On the other hand, it is also a fact that the established scientific base under-pinning our understanding of human biology and behavior, genetics, envi-ronmental and socio-economic determinants of diseases, fundamentals of critical thinking, diagnosis and therapy are the same no matter where it oc-curs. Also the ethical responsibilities - honesty, compassion, trust, integrity, duty - vital to the healing relationship between doctor and patient are present in virtually every culture. What is needed in this global village, are the internationally accepted "core competencies" required at time of graduation for entry into general practice in some countries, for further specialized training in most, and as a preparation for further continuing professional development (CPD) – "a must" for the medical practice of proper quality.

In the same time, the concept of essential linkages or continuity between the three phases of medical education: undergraduate or basic education, post-graduate or specialty training, and continuing education, was accepted as a lifelong process. Therefore, the graduates upon leaving the medical school should be equipped with knowledge, skills, attitudes, and critical thinking that would provide them with intellectual tools for lifetime study.

Though curricula assume similar appearances at all medical schools, details vary considerably. The differences most often reflect the scientific strength and influence of different departments at different schools. However, it is more and more accepted that we cannot deliver our learning programs effectively if we have not developed explicit learning outcomes that describe required knowledge, skills, and attitudes in measurable terms to be acquired by students on time of graduation. It leads to a triple loss: (a) the teacher cannot be sure they present relevant materials, (b) the students do not have important information facilitating independent learning, and (c) the educational institution is not able to provide clear evidence of high quality product by measuring possessed competencies.

In order to measure the quality of the medical education "product" and its effectiveness, it is important but not enough to indicate satisfactory educational resources and processes of the medical schools. The true test of academic quality is answer to the question "did students learn what they were supposed to learn?" Thus, the questions to be asked are: "What are the essential competencies the graduates must possess?", and "How to ensure that they possess them?" These questions can only be answered by the assessment of outcomes.

A small number of initiatives in the United States, Canada and the United Kingdom have attempted to define medical practice outcomes across multiple domains at the national level. Few years ago, the World Federation for Medical Education has developed a set of international accreditation standards, mostly process - oriented useful in ensuring that a medical school has the faculty and physical environment necessary to produce competent graduates. However, only the outcomebased standards have the potential of ensuring that graduates actually have the knowledge, skills and attitudes required to be a competent professional. In short, a medical school could pass accreditation requirements without producing competent graduates. It is of utmost importance that they be able to deliver similar standards of medical care regardless of their location.

Needless to say, such standards cannot simply be defined by the number of years in medical school or the number of hours of lecture or practice. It must be identified through the assessment of competence - regardless of educational methods used to achieve the competencies required. Thus, only the internationally accepted requirements that would specify the "core" knowledge, skills, attitudes and behavior of universal value to the practice of medicine that all physicians must possess became an issue of high priority.

Such efforts focusing on individual student outcomes have been mounted by the Institute for International Medical Education (IIME) established in 1999 in New York. The aim of the IIME was to define and promulgate a set of "global essential requirements and standards" or learning objectives deemed "core" for all medical students wishing to be called physician.

The first task was the defining and formulating the 'Global Minimum Essential Requirements' ("GMER") which was accomplished by the IIME Core Committee consisting of 17 senior educational and health policy experts from different regions throughout the world. The consensus process employed by the IIME resulted in the definition of 60 global learning objectives that were grouped into seven (7) broad domains: (1) Professional Values, Attitudes, Behavior and Ethics, (2) Scientific Foundation of Medicine, (3) Clinical Skills, (4) Communication Skills, (5) Population Health and Health Systems, (6) Management of Information, and (7) Critical Thinking and Research. (Figure 1)

There is no doubt that the domain entitled 'Professional Values, Attitudes, Behavior and Ethics' is essential to the practice of medicine. Many of the daily complaints against physicians and medical care relate to this area. The progress in biomedical sciences and technology and the increasing length of life are generating some unprecedented ethical, moral and philosophical dilemmas for doctors that call for proper solutions without compromising their primary responsibility in safeguarding the best interest of patients and their compassion, empathy, and the "healing touch".

The importance of the domains called "Scientific Foundation of Medicine" and "Clinical Skills" is well understood and universally accepted since they have always created the foundation for effective medical care. Since specific medical information is so quickly outdated, medical education must provide the student with a set of concepts most applicable to clinical situations and help develop problem-solving abilities and efficient management of patients’ care.

The "Communication Skills" are an essential tool for all physicians, particularly since effective communication is necessary to create an environment in which mutual understanding occurs among patients, their relatives, members of the healthcare team, colleagues and the public is well recognized. In addition, physicians must be able to teach, advice and counsel patients, families and the public about health, illness, risk factors and healthy lifestyles. Referrals and consultations, both oral and written, constitute another major communication modality. This area has been neglected as the medical schools have assumed that these communication skills evolve naturally or can be learned latter.

The domain "Population Health and Health Systems" reflects the growing conviction that it is no longer sufficient to focus on the diseases and ways they affect an individual. The physician is also responsible for disease prevention and public health. Global epidemics including HIV/AIDS, SARS, tobacco and violence, require physician knowledge and skills to promote and maintain health of society. It requires the ability to work in teams with other health professionals and knowledge of the principles upon which health systems are built and operated, and understand economic and legislative foundations. They have to know how to deal with rapidly increasing numbers of elders, with social changes and increasing numbers of people that find themselves unable to cope with physical and emotional stresses which physicians must be prepared to help relieve. Moreover, terrorism has added need for additional skills.

The "Management of Information" as domain is justified by the fact that the practice of medicine and management of a health system depends upon the effective flow of information. The physicians need to know how to use modern communication and information technology to access and manage medical information. Tele-medicine is now in widespread use by health professionals and the Internet is also being used by patients for self-diagnosis and to ask for second opinions – a challenge to family doctors. Physicians also have to understand the capabilities and limitations of information technol-ogy, and be able to use it for medical problem solving and decision-making.

The seventh domain "Critical Thinking and Research" reflects the need for ability to evaluate a relevance of rapidly growing knowledge, new technology and information what demand constant learning and self-development. Therefore, the ability of critical thinking and assessment of information and various evidences becomes the most important skill of physicians. Graduates also have to understand the role of research in medical practice, especially important since the medicine of today won’t be the medicine of tomorrow.

This requires motivation for continued acquisition of new knowledge and skills and commitment to life-long learning, being aware of their own limi-tations and ready to conduct regular self-assessments and accept peer-evaluations and be able to undertake the continuous self-directed study. Continuing professional development (CPD), including continuing medical education (CME), is an individual responsibility as well as an ethical duty of all health care professionals. Figure 2

This set of global "core" competencies" must be viewed as a three-tiered structure composed of global, national, and local layers. Thus, the concept of "GMER" does not imply a global uniformity of medical curricula and educational processes. The medical schools should adopt their own particular curriculum design to respond to local and national health needs. But in doing so, they must assure that their graduates will possess all core competencies stated in the GMER document.

It was clear for us from beginning that the "Essentials" alone are not likely to change the educational process and graduates’ competencies unless they are linked to the process of evaluation. The Task Force for Assessment, consisting experts in assessment technology, reviewed over 75 different potential assessment tools, and recommended the most appropriate from among those currently in use. This included: a multiple choice examination (MCQ), a multi-station objective structured clinical examination (OSCE) using standardized patients (SP) and a longitudinal faculty observation of students in clinical settings. The "GMER" items were then mapped onto these assessment tools and in the process, some competencies were assessed by more than one instrument.

The phase II of the IIME Project began in April 2002 with the "Briefing Seminar" conducted in Beijing where the high ranking representative of the Chinese Ministry of Education and Ministry of Health invited the IIME to evaluate graduating students at eight leading medical schools. The meeting was attended by the Presidents or Senior Executives from these top medical universities who expressed a full support for the project as they felt it would be a beginning of the road to improve the quality of medical education in China.

To prepare for the examination, three training workshops attended by educational leaders from each of the eight Chinese medical schools were con-ducted. During first "IIME Workshop on Assessment of Global Minimum Essential Requirements" held on June 27-29, 2002 in Beijing it was agreed that the pilot evaluation should performed on all graduates of 7th year course and that assessment tools and procedures must be of internationally recognized quality. The evaluation should indicate the degree to which each student possesses the competencies envisaged in the "GMER" document. Although the project involves the evaluation of individual students, the intention was to use the aggregation of student performance data to judge the relative strengths and areas needing improvement in the educational experiences provided by each of participating medical school.

The second "IIME Workshop on the Development of Assessment Tools", was hosted by Shanghai Medical College of Fudan University in October 2002. The participants agreed on the general principles of the assessment and developed the blueprint of the content of assessment tools and procedures to be used in students’ evaluation. The MCQ test was compiled by using mostly items from the National Board of Medical Examiners (NBME) database, 15 Stations of OSCE ten (10) of which were to use the Standardized Patients (SP), and the Structured Observations Ratings to be performed by faculty to evaluate students’ clinical skills while the students are performing on the wards and at the patients’ bedside were designed.

The third "IIME Workshop on the Development of Assessment Tools" took place in February 2003 in cooperation with the Sichuan University, West China University of Medical Sciences in Chengdu. The MCQ group developed a small number of new items which were not present in the NBME database, i.e. population health. The OSCE Group reviewed all 45 newly written cases for the OSCE stations. The Observation group developed scales for 17 "GMER" competences and established ways of training approximately 400 teachers who will observe and rate the graduates’ competences. It was agreed the date of the exam on October, 2003 to all seven-year track students’ at the eight schools. Examination materials were then translated from English into Mandarin in order that all students could understand the questions.

The preparation for the October 2003 examination included training for edu-cational staff from all participating medical schools in use of OSCE and training SP’s with partial financial support from the Ministry of Education. In addition, to ensure a better understanding of the purpose, format and ex-pected outcomes of the examination, pre-exam briefings for staff and students in all eight participating medical schools were provided by the IIME experts.

In October 2003, eight schools in China simultaneously administered the MCQ and OSCE examinations. The "MCQ" exam took place morning Oc-tober 16, and included 150 items related to the "GMER" competencies. The "OSCE" examination began on the 17th and was performed in 15 stations, including five long SP cases, five short SP cases, and five Non-SP stations. Students were evaluated by at least one faculty member using a predefined checklist and sliding scale for performance. The faculty observation part of the exam occurred over a three-month period extending from July until Oc-tober 2003, with a minimum of three faculty ratings per student.

While all schools had used the MCQ format in the past, the questions were almost always of the recall type. In contrast, the MCQs used in the GMER exam were more complex in that they were case-based questions and re-quired considerably more integrative ability to answer correctly. While faculty observations of student performance are routine in China, these are usu-ally do not involve longitudinal observation as required for the "GMER" exam nor do they involve sliding scales of evaluation with defined end-points. Therefore, faculties from each school were trained to teach other faculty at their home institutions on how to use these forms. The examination in all participating universities was supervised by the IIME/CMB Observers-experts. They also collected performance data of the students and brought to the IIME for analysis. Approximately 300,000 data points were collected on a total of 384 students at eight schools.

The next step in analysis of students’ performance was to set an international standard for the examination. Although there are many different tech-niques for setting standards, all of them rely on the judgment of experts. Thus, an international agreement on what constitutes a competent medical graduate was reached at the "International Student Standard Setting Group" Meeting on February 2004. This group consisted of 11 experts in student assessment from around the world who were recommended by IIME Core Committee members. They represented a wide variety of basic science and clinical specialties. Split into two sub-groups, these individuals set a "cut-score" on each element of the exam, by examination method and "GMER" domain. The results of this parallel panel process revealed nearly identical standards from the two groups. This increased the confidence the partici-pants had in their validity and the methods used to assess them. These "cut scores" ranged from 41% to 78%.

Once these student-level standards were established, it became possible to establish "cut scores" for institutions. This was done by assembling the Core Committee in March, 2004. After reviewing the examination materials and the student-level cut scores, using an Angoff-like process, the Committee identified the lowest acceptable percentage of students answering a question or series of questions correctly before they would conclude that the institution had a strength in the area. Conversely, any institution whose aggregate student performance fell below this "cut score" would be considered having "an area needing improvement".

Specifically, this was accomplished by asking the Committee to set a hypo-thetical level for acceptable performance. They were then told what the ac-tual performance on the exam was and were allowed to adjust their accept-able failure rate. These allowable failure rates ranged from 9% to 24%. Using these cut scores (i.e.: failure rates) and aggregating performance of students on a school-by-school basis, it was possible to define areas of strength, borderline performance, and areas in need of improvement for each institution. This approach to evaluating medical education had never been done before either at the student or the school level. Figure 3

When the international standards at the student-levels and school-levels were set, a series of reports were prepared. These detailed domain reports were addressed to each participating schools and all individual student performances. The Deans of the participating schools also received a report on the results of their individual students’ performance and a report on their students’ aggregated performance with comparisons to the average results of students of all participating schools. In addition, each student, each involved faculty member and each university received a certificate confirming their participation in the first international competency examination.

The reports of the pilot examination have provided information on areas that need improvements based on international standards. As such, each student, each school and China at large now possesses a blueprint for educational improvement.

As the confidentiality of the result of this pilot examination was a priority, no school was allowed to see performance of any other school, and students were not allowed to compare their performance with another student’s scores. The only comparisons allowed were with the international "cut point" standards established by the two global committees. A summary report on the aggregated strengths, borderline areas and areas needing improvement of all eight schools together was presented to the Minister of Education. Given the nature of the data presented, the Ministry received a blueprint for educational reform and improvement.

The IIME-initiated GMER project was designed as an experiment. Nothing of this kind has ever been done before either in its global goals or in its focus on outcome competences. The assessment of learning-outcomes should ensure that educators have focused on outcomes when they are planning their educational programs. As such, this pilot implementation presents a new conceptual framework for improvement of quality of educational product.

I would like to conclude with Professor Farmer’s statement: "Excellence in education does not occur accidentally - it is the result of a pursuit that requires careful planning and implementation, and it cannot grow unattended. The question of excellence does not depend on money - it depends on ideas, priorities and the focused energies of people." (Enhancing Student Learning: Emphasizing Essential Competencies in Academic Programs, 1988)