Dear Editor,

It is globally acknowledged that becoming a physician today brings complexities not faced in the past. There is growing evidence for new techniques in patient care as well as advancing technology that brings forth procedures never possible before. Moreover, patients today possess access to more medical information and thus expect the highest of quality. The Accreditation Council for Graduate Medical Education (ACGME) focuses on improving the health of society by ensuring that doctors are well trained in all aspects required of competent physicians.1 The death of a young woman, Libby Zion, in a hospital in New York gave this process overwhelming momentum. Investigations revealed that the lack of familiarity with Libby’s complex case, as well as the lack of supervision and resident fatigue, all contributed to the misfortunate event making it ground zero for what followed as a long series of reforms in the medical education system.2

The bulk of reforms, instated by the ACGME, focus on limiting the number of working hours and the frequency of in-house calls.1 After the reforms went into effect, a vital question remained unanswered: did the reforms improve patient safety, resident well-being, and education? Some suggest that there was an increase in errors due to disrupting the continuity of patient care. Furthermore, many studies resulted in controversial conclusions.3 Some found a potential balance between the harmful and beneficial effects of the accreditation, which dwarfed the actual benefits of the reforms.4 However, others concluded that the reforms had a positive impact.5,6  Furthermore, some studies suggested that the ῾one-size fits all’ approach may not be appropriate, given the variation in training needs, practice patterns, and various competencies required among disciplines. Subsequently, the answer to that vital question rests on a delicate interplay between resident weariness and patient safety. Thus, it is obvious that the evidence base is still nascent and more research needs to be done.7

Because of petitioning by institutions that the ACGME develop an international accreditation model, the ACGME-International (ACGME-I) was conceived. Subsequently, it became ACGME-I’s mission to cooperate with different countries to tailor graduate medical education (GME) based on the needs and resources of those countries.1

The first pilot project was conducted in Singapore in 2009. Singapore currently educates physicians in 15 specialties and 10 subspecialties (all under ACGME-I accreditation), at three different sponsoring institutions. In addition, the ACGME-I accreditation currently covers institutions and/or training programs in Qatar (one institution and 14 specialties), Abu Dhabi (six institutions and seven specialties), Beirut (one institution), Oman (one institution and 16 specialties), Saudi Arabia (one institution), Haiti (one institution), and Panama (one institution). The ACGME-I is also in exploration with countries such as Trinidad and Tobago, and Ecuador.1,8

Hamad Medical Corporation was one of the first hospital systems in the Middle East to achieve institutional accreditation from the ACGME-I in November 2012. Under the accreditation structure, resident physicians undergo structured and discipline-specific training under the supervision and mentorship of senior clinicians. They are periodically assessed on their professionalism, knowledge, patient care skills, and interpersonal and communication skills to ensure that the aspiring specialist doctors provide excellent care.9

Interestingly, no studies have been published from the Middle East to address the effectiveness of the reforms in improving patient safety, resident well-being, and education. Thus, this letter addresses all ACGME-I accredited institutions to engage in medical education research and generate evidence on the effectiveness of the accreditation process to guide the future development of GME globally.

references

1. 1. ACGME-I history. Acgme-i.org [cited 2018 January 5]. Available from: http://www.acgme-i.org/About-Us/History.
2. 2. Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med 1988 Mar;318(12):771-775.
3. 3. Howard DL, Silber JH, Jobes DR. Do regulations limiting residents’ work hours affect patient mortality? J Gen Intern Med 2004 Jan;19(1):1-7.
4. 4. Choma NN, Vasilevskis EE, Sponsler KC, Hathaway J, Kripalani S. Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0. JAMA Intern Med 2013 May;173(9):819-821.
5. 5. Fletcher K, Reed D, Arora V. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules. J Gen Intern Med 2011;26(8):907-919.
6. 6. Al-Lamki N, Al-Lamki L. International accreditation of postgraduate medical education: whither its role in Oman? Oman Med J 2016 Jan;31(1):1-4.
7. 7. Ulmer C, Miller Wolman D, Johns M. Resident duty hours. Washington (DC): National Academies Press; 2009.
8. 8. International benchmarking through accreditation drives Oman Medical Specialty Board (OMSB) to meet worldwide standards [cited 16 April 2018]. Available from: http://www.acgme-i.org/What-is-Accreditation/Accreditation-Stories/Accreditation-Story-Details/ArticleID/3/International-Benchmarking-through-Accreditation-Drives-Oman-Medical-Specialty-Board-OMSB-to-Meet-Worldwide-Standards.
9. 9. Hamad Medical Corporation. Our accreditations [cited 5 January 2018]. Available from: https://www.hamad.qa/EN/About-Us/Our-Accreditations/Pages/default.aspx.