An author developed, standardised survey was developed and administered to national, state and provincial licensing institutions across 6 continents. The standardised survey was composed of 5 questions, with proscribed answers as well as an option to input original answers. Questions centred on communication skills, knowledge base testing, technical and clinical skills evaluation and the tools used in these assessments.

The most populated countries of each of the six permanently populated continents were chosen as representatives for the survey. The survey aimed to address the licensing bodies in countries that carried the larger bulk of the world’s population. The representative licensing bodies for the most populated countries were identified by an online search. Licensing bodies were defined as the governing bodies responsible for medical licensing. Countries with non-centralised medical licensing boards were contacted separately with the most populated regions of those countries identified as representative. Specialist licensing institutions (e.g. separate subspecialty licensing surgical bodies) were not specifically targeted.

Thirty-seven licensing bodies were identified from 30 countries based on the selection criteria. 

The projected sum population to be represented by this group was 4.298 billion people, approximately 61% of the world’s population (Table 1).

Eleven of these countries were identified as possessing a developing economy based on the World Bank classification for 2013-2014. (Assessed by a GNI (gross national income/capita/year) of <US$11 905/capita/year).⁸

The survey was distributed through two attempts at email contact and two attempts with telephone contact. Website information was also searched and all information gained from the survey was verified and supported by web based documents. Where neither telephone nor email contact elicited responses, the gathered website information and available documentation was used to complete the survey. 

Statistical analysis of frequency data was conducted using SPSS (V.21, Armonk, NY, USA).⁹

Ethical approval was granted by the Faculty Research Ethics Committee at Trinity College Dublin of the University of Dublin. Data was anonymized prior to analysis to preserve the confidentiality of the survey respondents. Participant response is interpreted as implied consent. 

Contact was attempted for the thirty-seven licensing bodies identified from 30 countries based on the selection criteria. Verifiable information was available from 29 licensing bodies in 22 countries.  For the remaining eight countries, either no contact information was available or verifiable information could not be collected from appropriate websites.

Of these 29 licencing bodies, 26 responded to the first question, revealing 65.4% (n=17) assessed communication skills specifically, 100% of these involved language testing. Information gathering in the form of history taking was assessed as part of the integrated OSCE exam by 5 licensing institutions, and 11.5% (n=3) tested any other communication forms, e.g. breaking bad news, consent, patient instruction.

The methods of communication assessment varied and were often used in tandem. Language proficiency with written and verbal examination was most often assessed by a commercially available exam e.g. TOFEL.  An OSCE was conducted by 35.3% (n=6) to assess language during clinical skill evaluation.  A period of mentored practice was used by 23.5% (n=4) to observe clinical skill and communication. The remaining methods consisted of structured interview settings to assess language skill (Figure 1).

Knowledge based assessment was performed in all regions. 79.3% (n=23) used a country or region specific examination. Less than 1/3 (n=6) used a commercially available exam (most common example was the USMLE (United States Medical Licensing Examination) used within and outside of the United States).  More than 80% (86.2% n=25) used confirmation of certification and references in some capacity, for determining knowledge and 72.4% (n=21) used both review of certification and examination.  Fourteen percent 14% (n=4) used credentialing alone (Figure 2).

Technical or clinical skill assessment encompassed any skill set that excluded knowledge based or communication skills assessment. These were predominantly assessed by credential review, 86.2% (n=25), by written exam and confirmation of certification (62.1% n=18) and <40% (n=11; 37.9%) required engaged mentored practice of a variable duration from 3 months to 1 year (Figure 2).

Re-certification was assessed by 2 licensing bodies for practicing physicians at varying points in a career.

The use of mentored practice likely gives the best assessment or overview of a physician’s ability to practice and the capacity to identify any safety issues.  This is a more time consuming process for a licensing body to arrange, and may not be feasible on a scale to accommodate the volume of migration that a number of countries see.  Mentorship occurred in 37% of cases in this survey and was of a variable time frame, from three months to one year.  Though some countries or licensing bodies required mentorship for all applicants, exact criteria as to who qualified for a mentorship in the majority of countries was not clear, and was generally reserved to the discretion of the licensing body after credential review.

The information gathered here was difficult to access. Trying to identify the most appropriate department or the most responsible licensing body who would best be able to give the required information was not readily evident.  Physicians attempting to migrate may experience difficulty in accessing the necessary information for application. 

The impact of non-standardisation for the medical community is evident.  Governing bodies in medical education strive for the highest standard of teaching and assessment to guarantee fitness to practice of graduates.  This is important for medical educators in general and medical licensing bodies in particular for domestic graduates and also foreign graduates that seek to work in a new medical system.  The current status of assessment, as demonstrated by this survey, evaluates foreign applicant’s fitness for practice predominantly by credential review, relying on the inherent expectation that all medical systems train their trainees in the same manner and that assessment is equivalent. This is not the case, neither in current practice nor in how different education systems are perceived by each other.¹²This survey highlights the lack of necessary cohesion in training bodies surrounding the world, and the areas for potential standardisation development.

This paper carries a number of limitations. The survey was author developed and unvalidated, containing only 5 questions, and does not address specifics of how examinations are developed, particularly individual OSCE components, and the emphasis placed on communications skills in the specific OSCE.  Due to some difficulty in obtaining information, and the nature of surveys, the most appropriate and informed person may not have been the person who completed the survey.

The authors declare that they have no conflict of interest.