UNIQUE REQUIREMENTS OF MEDICAL EDUCATION:

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1 UNIQUE REQUIREMENTS OF MEDICAL EDUCATION: A COMPARISON OF ACCREDITATION REQUIREMENTS FOR HIGHER EDUCATION AND MEDICAL EDUCATION Author: Prof. Mohammed Galal El Din Ahmed 1 Co-author: Dr. Fouzia Shersad 2 ABSTRACT BACKGROUND: Medical education is accredited by regional accreditation bodies and medical education councils in different countries. AIM OF STUDY: This study explores the challenges faced by medical education institutions when conforming to general requirements of higher education. MATERIALS AND METHODS: Using the experience at Dubai Medical College, comparison was done between the Standards of Licensure set by the Commission for Academic Accreditation (CAA), UAE with standards for medical education set by World Federation of Medical Education Standards (WFME), WHO and Liaison Committee of Medical education (LCME), USA. RESULTS: The study shows that CAA standards have included requirements for professional education. The unique requirements of medical education in the areas of student, clinical faculty, social responsibility, partnerships and resources, covered by the latest standards for medical education are largely included in the 2011 version of the CAA standards. CONCLUSION: The study reiterates that CAA has provided special consideration in areas of regulatory, infrastructural, ethical and student level implications for maximum effectiveness of all higher education institutions including professional, community and university colleges. KEYWORDS: Medical education, accreditation, higher education, standards, INTRODUCTION Medical education is accredited by specialized medical education councils exclusively set for this purpose in some countries. In many other countries it is done by a general body for 1 Dean, Dubai Medical College 2 Director, Institutional Effectiveness, Dubai Medical College 1

2 accreditation which caters to all institutions of higher education. Accreditation standards of higher education institutions (HEI s) set by these bodies are mostly applicable to medical education, but may not cover all the crucial aspects for ensuring quality medical education. Hypothetically, in a situation like this, considerable discrepancy can arise if the accrediting authority is insensitive to the needs and priorities of institutions catering to specialized programs. For example, if a particular standard is less relevant for a program, it could lead to underutilization of resources. On the contrary, if some crucial areas specific for a course are not covered, it could cause loopholes which undermine the effectiveness of the institution. ACCREDITATION OF MEDICAL EDUCATION IN UAE In UAE, all institutions of higher education are accredited by the Commission of Academic Accreditation (CAA) under the Ministry of Higher Education using its Standards for Licensure and Accreditation. A licensure granted by CAA signifies that robust plans are in place for resources, policies, administration, documentation and financial stability. Program accreditation is the next step where CAA invites a team of visiting international experts (the External Review Team or ERT) to evaluate curricular areas specific for medical education. This step bridges the gap in the standards, for practical purposes, even though the standards may be more generic. ACCREDITATION OF MEDICAL EDUCATION INTERNATIONALLY Internationally, a need for uniform standards, solely pertaining to medical education, was felt for a long time. Several reforms were made to improve and standardize medical education according to the demands of medical profession. Following the reforms made by Flexner, the WHO framed the WFME standards, which is believed to go a long way in ensuring the metaanalysis of international accreditation standards for medical education. (Karle, 2006). WFME Global Standards WFME standards were formed, in 2003, for the purpose of stimulating educational institutions to create their own planning towards excellence and to set minimum standards for success. Since then, several studies across the globe have vouched for their usefulness in improving quality of medical education worldwide. (Smallwood, Frank, & Walters, 2010), (Hays & Baravilala, 2004), (Severyanova & Lazarev, 2005),Taiwan (Huang, Wung, & Yang, 2009) LCME Standards The Liaison Committee on Medical Education (LCME) standards were set as early as 1940 s for accrediting medical education programs leading to the medical degree in US and Canada. The LCME is sponsored by the Association of American Medical Colleges and the American Medical Association. Compliance to the standards means that the program assures that the graduates have the competencies required for the next stage of training and for providing proficient medical care. 2

3 Current scenario of Standards for Medical education This paper is relevant as it comes at a time when there is a call from medical educationists for changes to be made to the orientation of standards in order to prevent stagnation. The quantitative emphasis of the indicators rather than integration and alignment of the processes to the outcomes have been questioned (Davis & Ringsted, 2006). The challenges to medical education in the Middle East have been reported to be related to dearth of teaching faculty, facilities and integration with health services (Hamdy et al., 2010). As reported by Karle, a revamping is required to meet the current demands of transnational migration of doctors and emergence of for-profit medical schools. These trends, otherwise, could take medical education back to the preflexnerian era (Karle, 2010). However, there is a need to reiterate that medical education standards have improved over time rather than lowered in quality (Brink, 2010). Tremendous benefits from an institutional review leading to major reforms in a medical school in Ireland have been reported (Geraldine Maccarrick, Kelly, & Conroy, 2010) Undeniably, the communication strategy and project plan which evolves during the process has shown longstanding improvement in all institutions, which applied these standards. AIM OF STUDY This study is aimed at the following a) To explore the challenges faced by medical education institutions when conforming to general requirements of higher education. b) To confirm whether the requirements of higher education are applicable to medical education institutions The study uses WFME-2003 and LCME-2011 criteria as prototypes for standards for medical education. The use of the latest edition of LCME criteria dated May 2011 ensures inclusion of recent developments in medical standards. The CAA standards for Licensure and Accreditation which are applied to all HEIs in UAE have been used as a prototype for standards for higher education in this study. A comparison will show if there are lacunae in the standards, and if so, whether it will cause loopholes which undermine the effectiveness of the institution. MATERIALS AND METHODS Using the experience of reaccreditation at DMC, a list of unique characteristics of medical education was prepared. Then a comparison was done between the Standards of Licensure set by the CAA, UAE and the standards for medical education i.e. WFME and LCME criteria (See Table - 1) The CAA standards, 2011, were analyzed and the main areas were entered on to a matrix. In the next column the corresponding standards in the WFME was mapped out. The same was repeated with LCME criteria. Once the common areas were summarized within the matrix, the differences were studied in detail to ensure if it has been included in another category. 3

4 The results were collated in a Venn diagram to demonstrate the common areas for all HEIs which are common in both groups. The areas which are meant only for medical education, the areas which are specific for medical education and areas not applicable to medical education are elucidated. Table - 1 OVERVIEW OF CAA, WFME & LCME STANDARDS CAA WFME LCME Title Standards for Licensure and Accreditation Basic Medical Education: WFME Global Standards for Quality Improvement Functions and Structure of a Medical School- Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree Date Standards 11 sections of standards with several criteria for each 9 Standard areas with a total of 36 sub-areas 5 Broad areas with each area having specific criteria = 127 Type of criteria Each of the 11 sections of standards contains threshold requirements which institutions MUST meet for accreditation Some standards have stipulations which provided greater detail of requirements which MUST be adhered to. 2 levels (a) basic standards or minimum requirements; (b) standards for quality development. Basic standards are expressed by MUST -Mandatory Standard for quality SHOULD -Nonprescriptive and broader requirement MUST indicates absolutely necessity for accreditation SHOULD indicates compliance necessary except if strongly justified otherwise Use Institutional licensure and Program accreditation Self assessment, Peer review and Accreditation LCME is a programmatic rather than an institutional accreditor. RESULTS On doing a detailed analysis and comparison of the standards for accreditation for higher education institutions in general and that for medical education, it was seen that there were only minor areas of differences. Others were adequately covered in different sections to bring about the same desired end result. (See Table 2) 4

5 The detailed analysis based on the matrix in Table 2 is given below: 1. Mission, Organization and Governance: The development and revision of Mission, Organization and Governance has been adequately covered by CAA and standards of medical education. While the CAA lays greater emphasis on a policies and procedures manual, both require details of governance and administration, Educational Budget, Resource Allocation and Educational Exchanges. Interaction with Health Sector is included in the medical education standards. 2. Quality Assurance Both categories have clear-cut and similar requirements for a systematic Quality Assurance/Institutional Effectiveness Policy, which should be run by an independent unit. Planning Policy and how it is related to the performance evaluation is of utmost importance. 3. The Educational Program The major differences are all seen in this standard. The CAA criteria includes undergraduate, postgraduate and intensive courses and is generalized for all HEI s and states that curriculum should meet international norms. However, CAA mandates that the curriculum has to be evaluated by an external review team formed of invited experts. It is clear that curricular characteristics related to clinical phase will not be spelt out in the CAA standards. LCME & WFME go into details of the curriculum as follows: a. A single curriculum with two phases requires a transition program. A graduate should be able to enter any field, so all courses are mandatory b. Linkage with Medical Practice and the Health Care System c. What specific transition programs integration of clinical with preclinical phases? d. Curriculum design and content specified for medical education including Basic Biomedical Sciences Inclusion of latest modalities like molecular biology Behavioral and Social Sciences, Medical Ethics Clinical reasoning and Skills e. The details of the clinical course are required (E.g. Inpatient/Ambulatory health care, hospital/community, rural/urban, specialist/general etc.) f. Service learning concept and have been incorporated. g. The general design should meet social needs & Basic science should prepare for clinical exposure h. Cultural sensitivity, gender bias etc. i. Need for altruism j. "Scrupulous ethical principles" implies characteristics that include honesty, integrity, maintenance of confidentiality, and respect for patients, patients' families, other students, and other health professionals k. Curriculum review process student and faculty participation student contribution to curriculum review. Grading and Assessment Policy is the same in both categories requiring the general policy on assessment including timing, weighting and criteria for progression. Validity, standardization and improvement are part of the quality system required by all HEI s. The apparent 5

6 differences of requirement of in-course evaluations after clinical clerkships overlap with the formative and summative exams required by all HEI s. The only difference seems to be that in medical education student assessment includes non-cognitive assessment. This entails evaluation of Professional conduct, which is taught through informal and formal methods. 4. Faculty and Professional Staff Faculty and Professional Staff roles, qualifications and workloads are clearly stated in all documents. Recruitment Policy, evaluation, recognition, balance between fulltime and parttime and staff development policies are clearly propounded by both organizations. The glaring difference which could have caused several inconveniences would have been in relation to the large number of adjunct faculty required in the clinical phase. This has been commendable addressed by the CAA by way of a stipulation, which is newly added to suit requirements of medical education. While a professional development plan is prioritized in all documents, the need for a medical education unit is emphasized with greater zeal in the WFME and LCME documents. 5. Students Admission process and criteria for selection are the same in all standards of higher education. There is a greater role for attitudes in medical education. Transfer policy is applicable only for 50% or more of the course according to CAA but LCME states that in exceptional cases, it can be granted in the final year. Student Counseling, student activities, access to healthcare services, student academic integrity policy, student organization etc. are equally emphasized by all the documents evaluated. Mentoring and career guidance are important features in both cases. Exposure to environmental hazards and infection in medical students is an area of variation among the standards studied. Access to healthcare services deserves greater importance in medical students. Consent should be taken regarding the risk involved before admission. Medical Schools are also required to provide medical students performance evaluation and recommendations to facilitate acceptance for post graduate studies and residency. 6. Learning Resources & 7. Physical Facilities Physical facilities available for the delivery of the non-clinical components of the curriculum are the same in both groups of standards. Library requirements are the same for all documents with greater stress for latest journals. There is an additional requirement for Clinical Training Resources available for clinical training in hospitals, ambulatory services, community clinics, primary health care settings, skills laboratories, etc. This also requires a review of the adequacy of the facilities and patients available for clinical teaching. Interaction with Health Sector is required through documentation of the relationships between the Medical school and the health services regarding mission and objectives of the school, the educational program, the provision of resources, teaching facilities and staff. 6

7 There is a clear need for a written Agreement with hospital facility being used. The following are some of the details which should be included in the agreement: a. Permit medical students to have patient care duties b. Empowerment to utilize the resources c. Availability of patients d. Medical care for illness got during job. e. Facility for lockers on-call rooms software for education f. Medical ethics & confidentiality should be mentioned 7. Fiscal Resources Details of fiscal resources and allocation are more relevant to CAA as part of institutional licensure. In any case the differences are not relevant, except that there should be agreement with hospital regarding fiscal resources. 8. Public Disclosure and Integrity Public Disclosure & Integrity have not been covered in the medical standards examined in this study. However, CAA clearly requires the documentation of several policies like Conflict of Interest Policy, Copyright and Intellectual Property Policy, Teach-out Policy, Publications Policy and Institutional Relations Policy. These will help the stability of the institution and would be ideally required by medical colleges. 9. Research Research has been stressed by both groups of standards. According to CAA standards, it is required to clarify how it is related to the educational process. CAA requires ethical Issues Policy which includes regulations on the use of human and animal subjects. 10. Community Engagement CAA has newly included a Community Engagement Policy while WFME and LCME look for actual work and contribution in the community. It is clear that community orientation and community service are more important in medical education than other HEI s. The CAA has to be specially commended for the inclusion of the major area of potential conflict within medical education institutions by relaxing the restriction for part-time staff and including the adjunct faculty details. The inclusion of internship, partnership, and exchange student details way back in 2006 shows farsightedness of the CAA the standards. The latest additions include greater emphasis on internal review mechanisms, branch campuses, student transfers, and coordination between campuses. 7

8 Table -2 COMPARISON OF CAA 2011 STANDARDS WITH WFME AND LCME CRITERIA CAA 2011 WFME 2003 LCME Mission &Institutional Effectiveness - includes autonomy a. Quality Assurance /Institutional Effectiveness Policy should be by an independent unit b. Planning Policy and how it is related to the performance evaluation 2. Organization and Governance & leadership -Organization chart -Policies and procedures manual -Organization of multiple campuses 3. The Academic Program -Undergraduate, graduate and intensive courses are included. -Generalized requirement to meet international norms. -Multiple programs with Credits and electives -General education, internship, remedial course, advising, outreach courses and program effectiveness (In the case of professional courses, programs are assessed by external team formed from experts who are invited by CAA.) 1. Mission, vision and planning 7. Programme Evaluation Use of teacher and student feedback, student performance & stakeholders role 9. Continuous Renewal Updating its mission, structures and activities 8. Governance & Administration -Interaction with Health Sector 2. Educational Programme Curriculum specified for medical education e.g. - Basic Biomedical Sciences - Medical Ethics - Clinical Sciences & Skills Setting: (inpatient/ambulatory, hospital/community, rural/urban, specialist/general) - Linkage with Medical Practice and the Health Care System -specific transition programs -integration of clinical with preclinical phases -Role of faculty and students in curriculum development I. Institutional Setting -Mission, Organization and Governance -Accreditation & Autonomy -Policies and procedures manual - Feedback from faculty students important for program improvement by independent unit which reports to CEO -Centralization & integration II. Educational Program for the M.D. Degree -Objectives must specify the clinical conditions that students must see Unique features -Need for altruism -Should meet social needs Curriculum requirements -Basic science should prepare for clinical exposure -Single curriculum- should be able to enter any field -Cultural sensitivity, gender bias -"scrupulous ethical principles" -Consent, confidentiality & respect -Communication & clinical reasoning skills -Curriculum review uses 8

9 CAA 2011 WFME 2003 LCME 2011 student & faculty participation Grading and Assessment Policy. ( As a criteria of curriculum standard) -Use of a variety of assessment tools (not specified) -Validity, standardization and improvement. 4. Faculty and Professional Staff -Recruitment, roles, qualifications, promotions, evaluation and workloads are clearly stated. -Professional development plan is prioritized. Adjunct Clinical Faculty This is a stipulation, which is newly added to suit requirements of medical education. 5. Students Admission & selection of students -process & criteria Enrollment based on infrastructure. Transfer policy - only for 50% or more of the course. Student Counseling Student Activities Access to healthcare services Student organization etc. Student Academic Integrity Policy. 3. Assessment of Students -Method and policy including timing, weighting and criteria for progression. -Reliability and validity -Assessed against internal and external standards -new assessment methods -Relation between Assessment & Learning 5. Academic Staff/Faculty 6.5 Educational expertise should be assessed and improved Quality Standard: Should have access to an expert medical education unit or other educational expertise 4. Students 4.3 Student Support and Counseling 4.4 Student Representation student contribution to curriculum matters Student integrity Student assessment should utilize -continuous assessment feedback -Standardized examinations & - Objective structured evaluations recommended. - non-cognitive assessment -In course evaluations after clinical clerkships IV. Faculty -Specific requirements of clinical adjunct faculty -These community physicians should prove teaching skills to be faculty. -Workload considers clinical responsibilities. -Residents should receive instructions goals etc. -Departmental autonomy -Need for medical education unit III. Medical Students - transfer to final year only in rare circumstances B. Medical Student Services -Mentoring and career guidance -provide documents to promote admission into Residency -Student debt should not affect education -Prevent Exposure to infection - consent should be taken regarding the risk involved. -Professional conduct: informal and formal learning 9

10 CAA 2011 WFME 2003 LCME Learning Resources a. Library 7. Physical and Technology Resources a. Equipment and Software Replacement Policy. b. Health and Safety Policy. c. Data Security Policy d. Policy on appropriate use of Technology. 8. Fiscal Resources a. External Audit Policy. b. Financial Policy 9. Public Disclosure and Integrity a. Conflict of Interest policy b. Copyright & Intellectual Property Policy c. Teach-out Policy. Publications Policy e. Institutional Relations Policy. Partnership with other organizations for exchange faculty and students 10. Research a. Ethical Issues Policy. This includes, as appropriate, regulations on the use of human and animal subjects. b. Research Support Policy. 11. Community Engagement a. Community Engagement Policy. 6. Educational Resources - Physical Facilities for non-clinical components Same - Information Technology Clinical Training Resources -description of the facilities for clinical training in hospitals, clinics etc. -Availability of patients - Educational Budget and Resource Allocation Not mentioned Interaction with Health Sector relationships between the medical school and the health services 6.6 Educational Exchanges student exchanges, staff exchanges, and Research. Transfer policy 6.4 Research facilities and research programs of How does the school foster interaction between its research and educational Activities. V. Educational Resources A. Finances B. General Facilities D. Information Resources and Library Services-Latest journals C. Clinical Teaching Facilities Student scholarships and loans Not mentioned Centralized roster and protocol of visiting, transfer students and outside electives at Deans office Multiple sites policy -Agreement with hospital -Hospital should be accredited for graduate programs. -Partnerships for exchange programs Research should be facilitated for students who are interested community orientation and community service 10

11 Figure 1 COMPARISON OF HIGHER EDUCATION STANDARDS WITH THE STANDARDS SPECIFIC FOR MEDICAL EDUCATION CAA 2011 Includes undergraduate, Postgraduate& others General course Multiple electives & majors Internship Faculty & student handbooks Exchange students & outreach facilities Quality manual, risk management Adjunct clinical faculty new stipulation Public disclosure and integrity policies Animal research facility & ethics Student safety Common for All HEI s Clear strategic goals, mission & educational objectives o continuous assessment o Use of feedback o Improvement based on results Autonomy in Governance World-class curriculum, teaching methods & facilities Student assessment - process and validity Student counseling & organizations Student health services General Faculty requirements Up-to date Resources & financing Research facilities Quality assurance by independent unit Partnerships for exchange faculty & students Community service WFME & LCME 2011 Single course for all students Curriculum requirement o Basic & clinical competence o Medical ethics, humanism o communication skills o Internship Non-cognitive skills assessment Transition programs Student protection from infectious diseases Adjunct Clinical faculty requirement Hospital resources for teaching Agreement with hospitals Community based research 11

12 Figure 2 MAPPING OF UNIQUE REQUIREMENTS OF MEDICAL EDUCATION WITH CAA STANDARDS Fully Covered by CAA Partially covered by CAA +/- Not covered by CAA Unique Requirements of Medical Education The features peculiar to medical education excluding those which are in common with other HEIs are: 1) Institutional planning a) Clear planning with measurable outcomes b) Should foster interdisciplinary learning with other healthcare personnel. c) Partnership with hospital & healthcare sector 2) Curriculum a) Single curriculum, requiring integration, all disciplines compulsory for all b) Preclinical to Clinical transition program 12

13 c) Commitment to community 3) Clinical requirements a) Specific curricular & competency requirements like confidentiality, consent and communication skills required for patient encounter b) Altruism and professionalism c) Compulsory Internship requirements 4) Faculty a) Role in curriculum development b) Clinical Adjunct faculty requirements c) Continuous professional development 5) Student a) Attitudes, commitment, high ethical standards b) Student counseling & health services c) Student s health and protection from hazards of infection during hospital training 6) Facilities a) Preclinical facilities for learning basic sciences in preparation for clinical phase b) Library and learning resources which are up to date. c) Specialized clinical facilities & patients with written agreement with hospital for use of facilities These characteristics were evaluated for inclusion in the CAA standards at the end of the document. The unique requirements of medical education crucial for success are mapped out to note the congruence with accreditation standards of HEIs. (See Fig 2) DISCUSSION: On conducting a detailed analysis and comparison of the standards for accreditation for HEIs in general and that for medical education, it was seen that there were no major differences in areas of mission, vision, planning, Governance, quality management, student selection and preclinical resources. These are crucial quality indicators of medical education as noted ina previous study of WFME standards. (MacCarrick, 2010). The apparent lacunae regarding student feedback, curricula, resources, exchange student program etc. were found to be adequately covered in both the documents to bring about the desired same end result. CAA clearly emphasizes reliability and validity of student assessment and importance of professional development, which are important standards for medical education as stated in the literature.(maccarrick, 2011) The importance of curriculum management and relationship of research to the teaching process have been demonstrated in earlier studies. (G Maccarrick, 2010) The areas where CAA stressed more than WFME or LCME were in the requirement of a general course, documentation of faculty, staff and student handbooks, policies and procedure manuals, stream selection of students and public disclosures. The WFME & LCME stressed on assessment, resources, faculty and student feedback as separate main headings. The areas of requirement for ethics course, patient spectrum, clinical resources and association with health sector which have been covered in medical education are not adequately covered by CAA standards. 13

14 The knowledge, skills, professional behavior and ethics required for medical professionals are unique. (Schwarz & Wojtczak, 2002) Therefore, some degree of conflict is inevitable. One such area of potential conflict would have been regulations for part-time staff and adjunct clinical faculty policies. This has been circumvented by extensive coverage in a stipulation attached to the CAA standards. The inclusion of internship, partnership, exchange student details even in the older versions of the Standards shows farsightedness. Therefore, the CAA has to be commended for expanding its scope to include most of the key requirements of medical education. CONCLUSION: The study has shown that the CAA standards, released in 2011, have included all major requirements for most professional courses. The unique requirements of medical education covered by the WFME criteria are largely included in the 2011 version of the standards, with high degree of validity for internal quality assurance. The lacunae perceived in the older versions of the standards of CAA were in areas of medical ethics, social responsibility, clinical faculty requirements, partnerships and resources. The possibility of conflicts for the institution was minimized by the use of the external review team. With the newer additions in the CAA standards, the necessity of this step has been minimized suggesting that a subject expert included to the accreditation team may be sufficient to validate the process. However, this study illustrates the areas of regulatory, infrastructural, ethical and student level implications which necessitate special consideration for maximum effectiveness in accreditation of a medical school. The study also brings out a myriad of avenues which can be generalized requirements of Higher Education which also encompasses other HEI s including professional, community and university colleges. References: Basic Medical Education:WFME Global Standards for Quality Improvement (2003) World federation for medical education Brink, C. (2010). Quality and Standards: Clarity, Comparability and Responsibility. Quality in Higher Education, 16(2), Davis, D. J., & Ringsted, C. (2006). Accreditation of undergraduate and graduate medical education: how do the standards contribute to quality? Advances in Health Sciences Education: Theory and Practice, 11(3), doi: /s Functions and Structure of a Medical School-Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree (2011), Liaison committee on medical education 14

15 Hamdy, H., Telmesani, A. W., Wardy, N. A., Abdel-Khalek, N., Carruthers, G., Hassan, F., Kassab, S., et al. (2010). Undergraduate medical education in the Gulf Cooperation Council: a multicountries study (Part 2). Medical Teacher, 32(4), doi: / Hays, R., & Baravilala, M. (2004). Applying global standards across national boundaries: lessons learned from an Asia-Pacific example. Medical Education, 38(6), doi: /j x Huang, C.-I., Wung, C., & Yang, C.-M. (2009). Developing 21st century accreditation standards for teaching hospitals: the Taiwan experience. BMC Health Services Research, 9, 232. doi: / Karle, H. (2006). Global standards and accreditation in medical education: a view from the WFME. Academic Medicine: Journal of the Association of American Medical Colleges, 81(12 Suppl), S doi: /01.acm c4 Karle, H. (2010). How do we Define a Medical School?: Reflections on the occasion of the centennial of the Flexner Report. Sultan Qaboos University Medical Journal, 10(2), MacCarrick, G. R. (2010). A practical guide to using the World Federation for Medical Education (WFME) standards. WFME 1: mission and objectives. Irish Journal of Medical Science, 179(4), doi: /s z MacCarrick, G. R. (2011). A practical guide to using the World Federation for Medical Education Standards. WFME 3: assessment of students. Irish Journal of Medical Science, 180(2), doi: /s x Maccarrick, G. (2010). A practical guide to using the World Federation for Medical Education standards. WFME 2: educational program. Irish Journal of Medical Science, 179(4), doi: /s Maccarrick, Geraldine, Kelly, C., & Conroy, R. (2010). Preparing for an institutional self review using the WFME standards - an international medical school case study. Medical Teacher, 32(5), e doi: / x Schwarz, M. R., & Wojtczak, A. (2002). Global minimum essential requirements: a road towards competence-oriented medical education. Medical Teacher, 24(2), Severyanova, L., & Lazarev, A. (2005). Recognition of higher medical institutions in Russia. The Medical Journal of Malaysia, 60 Suppl D, Smallwood, R. A., Frank, I., & Walters, T. (2010). The Australian Medical Council: beyond the first 25 years. The Medical Journal of Australia, 193(10), Standards for Licensure and Accreditation (2011) Commission for Academic Accreditation, Ministry of Higher Education, United Arab Emirates 15

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