Bridging borders: The evolution of foreign medical graduate examinations in India – A comparative review with the UK and USA

INTRODUCTION International or Foreign medical graduates (IMG/FMG) contribute to significant health care in their own countries and foreign countries to which they migrated, for many years. They bring good work ethics, exchange of knowledge, hard work, and work hour flexibility to the jobs they choose in foreign lands. The IMG health workforce has been employed as physicians, researchers and healthcare facilitators and administrators around the world. Their contribution to global healthcare is significant. There is a substantial difference in the way of assessing a student’s fit for further medical education in foreign universities. Mostly it is in the exam paper. While Indian universities still hold the colonial way of long- and short-answer questions throughout the medical school semesters, internationally the exams are more standardized with single-best-answer approaches in clinical scenarios. The universities abroad give significant weightage to the candidate’s aptitude for the job by conducting personal interviews before issuing a selection letter. Our attempt, through this review, is to collect all the historical aspects of how these tests were developed and how the students fared in these exams. We have tried to understand why similarly trained students performed better in some exams but poorly in others (NEETPG versus FMGE). This is the first of its kind review on comparative statistics, and therefore, a lot of data has been taken from examination board websites. REVIEW OF LITERATURE In 2021, 1.6 million students appeared for the undergraduate National Eligibility cum Entrance Test (NEET-UG) in India to get admission to approximately 92,000 Bachelor of Medicine, Bachelor of Surgery (MBBS) seats.[1] In the same year, there were 28,690 applicants in the UK for 9500[2] and 62,443 applicants in the USA against 23,711 seats.[3] This amounts to a seat: Applicant ratio of 1:17, 1:3, and 1:2.6 in India, UK, and USA, respectively. The heavy competition to get into medical schools leads many Indian students to seek undergraduate medical education in foreign countries. After completion of medical school, these students return to India and must clear the Foreign Medical Graduates Examination (FMGE) to practice in India. Only after completion of FMGE, they can apply for NEET-PG in case they want to pursue postgraduation in India.[4] FMGE is an MCQ exam introduced in 2002 for Indian students trained in foreign medical colleges. The native students of Indian medical schools do not need to write FMGE before applying for postgraduate studies in either India or abroad. They can directly attempt the United States Medical Licensing Examination (USMLE) or Professional and Linguistic Assessments Board based on their choice of country. These exams were introduced much before in 1956 and 1978 respectively. These countries have a uniform exam, which means a medical student from any part of the world can directly apply for USMLE or PLAB exams, unlike India where FMG has to clear FMGE before NEET PG. There are no different exams for native and international students as far as the US is concerned. The UK also has a similar pattern to India where international students join after clearing PLAB whereas native students have grades from semesters for placements into postgraduate streams. The future in India and the UK is similar as both nations have already finalized and accepted the uniform test (NEET and UKMLA) which will be soon incorporated into medical school systems.[5,6] The National Board of Medical Examiners (NBME) was formed in 1915 in the US to oversee medical examinations. In 1956, Educational Commission for Foreign Medical Graduates (ECFMG) was founded and started a 1-day examination with 100% MCQs to International medical graduates (IMG).[7] Subsequently, the ECFMG examination was changed to Visa Qualifying Examination (VQE) and to Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS) then to USMLE in 1992.[8] Health professional education amendment H.R. 3508 was a historical decision passed in the 102nd United States Congress (1991-1992). This instructed the Department of Health and Human Services (DHHS) to determine whether the system is operating efficiently and without discrimination based on race, color, religion, gender, national origin, age, disability, marital status, or educational affiliation. It also advised the Council of Graduate Medical Education (COGME) to ensure similar assessments for American students and FMGs.[9] While an internet search could reveal the whole process of USMLE on how the idea was conceived and implemented, the same is not true for PLAB and FMGE. We have tried to compare the native exams of each country in Table 1. This table gives us an insight into the comparison of exams FMGE, USMLE, and PLAB.Table 1: COMPARISON OF EVALUATION PROCESSES IN INDIA, USA, AND UK[ 7 , 10 , 11 ]METHODOLOGY AND STATISTICS We have reviewed articles following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Searches were performed using PUBMED, Embase, world wide web in English language. We have relevant search terms (IMG, USMLE, PLAB, FMGE, FMG, MCQ, education, USA, India, UK). We have navigated through official websites of medical schools and councils of the USA, India, and UK. (like MCI, NMC, NBEMS, GMC, MSC, AAMC, USMLE, ECFMG, WFME, OET) which is gray literature. Thirteen peer-reviewed articles and 25 gray literature articles were included in data extraction [Figure 1].Figure 1: PRISMA framework for reviewDuplicated data was not considered. The extensive data thus obtained were tabulated as numbers and percentages. The Microsoft Excel statistical tool was used to prepare bar graphs representing the results. RESULTS Every year, many students are going from India to other countries for medical education. In the year 2021, 95.5% of 40,740 eligible Indian students who took FMGE to obtain a medical license in India were educated mainly in ten countries. These included China, Russian Federation, Ukraine, Kazakhstan, Kyrgyzstan, Georgia, the Philippines, Bangladesh, Armenia, and Nepal.[14] India (FMGE results) An average of 18.88% of students could successfully clear FMGE between 2017 and 2021. A little increase in pass percentage to 24.4% was seen in 2021. These observations are shown in Figure 2.Figure 2: The number of students who appeared and qualified in FMGE, India[ 15 ]These observations on the dismal performance on the FMGE exam prompted us to check the performance of Indian students in the NEET PG exam. Figure 3 shows that 62-75% (67.7% on average) of students qualified for the PG NEET examination for entering residency in India. In 2021, the examination was postponed because of the COVID-19 pandemic.Figure 3: The number of students who appeared and qualified in the NEET-PG, India[ 10 ]USA (USMLE results) We could access the statistics of American medical school students and international students’ results of USMLE. US Medical Graduates performed better than IMGs in USMLE 1,2 3 examinations by an average of 18%, 14.6%, and 10.8%, respectively. UK (PLAB) The PLAB results for IMGs show an average pass percentage of 70.28% and 69.48% in PLAB1 and PLAB 2, respectively, as shown in [Figure 4].Figure 4: The percentage of IMGs who passed PLAB 1 and 2[ 11 ]After examining the results of all three major exams, we have summarized them in [Figure 5, Table 2]. The best performance of IMGs is seen in USMLE followed by PLAB. However, the poorest performance was seen in FMGE examinations over the last 5 years.Figure 5: Average pass percentage of IMGs in qualifying examinations: USMLE (USA), PLAB (UK), and FMGE (India)[ 3 , 10 , 11 ]Table 2: USMLE STEP 1, STEP 2 CK, AND STEP 3 PASS PERCENTAGES AMONG US MEDICAL GRADUATES VS. IMGS[ 3 ]DISCUSSION The physician workforce of India, the UK, and the USA has been growing over the past 50 years, though not proportional to their growing population. Owing to a huge doctor-population gap, financial benefits, limited medical seats, and competitiveness, every year many students pursue MBBS from foreign countries. This trend was also noticed in India where many students choose medical education from Russia, China, and a few other countries. We have observed there was a disparity in the pass rate among the students trained within versus outside the country. The exam pattern, assessment modules, course curriculum, and number of exams varies among these countries. The differences on National Licensing Examinations (NLE) were studied, and it was suggested to help in ensuring basic quality standards across medical schools all over the world.[16] The compulsory internship rotation introduced in India with NExT[17] could help FMGS in adapting to the Indian healthcare system for better transition and thereby improve their pass percentage in FMGE. Further to improve the performance of students in FMGE, a change in the formation of MCQs is also suggested. These should be based on clinical scenarios including radiographical and biochemical investigations-based question stems. Well-structured MCQs can assess higher order with knowledge application in analyzing and justifying the answer options.[18] Darina Scully[19] and P.A. Coughlin[20] produced guidelines to create well-structured MCQs, which can be used in training clinicians. These best-answer-type questions cover more content, are more feasible, and have better reproducibility. In a study done recently by Vega et al.,[21] 85% of medical students in India felt that MCQ oriented pattern would help in preparing well for exams, and 90% preferred concept and case scenario-based questions. Subject revisions before appearing for foreign medical examination can be done through internet-based applications and medical websites. Internet connectivity and infrastructure are the main concerns for this pattern of education especially in rural areas.[22] Muthuprasad et al.[23] reported that the majority of students preferred having online recorded or live sessions. Around 75% preferred having assignments after the session for effective learning. The article has limited information on the performance of UK native students in the PLAB examination for the purpose of comparison. In a previous report from 1996, McManus et al.[24] observed there are better performances by non-UK ethnic minorities as compared to UK white students. They also noticed that ethnic minority students were 2.4 times and male students were 1.65 times more likely to fail in one or more MBBS examinations and the student pass rate was around 81%. More recently in 2014, McManus et al.[25] also reviewed the evidence of knowledge and skills of IMGs who had passed the PLAB test, and suggested these were substantially below those of UK graduates at the point when they sat for the same postgraduate examinations. Tiffin et al.[26] found that IMGs who passed PLAB had lower satisfactory outcomes in the Annual Review of Competence Progression (ARCP) when compared with UK medical graduates. More research is needed on this topic as Indian Parliamentary Standing Committee on Health has recommended that the National Medical Commission (NMC) should undertake a comparative study of the best practices of its parallel organisation in various countries. Parliamentary Standing Committee on Health in its report “Quality of Medical Education in India” presented in Rajya Sabha on Friday said that this measure can help NMC to usher in best practices followed around the world and help in making it an institution par excellence. It said countries across the world have adopted the Flexner model, changing it suitably whenever required.[27] Limitations of the study The statistics of undergraduate pass out results was not readily available from different medical institutions from India and UK. This is because each medical school in the UK and India has its own examinations. The information on the number of students who appeared in FMGE before 2017 was not available. We are not sure about the repeaters (unsuccessful candidates in previous attempts) in the examinations. The review also does not comment on the number of FMGE in India who have cleared in NEET-PG examination in India subsequently. CONCLUSION Medical education, assessment and healthcare delivery can be uniform across the world. Indian students do seek medical education in the West also with an intention to graduate from a WFME-accredited medical school. There is abysmal performance in pass rates for foreign medical graduates on their return to India. On the other hand, these students are performing well in the USMLE and PLAB examinations. We suggest reorganization of the exam with the implementation of standardized testing. We suggest that training of FMGEs on Indian shores can be improved with online classroom teachings with pre and post-test questionnaires, especially on the tropical and other diseases unique to our subcontinent. FMGE should aim to achieve an equivalence to USMLE and PLAB. The NEXT exam is the way forward and should follow the pattern of established examinations for a fair evaluation of all students, whether native or from international medical schools. Abbreviations AAMC = Association of American Medical Colleges CK = Clinical Skills COGME = Council of Graduate Medical Education DHHS = Department of Health and Human Services ECFMG = Educational Commission for Foreign Medical Graduates FMG = Foreign Medical Graduates FMGE = Foreign Medical Graduates Examination FMGEMS = Foreign Medical Graduate Examination in the Medical Sciences GMS = General Medical Council IMG = International Medical Graduates MCI = Medical Council of India MCQ = Multiple Choice Questions NBEMS = National Board of Medical Examiners NEET-PG = National Eligibility cum Entrance Test for Postgraduate Studies NEET-UG = National Eligibility cum Entrance Test for Undergraduate Studies NEXT = National Exit Test NLE = National Licensing Examinations NMC = National Medical Commission PLAB = Professional and Linguistic Assessments Board PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis OET = Occupational English Test UK = United Kingdom UKMLA = United Kingdom Medical Licensing Assessment USA = United States of America USMG = United States Medical Graduates USMLE = United States Medical Licensing Examination VQE = Visa Qualifying Examination WFME = World Federation for Medical Education Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.