present and discuss conceptual recommendations from the Board for Medicine and the Office of the Professions

 

RECOMMENDATIONS FOR REGENTS CONSIDERATION

            Following these meetings, we asked a State Board subcommittee for a series of recommendations regarding a) comparable standards for education and oversight over the clerkships and other factors that have been discussed  b) the process utilized for review of applications for students to do 12 weeks + , and c) the structure, OP capacity, and clarity and transparency of the evaluations, including doing cross-walks from current "administrative assumptions and guidelines" to definitive articulations of the expectations and process in Commissioner’s Regulations.

            The State Board subcommittee outlined recommendations that would integrate the suggestions made during the various meetings and the goal of ensuring comparable standards that could be utilized within an oversight system capable of implementing and monitoring the standards.  While arguments have been made that the current standards and regulations are sufficient for robust and efficient oversight, that argument is unpersuasive when the Medical Board Office is operating with approximately 50% of staffing of several years ago and substantially increased workload and responsibility.  Simply stated, we are incapable under the current structures and processes of efficiently discharging the oversight responsibility, especially when the standards lack specificity and thus consistency when implemented with severe staffing shortages. OP leaders, Tom Burke, and Dr. John Morley from the Department of Health discussed the recommendations.  Based on those discussions, we plan to develop and present in December three central initial recommendations for Regents discussion and guidance that address structure, process, and transparency.

1. Structure:  Key responsibilities should be delegated to an entity that would add specific expertise, transparency, consistency, and independence to evaluations of applications from the dual-campus schools and the continued acceptance of didactic education leading to licensure.  We suggest for consideration the creation of a sub-committee of the Medical Board specifically appointed by the Regents to discuss and review the applications for clerkship approvals and recommend whether the application sufficiently addresses applicable standards to merit a site visit, which will continue to be conducted by the State Medical Board. 

 

The current regulations can be revised to require that the Committee on the Professions (COP) or the Deputy Commissioner for the Professions review the recommendations from the site visit; the COP or the Deputy Commissioner will in turn make a recommendation to the Board of Regents for decision.  This is a substantial departure from the current system, which does not involve the Regents review, and relies on the understaffed Medical Board office for the evaluation of data, the site visit, and every other related responsibility. The subcommittee will also apply the applicable comparable standards (see II below) regarding the acceptance of education from the dual-campus schools that seek Regents approval for the clerkships. 

1. Comparable Standards:   During the discussions within the Study Group on International Medical schools there has been consensus that the evaluation of international medical schools who seek approval to operate in New York State should be consistent and based on standards that are comparable to the standards utilized by the Liaison Committee on Medical Education (LCME) in evaluating domestic medical schools. 

 

The current regulations regarding the evaluation of international medical programs specifically incorporate the standards enumerated in Part 52 for accredited and registered programs. The Guide for Unregistered Medical Schools Seeking Approval to Operate in New York State, published by the Board for Medicine, incorporates, by reference, the standards of the LCME. However, the Part 52 standards do not provide sufficient specificity and guidance.  The LCME standards, on the other hand, provide more clearly articulable and objectively measurable standards. 

The substantial variation in programs that have been approved thus far, and evidence of inconsistent adherence with recommendations made by site visit teams suggests that the process for ensuring the implementation of the guidance provided by Part 52 of the Commissioner’s Regulations and the standards of the LCME must be strengthened.  Accordingly a subcommittee of the medical board was asked to explore methods by which international medical schools seeking approval would:

1. be governed by objectively measurable standards
2. be evaluated based upon consistently applied standards
3. include professionally developed remediation plans and rigorous enforcement
4. demonstrate continuous curriculum improvement

 

Additionally, factors to further strengthen the evaluation process were identified, including:

1. School performance as measured by reference to national averages on generally accepted outcome measures (USMLE STEP 1, STEP 2, ECFMG)          
2. Student performance as measured by a uniform nationally accepted standard (NBME course exams, NBME cumulative exams etc.)  
3. Didactic and clinical faculty qualifications
4. Standards for out-of-state clinical clerkships for approved schools
5. Clinical student to faculty ratios
6. Resource standards (labs, microscopes, cadavers etc.)
7. Specific curriculum requirements

 

1. Transparency:  Currently, the ability of the NYSED to approve students at programs offered by international medicals to complete clerkships greater than twelve weeks is gained largely from a general regulatory authority. However, that authority lacks specificity and the process for determining which schools are acceptable is almost totally determined by internal administrative guidance. As a result, the process employed and the standards that govern are subject to a lack of formality and difficult to ascertain with respect to specificity.  Accordingly, a regulatory structure, adopted by the BOR, would establish a clear and equally applied process that could be understood by all of the impacted parties.  Understanding that the current process lacks transparency, we believe that the implementation of a regulatory structure outlining the method of approval, the factors to be considered and the process of approval will add a strong level of fair oversight as we continue to advance the Regents oversight of medical education. 

Recommendation

Guidance sought.

Timetable for Implementation

The conceptual changes have been shared with the stakeholders.  Based upon the Committee’s guidance, we will return to the Committee with proposed regulations addressing the issues identified above.