Background: India's current estimated doctor-population ratio of 1:1700 against targeted ratio of 1: 1000 shows a clear shortage. A mismatch in number of medical aspirants and available seats, intense competition and unaffordable costs of medical education prompt many Indian students to pursue training opportunities abroad. Many later return to India, and these foreign medical graduates (FMGs) must pass a qualification test which is a required to practice medicine in India. This review undertakes a situational analysis of FMGs in India and suggests a roadmap to better utilize this resource pool of physicians. Methods: A thorough literature search was carried out using Google Scholar, PubMed and websites of the Central Board of Secondary Education and Medical Council of India. Foreign Medical Graduate Examination (FMGE) data was obtained from India's National Board of Examinations. Results: From 2002 to 2014, growth was seen in the number of FMGs who took the FMGE, with more having trained in China than any other country. However, typically only 25% of FMGs pass the FMGE. In 2013, 9,700 FMGs were unable to pass the FMGE to enter practice in India. At least 7,500 FMG physicians are unable to become licensed each year for failure to pass the FMGE, including those who retake and again fail the exam. Discussion: There are possible solutions. Additional training and hands-on apprenticeships can be introduced to help FMGs build their skills to then be able to pass the FMGE. FMGs can now learn by participating as observers in the established programs. Opportunities also exist for FMGs to work outside of clinical care, including in research, hospital administration and public health. As of now, FMGs are an untapped resource and lost opportunity to a country with shortages of physicians.

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Background: The use of patient centred approaches to healthcare education is evolving, yet the effectiveness of these approaches in relation to professional ethics education is not well understood. The aim of this study was to explore the experiences and learning of health profession students engaged in an ethics module as part of a Health Mentor Program at the University of Toronto. Methods: Students were assigned to interprofessional groups representing seven professional programs and matched with a health mentor. The health mentors, individuals living with chronic health conditions, shared their experiences of the healthcare system through 90 minute semi-structured interviews with the students. Following the interviews, students completed self-reflective papers and engaged in facilitated asynchronous online discussions. Thematic analysis of reflections and discussions was used to uncover pertaining to student experiences and learning regarding professional ethics. Results: Five major themes emerged from the data: (1) Patient autonomy and expertise in care; (2) ethical complexity and its inevitable reality in the clinical practice setting; (3) patient advocacy as an essential component of day-to-day practice; (4) qualities of remarkable clinicians that informed personal ideals for future practice; (5) patients' perspectives on clinician error and how they enabled suggestions for improving future practice. Discussion: The findings of a study in one university context suggest that engagement with the health mentor narratives facilitated students' critical reflection related to their understanding of the principles of healthcare ethics.

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Background: Efforts to address shortages of health workers in low-resource settings have focused on rapidly increasing the number of higher education programs for health workers. This study examines selected competencies achieved by graduating Bachelor of Science and nurse anesthetist students in Ethiopia, a country facing a critical shortage of anesthesia professionals. Methods: The study, conducted in June and July 2013, assessed skills and knowledge of 122 students graduating from anesthetist training programs at six public universities and colleges in Ethiopia; these students comprise 80% of graduates from these institutions in the 2013 academic year. Data was collected from direct observations of student performance, using an objective structured clinical examination approach, and from structured interviews regarding the adequacy of the learning environment. Results: Student performance varied, with mean percentage scores highest for spinal anesthesia (80%), neonatal resuscitation (74%), endotracheal intubation (73%), and laryngeal mask airway insertion check (71%). Average scores were lowest for routine anesthesia machine check (37%) and preoperative screening assessment (48%). Male graduates outscored female graduates (63.2% versus 56.9%, P = 0.014), and university graduates outscored regional health science college graduates (64.5% versus 55.5%, P = 0.023). Multivariate linear regression found that competence was associated with being male and attending a university training program. Less than 10% of the students believed that skills labs had adequate staff and resources, and only 57.4% had performed at least 200 endotracheal intubations at clinical practicum sites, as required by national standards. Discussion: Ethiopia has successfully expanded higher education for anesthetists, but a focus on quality of training and assessment of learners is required to ensure that graduates have mastered basic skills and are able to offer safe services.

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Background: The purpose of this study was to determine whether gender bias was present in the final third-year medical student obstetrics/gynecology clerkship performance evaluation completed by faculty and resident physicians. Methods: This was a retrospective cohort study of third-year medical students over the course of ten years (2004 – 2014) at a private medical school in the northern US state of Wisconsin. Each student's performance during their required 6-week obstetrics/gynecology clerkship was assessed by a combination of the student's scores on a clinical performance evaluation and on a standardized national subject examination. The clinical performance evaluations are comprised of 10 domains, each using a 9-point Likert scale and completed by faculty and resident physicians. All clerkships at our institution use the same evaluation form, which was designed and validated by the medical education statistics department. Final obstetrics/gynecology clerkship average clinical evaluation scores (Scale 1-9) and obstetrics/gynecology standardized national subject examination scores (Percentile 1-99) were compared to see if a gender based difference between subject examination and performance evaluation scores existed. Results: 1,976 student records were analyzed. Mean standardized national subject exam scores were significantly higher for females [74.4 (8.1)] than males [72.9 (8.2)] (Possible range 1-99) with Cohen's d = 0.2 (P = 0.001). The average female score on the clinical evaluation was mean (SD) = 7.4 (0.9), compared to an average clinical evaluation score of 7.2 (1.0) for males (P = 0.001) (range 1-9). Performance on the standardized national subject exam was significantly correlated (r = 0.3, P = 0.001) with clinical evaluation scores, and when split by gender the strength of the correlation remained. Discussion: Medical student performance on the standardized national subject exam correlated with clinical evaluations independent of gender. Women had higher scores on both the subject examination and the clinical performance evaluations. There was no evidence of gender bias in the students' clinical evaluation scores.

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Background: The Dundee Ready Educational Environment Measure (DREEM) has been widely accepted and recognized for the assessment of the educational environment in a variety of health professions education programs. Concerns regarding the psychometric properties of the DREEM have been raised. This study evaluated the psychometric properties of the DREEM in a sample of Ghanaian medical students following a problem-based learning curriculum. Methods: A sample of 234 second to fourth year medical students of the University for Development Studies, School of Medicine and Health Sciences were invited to complete the DREEM questionnaire. Psychometric measures employed included Cronbach's alpha analysis, confirmatory factor analysis and principal component analysis with varimax rotation. Results: The internal consistency for the overall DREEM was 0.92. Apart from two subscales that had Cronbach's alpha values < 0.70, the remainder had values ranging from 0.73 – 0.78. Confirmatory factor analysis did not support the original five factor structure of the DREEM. Large significant correlation coefficients were found between the five factors raising concerns about the independency of the individual subscales. Exploratory factor analysis suggested various factor solutions ranging from 4 to 14 factors. The four factor structure was interpretable and was maintained. All of the four factors achieved eigenvalues > 1, and in total they accounted for 37.6% of the variance. Alpha values for the subscales of the new four factor structure ranged from 0.618 – 0.915. Discussion: The overall internal consistency of the DREEM was found to be excellent. The internal consistency of the individual subscales was variable, as two subscales had alpha values < 0.70 and the remainder exceeding 0.70. The original five factor structure of the DREEM was not supported. Exploratory factor analysis suggested a four factor solution as a possible alternative to the five factor structure of the DREEM.

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Background: Less than 6% of U.S. medical school applicants are African-American. The lack of diversity among physicians, by race as well as other measures, confers a negative impact on the American healthcare system because underrepresented minority (URM) physicians are more likely to practice in underserved communities and deliver more equitable, culturally competent care. Methods: MERIT (Medical Education Resources Initiative for Teens) is a nonprofit organization based in Baltimore, Maryland, USA. MERIT prepares URM high school students for health careers by providing a holistic support system for seven consecutive years. The program model, which utilizes weekly Saturday sessions, summer internships, and longitudinal mentoring, is built on four foundational pillars: (1) Ignite the Fire, (2) Illuminate the Path, (3) Create the Toolkit, and (4) Sustain the Desire. Results: Since 2011, MERIT has supported 51 students in the Baltimore City Public School System. For the past two years, 100% (n = 14) of MERIT seniors enrolled in universities, compared to only 20.2% of Baltimore City students overall. While it is too early to know whether MERIT alumni will realize their goals of becoming healthcare professionals, they are currently excelling in universities and over 75% (n = 17) are still planning to pursue graduate degrees in health-related fields. Discussion: After piloting an effective program model, MERIT now has three key priorities moving forward: (1) Creating a sustainable and thriving organization, (2) increasing the number of scholars the program supports in Baltimore, and (3) expanding MERIT to other cities.

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Background: Although public health degree programs typically require practica and other field experiences, service-learning courses, with a focus on civic engagement and the application of classroom learning in real world settings, can go beyond these requirements and provide benefits to students and community-based practice partners. The goal of this paper is to assess potential benefits of service-learning programs for both graduate-level public health students and state and local public health agency partners. Methods: EpiAssist is a new service-learning program developed at the School of Public Health of the Texas A and M University Health Science Center, USA, in January 2015. EpiAssist was integrated into a new course, Methods in Field Epidemiology. The integration of service-learning was guided by a partnership with the Texas A and M Center for Teaching Excellence. Results: State, regional, and local public health partners requested EpiAssist via email or telephone. A listserv was used to recruit student volunteers to meet requests. 54 of 86 registered EpiAssist students (63%) participated in at least one of ten service-learning and three training activities between January and June, 2015. Service-learning activities included questionnaire development, in-person and telephone data collection, and data analysis. Training topics for students included the Epi Info^™ software, community assessment and communicable disease reporting. Students and partner organizations provided generally positive assessments of this service learning program through an online evaluation. Discussion: Service-learning provides students with enhanced classroom learning through applied public health experience in state, regional and local health departments. These experiences provide both needed surge capacity to public health departments and valuable hands-on field experience to students.

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Background: We created a tool to improve communication among health professional trainees in the ambulatory setting. The tool was devised to both inform practice partner teams about high-risk patients and assign patient follow-up issues to team members. Team members were internal medicine residents and nurse practitioner fellows in the VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE), an interprofessional training model in primary care. Methods: We used a combination of Likert scale response questions and open ended questions to evaluate trainee attitudes before and after the implementation of the tool, as well as solicited feedback to improve the tool. Results: After using the primary care sign out tool, trainees expressed greater confidence that they could identify high-risk patients that had been cared for by other trainees and that important patient care issues would be followed up by others when they were not in clinic. In terms of areas for improvement, respondents wanted to have the sign out tool posted online. Discussion: Our sign out tool offers a strategy that others can use to improve communication and knowledge of shared patients within teams comprised of interprofessional trainees.

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Background: The Kenyan Ministry of Public Health and Sanitation was the first in Africa to introduce the new 10-valent Pneumococcal Conjugate Vaccine, PCV-10, in 2011. For successful implementation and to avoid adverse events following immunisation, specific training on handling and storage of the PCV-10 vaccine was required. Therefore, a training DVD was recorded in English and partly in Kiswahili to be used in combination with in-classroom training. Since the Kenyan Immunisation Programme was the first to use a DVD for training healthcare workers, an evaluation was done to obtain feedback on content, format and use, and propose suggestions to improve quality and uptake of the DVD. Methods: Feedback was obtained from nurses and vaccinology course participants through the completion of a questionnaire. Nurses also participated in focus group discussions and trainers in key informant interviews. Results: Twelve trainers, 72 nurses and 26 international vaccinology course participants provided feedback, with some notable differences between the three study groups. The survey results confirmed the acceptability of the content and format, and the feasibility of using the DVD in combination with in-classroom teaching. To improve the quality and adoption of the DVD, key suggestions were: Inclusion of all EPI vaccines and other important health issues; broad geographic distribution of the DVD; and bilingual English/Kiswahili use of languages or subtitles. Discussion: The Kenyan DVD is appreciated by a heterogeneous and international audience rendering the DVD suitable for other Anglophone African countries. Differences between feedback from nurses and vaccinology course participants can be explained by the practical approach of the DVD and the higher education and service level of the latter. A drawback is the use of DVD players and televisions due to lack of electricity, but it is a matter of time before all rural health facilities in Africa will have access to electricity and modern technology.

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