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International medical graduates must pass the new Clinical Skills Assessment (CSA) examination to be certified by the Educational Commission for Foreign Medical Graduates (ECFMG), beginning this July. IMG's currently certified by the ECFMG, a requirement to enter residency training in the United States, can also take the test, but it is optional.
"The CSA provides a hands-on way of evaluating IMG's that is standardized and reliable in the absence of specific knowledge of their clinical experiences," according to Sidney Weissman, M.D., a corresponding member of APA's Council on Medical Education and Career Development and past president of the American Association of Directors of Psychiatric Residency Training (AADPRT).
The purpose of the CSA is to evaluate a physician's ability to obtain a relevant patient medical history, perform an appropriate physical examination, generate a complete and accurate written patient record, and demonstrate appropriate interpersonal skills and proficiency in spoken English.
The new test will use so-called "standardized patients": lay people trained to portray patients accurately and consistently. Practicing physicians and medical educators experienced in working with standardized patients author, review, and validate all CSA cases and represent diverse specialties.
Currently, the ECFMG requires a written exam for IMG's to demonstrate their clinical skills and knowledge of English.
Weissman told Psychiatric News, "I believe passing the CSA will give all IMG's applying for residency positions next year a competitive edge."
The CSA will be offered in Philadelphia throughout the year beginning in July.
Weissman observed that psychiatric residency training directors may receive up to 1,000 applications a year from IMG's. "An IMG who has passed the CSA can show competency in core clinical skills and spoken English."
Moreover, because training directors tend to give priority to IMG applicants from medical schools known to them, requiring the CSA should help level the playing field for all IMG applicants, continued Weissman.
The new requirement, however, has its critics. Among them is APA President-elect Rodrigo Muņoz, M.D., who told Psychiatric News, "it simply creates another obstacle for IMG's seeking graduate medical training in the U.S. By offering the exam only in Philadelphia, IMG's will have to bear the cost and inconvenience of additional travel, obtaining the necessary documents, and lodging."
The ECFMG and U.S. Medical Licensing Examination (USMLE) now offer their exams in several foreign countries.
Muņoz questioned the need for yet another test for IMG's. "The CSA now appears to be the gold standard without clear evidence of a relationship between performance on the test and excellence in psychiatric care," he commented. "I believe this new requirement is part of a continuing effort to reduce the number of psychiatrists in the U.S. By eliminating IMG's who make up half of PGY-1 psychiatric residents, the total number will decline."
Weissman responded, "I believe it is unwise to think that this requirement, which has been under development for over five years, is aimed at psychiatry. The use of standardized patients now allows medical educators to provide valid and reliable assessments of clinical performance."
He continued, "The new exam is merely one more way of assuring that individuals entering graduate medical education are adequately prepared. If this exam becomes a barrier to IMG's obtaining residencies in the U.S., thus reducing the number of available residents below current training levels, internal medicine will be seriously impacted, not psychiatry.
"I believe most IMG's who take this exam will pass, and the long-term impact will be to enhance their acceptance and credibility as physicians."
Nyapati Rao, M.D., director of psychiatry for education and general psychiatry residency training at Brookdale University Hospital in Brooklyn, N.Y., commented in writing to Psychiatric News that the timetable for implementing the new requirement doesn't give training directors and IMG applicants adequate time to adapt to the changing circumstances. This may result in programs competing for fewer qualified IMG's in two years.
Rao, who also directs the AADPRT/Wyeth-Ayerst IMG mentorship program, recommended that the CSA remain voluntary until July 1, 1999.
Some IMG's may believe the new CSA requirement is discriminatory because U.S. medical graduates do not have to take it, Rao continued.
Weissman responded, "We know that U.S. medical schools require assessments of students' clinical skills in their curriculum. In contrast, we do not know what the requirements are for each foreign medical school."
The USMLE board, which develops current licensing examinations, is considering requiring that senior U.S. medical students take the standardized patient version of the CSA. A decision is expected sometime next year.