Canadian Standard for Full Licensure

• have a medical degree from a medical school listed in the FAIMER’s International Medical Education Directory (IMED) or the WHO's World Directory of Medical Schools (WDMS); and
• be a Licentiate of the Medical Council of Canada;
• have satisfactorily completed a discipline-appropriate postgraduate training program and evaluation by a recognized authority; and
• be certified by the College of Family Physicians

National Standards for Provisional Licensure

The national standard for the issuance of a provisional license requires the physician to:

• have a medical degree from a medical school listed in the FAIMER’s IMED or the WHO’s WDMS,
• satisfactorily complete a discipline-appropriate postgraduate training program and evaluation by a recognized authority,
• have passed the Medical Council of Canada Evaluating Exam or other acceptable screening exam, and
• satisfactorily complete a practice assessment as a condition of continued practice.

OR:

• have a medical degree from an acceptable medical school listed in the FAIMER IMED or the WHO’s WDMS, and
• satisfactorily completed a discipline-appropriate postgraduate training program and evaluation by a recognized authority, and
• enter into appropriate licensure terms, limitations, conditions or restrictions, as agreed by FMRAC and its members.

College of Physicians & Surgeons of British Columbia

College of Physicians and Surgeons of Alberta

College of Physicians & Surgeons of Saskatchewan

College of Physicians & Surgeons of Manitoba

College of Physicians & Surgeons of Ontario

Le Collège des médecins du Québec

College of Physicians & Surgeons of Nova Scotia

College of Physicians & Surgeons of New Brunswick

College of Physicians and Surgeons of Newfoundland & Labrador

College of Physicians and Surgeons of Prince Edward Island

Yukon Medical Council

Northwest Territories Medical Regulatory Authority

Nunavut Territory Medical Regulatory Authority

Medical Council of Canada

Graduates of one of the approved programmes in Ireland (and graduates of recognised medical schools within EU member states) are entitled to apply for Registration. Interns are still identified as such but are now registered in the Trainee Specialist Division. Registration as an Intern allows a doctor to undertake internship training in an individually numbered, identifiable intern training post which has been approved by the Council for the purpose of intern training. They must satisfactorily complete a minimum aggregate period of twelve months' internship training in order to be eligible for a Certificate of Experience on completion of internship training. There are specifications about the type of recognised rotation.

The Medical Council recommends that medical practitioners enroll in and complete specialist training programmes, where possible. Medical practitioners holding Internship Registration should normally apply for Trainee Specialist registration when they are nearing completion of their internship training. Medical practitioners holding Trainee Specialist registration who have not completed their specialist training but wish to be transferred to the General Division should establish in the Registration Rules whether or not they may be eligible for General Registration.

National Board of Medical Examiners (NBME)

National Board of Osteopathic Medical Examiners (NBOME)

COMLEX-USA

United States Medical Licensing Examination (USMLE)

Non-specialist:

• The Competent Authority Pathway
• The Australian Medical Council Examination

Specialists:

• Assessment by the relevant Specialist Medical College against the standards required for an Australian trained specialist in the same specialty field.

Canadian Standard for Full Licensure

• have a medical degree from a medical school listed in the FAIMER’s International Medical Education Directory (IMED) or the WHO's World Directory of Medical Schools (WDMS); and
• be a Licentiate of the Medical Council of Canada;
• have satisfactorily completed a discipline-appropriate postgraduate training program and evaluation by a recognized authority; and
• be certified by the College of Family Physicians

National Standards for Provisional Licensure

The national standard for the issuance of a provisional license requires the physician to:

• have a medical degree from a medical school listed in the FAIMER’s IMED or the WHO’s WDMS,
• satisfactorily complete a discipline-appropriate postgraduate training program and evaluation by a recognized authority,
• have passed the Medical Council of Canada Evaluating Exam or other acceptable screening exam, and
• satisfactorily complete a practice assessment as a condition of continued practice.

OR:

• have a medical degree from an acceptable medical school listed in the FAIMER IMED or the WHO’s WDMS, and
• satisfactorily completed a discipline-appropriate postgraduate training program and evaluation by a recognized authority, and
• enter into appropriate licensure terms, limitations, conditions or restrictions, as agreed by FMRAC and its members.

College of Physicians & Surgeons of British Columbia

College of Physicians and Surgeons of Alberta

College of Physicians & Surgeons of Saskatchewan

College of Physicians & Surgeons of Manitoba

College of Physicians & Surgeons of Ontario

Le Collège des médecins du Québec

College of Physicians & Surgeons of Nova Scotia

College of Physicians & Surgeons of New Brunswick

College of Physicians and Surgeons of Newfoundland & Labrador

College of Physicians and Surgeons of Prince Edward Island

Yukon Medical Council

Northwest Territories Medical Regulatory Authority

Nunavut Territory Medical Regulatory Authority

Medical Council of Canada

The Register of Medical Practitioners comprises four Divisions of the Register - General Division, Specialist Division, Trainee Specialist Division, and Visiting EEA Practitioners Division. There are four main Categories of applicant depending upon where applicants graduate from (For more information refer to the related link). IMGs should establish which Division they are eligible to apply and their Category.

Category 4 applicants are required to pass the Pre-Registration Examination System (PRES) unless exempt.

Applicants for Trainee Specialist, General or Specialist Registration who are not EU/EEA/Swiss citizens are required to pass or be exempted from the Academic International English Language Testing System (IELTS).

Amendments to the current Medical Council of Ireland Registration Rules are under public consultation, and if adopted by Council, the criteria for Registration Rules and Rules relating to the Pre-Registration Exams and Exemption from the Pre-Registration Exams may change. The new Rules will not be made for another couple of months at least. Contact should be made directly with the Medical Council regarding the changes.

1. Those who hold a primary medical degree from an Australian university medical school
2. Those who hold a primary medical degree from a medical school accredited by a competent authority and who have a year of general medical experience.
3. Those who hold a degree from an approved medical school, have met requirements to sit the New Zealand Registration Examination (NZREX) and who successfully pass NZREX (or other examination approved by the MCNZ) within 5 years of eligibility.
4. Hold a primary medical degree from a medical school approved by the MCNZ, have worked for a minimum of 36 months in a comparable health system during the previous 4 years with full registration or is participating in training with an American Board or Canadian specialist college.

• are sponsored under an arrangement approved by the GMC
• hold an approved postgraduate qualification
• are a trained GP or specialist

All IMGs must provide objective evidence of their proficiency in English, either by achieving our minimum required scores in the International English Language Testing System (IELTS) assessment, or by providing us with alternative evidence.

Doctors who qualify inside the European Economic Area and who are 'exempt persons' (i.e. have exercised their right to freedom of movement within the EU) are covered by European legislation which provides an assurance that their qualification and experience has met a minimum standard and are therefore eligible for full registration without further testing of knowledge and skills.

Registration for international medical graduates

English language requirements

National Board of Medical Examiners (NBME)

Educational Commission for Foreign Medical Graduates (ECFMG)

United States Medical Licensing Examination (USMLE)

The AMC examination is intended to assess for the purposes of general (or non-specialist) registration, the medical knowledge and clinical skills of IMGs whose basic (non-specialist) medical qualifications are not recognised under the Health Practitioner Regulation National Law Act.

IMGs who complete the AMC exam are eligible for Provisional Registration by the Medical Board of Australia and, unless exempted by the Board, must complete 12 months supervised training at PGY1(intern) level prior to being granted general registration (unconditional licensure).

MCC Evaluating Examination (MCCEE)
The MCCEE's purpose is to evaluate an International Medical Graduate’s (IMG) or an International Medical Student’s (IMS) readiness to enter the MCC Qualifying Examination Part I and/ or further his/her medical education experience in Canada.

National Assessment OSCE - the purpose is to evaluate the critical clinical skills, clinical decision making especially in therapeutics and communication skills necessary to enter postgraduate education.

The PRES is primarily a test of clinical skills, knowledge and attitude necessary to practise as a medical practitioner in Ireland.

Only candidates from Category 4* applying for Trainee Specialist Registration and General Registration are required to pass the Pre-Registration Examination System (PRES). (*who are Medical practitioners who have graduated from a medical school in a third country (outside EU/EEA/Switzerland) and have their qualification listed in WHO/IMED, who have completed recognised internship training, hold full/general registration in another jurisdiction (other than Ireland) and do not meet the criteria for any of the other categories).

IMGs who are successful in PRES are eligible for Trainee Specialist/General Registration.

The stated purpose of NZREX is "to ensure that candidates are competent to enter of period of registration in a provisional general scope of practice in New Zealand during which time they will be further assessed". COMMENT: The medical degree course in New Zealand is 6 years duration. The final year students (6th year) are termed ‘Trainee Interns' and have limited clinical responsibility. They cannot prescribe. At the end of the trainee intern year, New Zealand graduates should be of a comparable standard to successful NZREX candidates. This is a useful guide for the NZREX examiners who are usually experienced teachers of clinical medicine and therefore have considerable knowledge concerning appropriate standards.

The registration awarded to successful candidates (registration within a provisional general scope) allows them to work in a restricted hospital setting. During such hospital work the standard and progress of the doctor is monitored by consultants. Reports are forwarded to the Medical Council every 3 months. Registration in a general scope of practice (i.e., no longer required to work under supervision) requires satisfactory performance over a 12-month period.

To assess that international medical graduates (doctors who qualify outside the European Economic Area and who are not 'exempt persons' i.e. have exercised their right to freedom of movement within the EU) have the knowledge and skills necessary to practise medicine in the UK.

The USMLE is taken by all domestic graduates of medical schools granting the MD degree, and by all IMGs seeking postgraduate training and practice opportunities in the United States. It can also be taken by graduates of US schools granting the DO degree, if the individual desires, but the primary assessment route for DO students and graduates is the COMLEX program. USMLE is produced by the Federation of State Medical Boards and the National Board of Medical Examiners. The program, which consists of three parts ("Step" examinations), assesses a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.

The COMLEX-USA is taken by domestic graduates of medical schools that grant the Doctor of Osteopathic Medicine degree. The multi-part examination is produced by the National Board of Osteopathic Medical Examiners and consists of Level 1, Level 2 Cognitive Evaluation, Level 2 Performance Evaluation and Level 3.

The examination tests for the knowledge and clinical skills of those candidates who seek to be licensed as osteopathic physicians, and it is the primary pathway by which osteopathic physicians apply for licensure to practice osteopathic medicine. A passing score verifies the candidate’s adequacy of medical knowledge and clinical skills and facilitates assessment of the candidate’s competency as a physician about to enter practice. The COMLEX-USA is recognized and accepted for licensure with full practice rights, including osteopathic manipulative treatment, in all fifty states (U.S.) and a number of international jurisdictions.

To be eligible for the AMC examination an IMG must:

• have been awarded a degree of Medicine and Surgery after an approved course of study conducted by a University listed in the WHO World Directory of Medical Schools or in the International Medical Education Directory of FAIMER
• Have satisfied the English Language Proficiency requirement of the Medical Board of Australia (an overall Band 7 score and Band 7 scores in each of the test components or its equivalent)

The standard of the AMC exam is set at the level of medical knowledge and clinical skills expected of a graduate of an Australian medical school at the commencement of intern training.

Competent Authority Assessment
An IMG must have satisfactorily passed one of the following specified examinations AND have completed at least 12 months rotating internship or equivalent in a Competent Authority country to be eligible to proceed through this pathway:

• The UK PLAB examination PLUS Foundation Year 1 or equivalent in a Competent Authority country.
• The MCCQE Parts I and II including the period of supervised training prior to the MCCQE II.
• The USMLE Parts 1,2 and 3 PLUS the required residency program or equivalent.
• The NZREX PLUS the required rotations for general registration.
• Graduates of GMC accredited medical schools PLUS Foundation Year 1.
• Graduates of Medical Council of Ireland accredited medical schools PLUS a rotating internship in a Competent Authority country.

IMGs who are eligible to proceed through this pathway are required to complete a workplace-based performance assessment prior to general registration.

Specialist Assessment
To be eligible for assessment through the Specialist Assessment pathway and IMG must have completed postgraduate specialist training and be recognised as a specialist in the country in which the training was provided.

An International Medical Graduate (IMG), for the purpose of eligibility for the MCC examinations, must have completed all of the requirements for the final medical diploma in a university outside of Canada or the United States which is listed in either the International Medical Education Directory or the World Health Organization World Directory of Medical Schools.

Eligibility for the Licentiate of the Medical Council of Canada
Requires a pass standing on both MCCQE Part I and II plus an acceptable medical degree and postgraduate education

Language Proficiency
Most Canadian provincial and territorial regulatory bodies (except Québec and New Brunswick) require that IMGs who have graduated from a medical school where English is not the language of instruction pass the TOEFL. Most regulatory bodies require a minimum TOEFL score of 250. Newfoundland also requires that IMGs obtain a score of 50 on the TSE (Test of Spoken English). Québec requires applicants who have graduated from a medical school where French is not the language of instruction pass a French language proficiency test. Newfoundland also requires that IMGs obtain a score of 50 on the TSE.

In order to be eligible to sit the PRES examination an IMG Category 4 applicant must have:

• been awarded a basic (primary) medical qualification which was received on the day that one was conferred, clearly displaying the full date of conferral. In general, the Medical Council recognises basic medical qualifications awarded by schools listed in the current edition of the World Health Organisation ("WHO") Directory of Medical Schools and/or the Foundation for Advancement of International Medical Education and Research ("FAIMER") International Medical Education Directory ("IMED").
• been awarded an Internship Certificate or Certificate of Experience or equivalent.
• obtained the English Language Requirement of Academic IELTS Certificate with required minimum scores (7.0 in each band and overall band score of 7.5) dated within the last 21 months (unless exempt).

Only doctors who satisfy the above requirements may be admitted to sit the Pre-Registration Examination System (PRES).

Applicants must: hold a primary medical degree from a university medical school listed in the WHO Directory of Medical Schools or the ECFMG FAIMER Directory; and have passed either USMLE Steps 1 and 2(CK), or PLAB (Part 1) or AMC MCQ within the last five years.

English Language Testing Requirement
Although there may be some exceptions to the English language requirement for graduates of medical schools where English is the sole language of instruction and English is the graduate’s first language, doctors applying to sit NZREX Clinical, and doctors applying for registration, will be required to achieved the required standard in the academic module of IELTS (or been exempt from this requirement) within two years before applying to sit NZREX Clinical. The minimum standard is: Speaking 7.5, Listening 7.5, Writing 7.0, Reading 7.0 or above in the academic module of International English Language Testing System (IELTS), within the last two years. A minimum band of 7 is required in each of the four individual components of the test (listening, reading, writing and speaking).

The Test of English as a Foreign Language (TOEFL) and Occupational English Test (OET) are not accepted by the Council as alternatives to IELTS.

An acceptable primary medical qualification is from the World Directory of Medical Schools (WHO), published by the World Health Organisation (now the Avicenna Database). There are a few other primary medical qualifications that are not on the former WHO list but are nevertheless acceptable and these are listed on the GMC website as is the full detail of the GMC's criteria for an acceptable overseas primary medical qualification.

English Language Proficiency
Acceptable scores in the International English Language Testing System (IELTS) test. These are the minimum scores required: Overall 7, Speaking 7, Listening 6, Academic reading 6, Academic writing 61.

The IELTS certificate is valid for two years. If the certificate has expired, the doctor can send in evidence that he or she has maintained his or her English language skills. Candidates are recommended to have 12 months' postgraduate clinical experience (Foundation year 1 (F1)/internship post) from a teaching or other hospital approved by the medical registration authorities in the appropriate country. Those who pass the test without this experience have to seek employment in Foundation Year 1 (the grade occupied by new medical graduates).

Acceptable primary medical qualification

Professional and Linguistic Assessments Board (PLAB)

Step 1, Step 2 CK, and Step 2 CS: To be eligible, an examinee must be in one of the following categories at the time of application and on the test day:

• a medical student or graduate of a US or Canadian medical school program that is accredited by either the Liaison Committee on Medical Education or the American Osteopathic Association, or
• a medical student or graduate or a medical school outside the United States and Canada who is eligible for examination by the Educational Commission for Foreign Medical Graduates (ECFMG) for its certificate (see note below).

Step 3: To be eligible for Step 3, the examinee must:

• meet the Step 3 requirements set by the state licensing authority to which they are applying,
• obtain the MD degree (or its equivalent) or the DO degree,
• pass Step 1, Step 2 CK and CS
• obtain certification by the ECFMG

English Language Proficiency
Currently, there are no English Language Proficiency requirements to be eligible to take Step 1, Step 2 CK, or Step2 CS. However, examinees must pass the Spoken English Proficiency subcomponent of Step 2 CS in order to become eligible to register for Step 3.

The following are eligibility requirements for each Level of the COMLEX-USA:

COMLEX-USA Level 1
To be eligible, the osteopathic medical student or physician must have satisfactorily completed the first academic year of study at an osteopathic medical school accredited by the American Osteopathic Association’s Commission on College Accreditation (AOA COCA); be in good standing as a matriculated student in an accredited osteopathic medical school, and receive approval from the school’s dean, or if the candidate has graduated, provide a verified copy of his or her diploma.

COMLEX-USA Level 2-CE (Cognitive Evaluation) and Level 2-PE (Performance Evaluation)
To be eligible, the osteopathic medical student or physician must have passed the COMLEX-USA Level 1 examination, satisfactorily completed the second academic year of study at an osteopathic medical school accredited by the American Osteopathic Association’s Commission on Osteopathic College Accreditation (AOA COCA), be in good standing as a matriculated student in an accredited osteopathic medical school, and receive approval from the school’s dean, or if the candidate has graduated, provide a verified copy of his or her diploma.

COMLEX-USA Level 3
To be eligible, the osteopathic physician must have passed the COMLEX-USA Level 1, COMLEX-USA Level 2-CE and Level 2-PE examinations, have graduated from an osteopathic medical school accredited by the American Osteopathic Association's Commission on Osteopathic College Accreditation (AOA COCA), and provide verification of graduation.

English Language Proficiency
COMLEX-USA Level 2-Performance Evaluation incorporates the assessment of basic spoken and written English language proficiency in the context of clinical encounters with standardized patients.

The format and standard of the AMC examination is set by the full, Council which includes members drawn from each of the State Medical Boards, Medical Schools, the Specialist Medical Colleges, State and Federal Government, the Australian Medical Association and health consumers and community representatives.

The content and administration of the AMC examination, including confirmation of results, is determined by a Board of Examiners which consists of registered (licensed) medical practitioners drawn from each of the major discipline areas covered by the exam, who have expertise in teaching and assessment at both the undergraduate and postgraduate levels. Membership of the Board includes individuals with expertise in assessment methodology, medical education and psychometrics.

Individual examinations are constructed from banks of items and structured clinical scenarios, which are regularly reviewed to ensure that they reflect current best practice. Each MCQ item and clinical scenario is linked back to assessment objectives based on presenting clinical conditions. These are published in the Anthology of Medical Conditions.

The results of each examination administration are also reviewed by panels of MCQ and clinical examiners, to ensure that examinations performed in accordance with the prescribed performance criteria and standards for the examination.

The Evaluating Examination Composite Committee (EECC) is responsible for preparing the examination. The EECC shall in accordance with the evaluation objectives adopted by the MCC, prepare a balanced examination, including test items and clinical problems that are pertinent to:

• assessment of the candidate's knowledge, understanding, clinical skills and ability to make use of current medical knowledge in a subject;
• frequency of disease and injury;
• prevention of health hazards and rehabilitation;
• maintenance of psychological, physical and social well-being and good health;
• essential interpersonal skills with patients, family and other members of the health care system and the community;
• knowledge of gender, moral, ethical and legislative issues that are relevant to the needs of society; and
• self-learning autonomy and maintenance of competence.

The Pre-Registration Examination System (PRES) came into effect on 16th March 2009 with the implementation of Registration Rules the Medical Practitioners Act 2007. The PRES replaces the TRAS which had come into effect in 1996. The PRES examination is currently going through a major restructure. A number of short-term changes have been implemented. It is anticipated that long-term changes will be implemented and come into operation towards 2011.

Governance
The format and standard of the PRES examination is governed by the Medical Council's Professional Development Committee and approved by the Council. The results and report of each examination is brought to the Professional Development Committee for approval and is noted by Council.

Question and station writing/Blueprint
An Examination Development group has been formed to develop the longer term changes to the PRES. A formal blueprinting process and questions/station writing sessions will also be undertaken. An audit of the exams and review of content also takes place. Council has approved part-time assessment advisers.

The examination is a 16 station OSCE with each station lasting 10 minutes. The examination is driven from a blueprint. The competencies examined are communication skills, ability to take a history, ability to undertake a physical examination, managing acute serious deterioration, problem prioritisation and knowledge of both tests and procedures. A process of continuous quality improvement is used to analyse the performance of stations and improve those with less ability to discriminate between candidates.

Governance
The development and quality assurance of the test is overseen by a Board, which reports to the Registration Reference Group of the GMC. Each examination is developed and run by an Examination Panel, which reports to the Board.

Blueprint
A blueprint was constructed from data detailing what doctors do in hospitals and general practice.

Question and station writing
Question and OSCE station writing workshops are held regularly at which practising clinicians write in pairs on topics chosen for them from the blueprint. Questions and stations are peer reviewed by another pair at the workshop. Examination Panel members oversee the process. Panel members (clinicians from a range of specialties) edit questions and stations.

Creating question papers and OSCE circuits
Papers and OSCE circuits are created using a sampling grid and Panel members approve the selection.

Review
Questions and stations are regularly reviewed to ensure that they are up-to-date to match a changing evidence base.

The overall design and test construction blueprints are guided by committees of physicians and scientists who bring perspectives from the medical education, licensing and practice communities. Test content is developed by additional groups of physicians who have expertise in the content areas being addressed. New members to these groups complete a special item-writing workshop before beginning their term. Members are given assignments for the creation of test material; the assignments being based upon their expertise/interest and upon requirements for meeting a prescribed test blueprint. All newly written material must then be reviewed by a full committee of experts. If acceptable, this test content is included in the examination as a pre-test (not used for scoring). After pre-testing, the test content goes through another round of review, by a different committee, which decides if the material can be used in the live examination. All live test content goes through a further review, approximately every three years, to make sure that the material is still appropriate and accurate.

The NBOME utilizes an extremely rigorous process to construct the COMLEX-USA licensing examination. First, the blueprint is developed based on review of national data indicative of osteopathic medical practice and focused on the manner in which patients present for care. Consideration is also given to current curricula in the osteopathic medical schools with particular emphasis on evidence-based medicine and clinical competencies.

Test items and clinical cases are elicited from a broad base of content experts from all geographic regions of the country through assignments determined from the blueprint of specifications. Content experts are selected for their expertise within a discipline or subject area, their academic experience in undergraduate or post-graduate medical education or within the licensure community, or by virtue of the type and scope of their practice. Item writers and case authors receive training on best practices.

Each COMLEX-USA cognitive examination test item goes through five independent committee reviews and is pre-tested before use in an actual examination. After pre-testing, items are selected based on statistical quality (test item performance) and content. All such items are then reviewed by the separate committee, coded for use and edited for content, correctness, grammar, clarity and adherence to the specifications of the blueprint. Once the committee has approved the examination, it is ready to publish for computer-based delivery.

The COMLEX-USA Level 2-Performance Evaluation (Level 2-PE), the clinical skills component, undergoes a similar process. The Level 2-PE uses the same blueprint for its clinical presentations as is utilized by the COMLEX-USA cognitive examinations. Cases are further developed in workshops where authors observe case portrayals by standardized patients. All cases used in the PE examination are pre-tested. The PE examination uses standardized patients (SPs) in all of the clinical encounters.

The AMC examination is a comprehensive test of medical knowledge and clinical competency across a wide range of topics and disciplines, involving and understanding of the disease process, clinical examination, diagnosis, investigation, therapy and management. It also assesses the IMGs ability to exercise discrimination, judgment and reasoning. The clinical component of the examination assesses an IMG's capacity to take a history, conduct a physical examination, formulate diagnostic and management plans, and communicate with patients, their families and other health workers.

IMGs on completing the AMC examination are required to complete 12 moths supervised practice (at the level of an internship) in a position approved by a State Medical Board. For this reason the standard of the AMC examination is formally defined as the level of knowledge, clinical skills and attitudes which is required of newly qualified graduates of Australian medical schools who are about to commence intern training.

The MCCEE assesses the candidate's basic medical knowledge in Child Health, Maternal Health, Adult Health, Mental Health, and Population Health and Ethics.

The Objectives for the Qualifying Examination, third edition (2004), published by the MCC and available as an on-line resource, serve as the basis for the development of examination questions. The general objectives deal with data gathering, clinical reasoning and the principles of management, which are applicable, in part or in whole, to all clinical situations faced by physicians.

Objectives for the Qualifying Examination

The PRES is primarily a test of clinical skills, knowledge and attitude in the main clinical disciplines of Obstetrics & Gynaecology, Paediatrics, Psychiatry, Surgery, Medicine and General Practice.

The Level 2 exams factual knowledge. The Level 3 exams three types of clinical skills.

i) Communication skills
These stations assess the candidate's ability to obtain a history, to demonstrate interviewing and communication skills and/or to apply clinical management skills. This may include:

• Breaking bad news to a patient
• Communication with patients/relatives/children/healthcare professionals
• Ethics
• Explaining diagnosis, investigation and treatment
• Patient management plan/education exercises
• Seeking/obtaining informed consent
  • Taking a history

ii) Interpretation skills
It is expected that the candidate will be able to interpret results from tests and procedures. These stations may involve the candidate interpreting:

• an electrocardiogram (ECG)
• laboratory tests
• paediatric growth charts
• photographs, or
• X-rays

iii) Practical skills
These stations are practical and include skills such as performing a physical examination, demonstrating a practical procedure, or examination of someone’s mental state. These practical skills may include:

• Assessment of a patient’s mental state
• Injection Techniques
• Inserting a cannula
• Pharmacology and Prescribing Medication
• Physical examination of an adult or child on simulated patient or anatomical model.
• Suturing/dressing change
• To demonstrate the ability to respond to emergency situations Emergency Cardiovascular Care (i.e. cardiopulmonary resuscitation (CPR), BLS, ACLS, AED - this list is not exhaustive)

The blueprint informs the content of the examination. Stations can be drawn from any cross section of domains and competencies found in the blueprint. Domains are arranged into broad clinical categories. Subcategories are used to describe clinical presentations in which candidates are required to display competence. The blueprint is available on the NZREX web site.

The test is designed to assess the knowledge, skills and attitudes relating to conditions commonly seen in a first appointment in Foundation Year 2 (i.e. the second year after graduating), the management of life- threatening situations and rarer, but important, medical problems.

In Part 1, candidates must show that they are capable of applying knowledge to the care of patients. Four skill areas will be tested:

• Diagnosis;
• Investigations;
• Management/Treatment;
• The context of clinical practice

In Part 2 (OSCE) the skills assessed are:

• History Taking
• Clinical Examination
• Practical Skills
• Communication Skills

Step 1
Step 1 includes test items in the following content areas: anatomy, behavioural sciences, biochemistry, microbiology, pathology, pharmacology, physiology, and interdisciplinary areas such as nutrition. Step 1 is a broadly based, integrated examination. Test items commonly require performance of one or more of the following tasks: interpret graphic and tabular material, identify gross and microscopic pathologic and normal specimens, apply basic science knowledge to clinical problems.

Step 2 Clinical Knowledge (CK):
Step 2 CK includes test items in the following content areas: internal medicine, obstetrics and gynaecology, paediatrics, preventive medicine, psychiatry, surgery, and other areas relevant to provision of care under supervision. Most Step 2 CK test items describe clinical situations and require that the examinee provide one or more of the following: a diagnosis, prognosis, indication of underlying mechanisms of disease, or the next step in medical care, including preventive measures.

Step 2 Clinical Skills (CS):
Step 2 CS assesses whether an examinee can demonstrate the fundamental clinical skills essential for safe and effective patient care under supervision. The subcomponents of Step 2 CS include the Integrated Clinical Encounter or ICE (data gathering and documentation), Communication and Interpersonal Skills or CIS (questioning skills, sharing information, and professional manner/rapport), and Spoken English Proficiency or SEP.

Step 3
Step 3 is organized along two principal dimensions: clinical encounter frame and physician task. Encounter frames capture the essential features of circumstances surrounding physicians’ clinical activity with patients. They range from encounters with patients seen for the first time for non-emergency problems, to encounters with regular patients seen in the context of continued care, to patient encounters in (life-threatening) emergency situations. Each test item in an encounter frame also represents one of six physician tasks. Step 3 also includes computer-based case simulations which assess the examinees ability to provide care for a series of simulated patients.

COMLEX-USA is a comprehensive examination covering a broad scope and depth of medical knowledge and clinical skills as required for the practice of osteopathic medicine. COMLEX-USA is a bi-dimensional examination. Dimension I addresses the clinical presentations of patients. Dimension II deals with the tasks a physician uses to assist patients with these presentations. Osteopathic principles and practices, including the use of osteopathic manipulative treatment (OMT), are integrated throughout all of the examinations in the COMLEX-USA series.

COMLEX-USA Level 1 is a cognitive evaluation that emphasizes medical science concepts and principles necessary for understanding patients in health and disease. Level 1 integrates the medical sciences of anatomy, behavioral science, biochemistry, microbiology, osteopathic principles, pathology, pharmacology, physiology and other areas necessary to solving clinical problems and promoting and maintaining health.

COMLEX-USA Level 2-Cognitive Evaluation is an examination that emphasizes the concepts and principles necessary for making appropriate medical diagnoses through patient history and physical examination findings. Level 2-CE integrates the clinical disciplines of emergency medicine, family medicine, internal medicine, obstetrics/gynecology, osteopathic principles, pediatrics, psychiatry, surgery, and other areas necessary to solve medical problems and promote and maintain health.

COMLEX-USA Level 2-Performance Evaluation is a standardized patient-based clinical skills examination that assesses fundamental clinical skills, including patient-physician communication, interpersonal skills and professionalism; medical history-taking and physical examination skills; osteopathic principles and osteopathic manipulative treatment; and written communication skills, including synthesis of clinical findings, integrated differential diagnosis, and formulation of a diagnostic and treatment plan.

COMLEX-USA Level 3 is a cognitive evaluation that emphasizes the medical concepts and principles required to make appropriate patient management decisions. Level 3 integrates the clinical disciplines of emergency medicine, family medicine, internal medicine, obstetrics/gynecology, osteopathic principles, pediatrics, psychiatry, surgery, and other areas necessary to solve medical problems and promote and maintain health.

The AMC examination is currently sequential test, consisting of 2 stages. The first stage must be passed before an IMG may proceed to the second.

The format of the AMC computer-administered MCQ examination will change from January 2011 to a Computer Adaptive Test (CAT). The test will consist of:

• 150 type A format (1 correct out of 5 responses) items - 120 scored and 30 pilot (non-scored) items
• 1 examination session or 3.5 hours
• Assessment domains:
  • Pathogenesis
  • Clinical features
  • Investigative findings
  • Differential diagnosis
  • Management and treatment
• Subject components (and numbers of scored items):
  • Adult Health [Medicine] (35 items)
  • Adult Health [Surgery] (25 items)
  • Women's Health (15 items)
  • Child Health (15 items)
  • Mental Health (15 items)
  • Population Health (15 items)

An integrated 16 component multi-station structured clinical assessment, with provision for an 8 component retest for marginal candidates, covering

• Subject components:
  • Medicine
  • Surgery
  • Paediatrics
  • Obstetrics and Gynaecology
  • General Practice (Family Medical Practice)
  • Psychiatry
• Assessment domains:
  • History taking
  • Physical examination
  • Investigations
  • Diagnosis/differential diagnosis
  • Therapeutics/management
  • Counseling/patient education
  • Clinical procedures

The Evaluating Examination is a four-hour computer-based examination comprised of 175 multiple-choice questions (MCQ).

The structure of the PRES
The PRES is structured to assess the candidate’s knowledge, clinical skills, attitude and clinical judgment in Obstetrics & Gynaecology, Paediatrics, Psychiatry, Surgery, Medicine and General Practice. The assessment is also designed to ensure that a candidate has good communication skills and the ability to make accurate clinical judgments.

There are two components to the PRES and, to be successful, a candidate is required to pass both components. Candidates must pass Level 3 within two years from the date of passing Level 2.

Level 2
Level 2 tests factual knowledge in the main clinical disciplines. Level 2 comprises of a computer based written examination at test centres in Ireland, Egypt, India, and Pakistan. This currently takes place in the form of a Multiple Choice Questions (MCQ) examination of 2½ hours (150 minutes) duration. There are 60 questions in total. Each question consists of a stem followed by five statements (giving 300 questions in total). The Level 2 is negatively marked.

Level 3
Level 3 is a clinical based assessment. This currently takes place in the form of an Objective Structured Clinical Examination (OSCE). Level 3 is usually offered in a centre in Ireland, either in Dublin or in a major provincial centre. The Level 3 examination currently has a minimum of seventeen stations in total. This currently includes 15 "active" stations and a minimum of two "rest" stations. The number of rest stations may be increased at the discretion of the Medical Council. It is possible that there may be up to twenty stations in total, which would include five rest stations. Each station is currently six minutes in duration.

NZREX is an objective, structured clinical examination (OSCE). The emphasis of the examination is to test the application of knowledge and clinical decision-making. There is no written component as this has been included in the 'entry requirements.' There are a total of 16 stations based on the competencies of communication, prioritisation of management, recognition of acute serious deterioration and its management, history taking, physical examination and interpretation of tests and procedures.

The test is in two parts. Candidates must pass Part 1 before entering Part 2.

Part 1 is a written paper consisting of extended matching questions (EMQs) and single best answer (SBA) questions. The paper contains 200 questions and may contain photographic material. It lasts three hours and is machine markable.

Part 2 is an Objective Structured Clinical Examination (OSCE). It takes the form of 14 clinical scenarios or 'stations', a rest station and one or two pilot stations. Each station lasts five minutes.

Step 1: One day examination (8 hours). Item format: multiple choice question items (MCQ), one best answer, in single item presentations.

Step 2 CK: One day examination (9 hours). Item format: MCQ items, one best answer, in single item presentations and multiple item sets.

Step 2 CS: One day examination (8 hours). Item format: Encounters with standardized patients (15 minute standardized patient encounters; 10 minutes for writing a patient note after the encounter).

Step 3: Two day examination (16 hours). Item format: MCQ items, one best answer in single item presentations and multiple item sets, and computer-based case simulations (CCSs).

COMLEX-USA Level 1, Level 2-CE, and Level 3 are computer-based, cognitive examinations administered at professional testing centers across the United States and at a limited number of international locations. These are one-day examinations (8 hours) containing 400 test questions, predominantly of the multiple-choice (single best answer) items. Questions can be single-item presentations, or in multiple-item sets.

The COMLEX-USA Level 2-Performance Evaluation (Level 2-PE), the clinical skills portion of the examination, is a 12-station examination utilizing standardized patients (SPs) in each of the clinical encounters. The examination is a one-day test (8 hours) administered at NBOME’s National Center for Clinical Skills Testing. Candidates are permitted to evaluate and treat the standardized patient for 14 minutes, and to synthesize and document their findings, a differential diagnosis, and a treatment plan for the remaining 9 minutes in each station. The SPs are trained to document the candidate’s performance in certain clinical skills using standardized checklists, and to evaluate doctor-patient communication skills, interpersonal skills, and professionalism. Specially trained and certified osteopathic physician examiners score the candidates’ ability to use osteopathic principles and osteopathic manipulative treatment (OMT), and another specially trained group of physician examiners scores the post-encounter SOAP (Subjective Objective Assessment and Plan) notes.

Currently, under the legislation in force in Australia, there are no time limits on the validity of the AMC examination results. Previous time limits were removed on the basis of legal advice.

There is no longer a limit to the validity period.

The Medical Council currently imposes a limit of three attempts at any Level (Level 2/Level 3) of the PRES. Any candidate wishing to re-attempt an examination, having failed it three times or more, must apply in writing to the Medical Council.

Level 2
Candidates attempting Level 2 have a two years period of eligibility from the date when they are declared eligible to sit PRES. If unsuccessful in the Level 2, candidates may attempt the Level 2 up to and including a maximum of three times, until they either pass, they fail three times or their eligibility expires.

If a candidate is unsuccessful in either their first or second attempt of the Level 2 examination, they must allow six weeks to lapse from their previous attempt before they are eligible to schedule/book their next Level 2.

Level 3
Candidates attempting Level 3 have a two years period of eligibility from the date when they passed Level 2. If unsuccessful in the Level 3, candidates may attempt the examination up to and including a maximum of three times, until they either pass, they fail three times or their eligibility expires.

After Level 3
IMGs who are successful in PRES are eligible for Trainee Specialist/ General Registration.

A pass in NZREX is valid for 3 years. There is no limit on the number of attempts for a candidate.

Part 1 - Candidates can have an unlimited number of attempts but must pass Part 1 within two years of the date of their IELTS certificate, or the date we specify when accepting alternative evidence.

Part 2 - If they wish to register with the GMC they must do so within three years of passing Part 2 of the test. Candidates must pass Part 2 within three years of passing Part 1. They can have four attempts at

Part 2. If they fail at the fourth attempt they have to retake IELTS (unless they are exempt) and both parts of the PLAB test.

Although there is no limit imposed by the USMLE program on the total number of times an examinee can retake a Step or Step Component, USMLE does recommend to medical licensing authorities that they require the dates of passing the Step 1, Step 2, and Step 3 examinations to occur within a seven-year period; and allow no more than six attempts to pass each Step or Step Component without demonstration of additional educational experience acceptable to the medical licensing authority. These requirements are at the discretion of the state licensing authority and most of the authorities impose some form of time limit or number of attempt limit. Information on specific requirements can be obtained by contacting the Federation of State Medical Boards. Once all USMLE examinations have been successfully completed, the “validity period” for USMLE is currently indefinite.

Federation of State Medical Boards

All states in the U.S. use COMLEX-USA scores, as well as other criteria, for granting initial medical licensure for osteopathic physicians. Most states require successful completion of the COMLEX-USA series, in addition to the equivalence of three (3) years of postgraduate training. Candidates who pass any COMLEX-USA examination are not permitted to retake that examination for a higher score. In addition, candidates who are unsuccessful in passing any COMLEX-USA examination are permitted to retake that examination on an unlimited basis, provided they remain eligible. However, the NBOME strongly recommends that any jurisdiction consider requiring any candidate applying for licensure to have successfully completed the entire three-level COMLEX-USA sequence within seven (7) years from the date when the Level 1 examination was successfully passed.

Nova Scotia will accept USMLE for both GPs and Specialists and a number of other (non-cited) examinations.

Ontario will accept USMLE for both GPs and specialists and in some cases COMLEX.

Prince Edward Island will accept NZREX for GPs and AMC for both GPs and specialists.

Quebec will accept USMLE for both GPs and specialists and a number of other (non-cited examinations).

Saskatchewan will accept USMLE for both GPs and specialists.

Some jurisdictions accept COMLEX in the case of Osteopaths.

In some jurisdictions there may be further requirements to be fulfilled prior to registration such as a language test.

For further information regarding exemptions from PRES please refer to the Rules Specifying Pre-Registration Exams and Exemptions

• USMLE Step 1 and 2 (CK)
• Australian Medical Council MCQ
• General Medical Council PLAB Part 1

• those who have a qualification recognised by Council (i.e. graduated from a medical school in Australia, the UK and Ireland)
• those who have worked for a minimum of three years in a country with a comparable health system (i.e. UK, US, Canada, Belgium, Hong Kong, ect)
• and those who are qualified specialists with an appropriate postgraduate qualification.