International Accreditation of Postgraduate Medical Education: Whither Its Role in Oman?

"The only constant is change"

"You could not step twice into the same river..." 
Greek philosopher Heraclitus (402 BCE)

Several educators, particularly in developing countries, question the need for international accreditation. Why is that? Is change frightening and hard to accept? Is it the effort involved? Or is it simply pride under the umbrella of patriotism? The answer is not simple or clear. There are at least three types of people who question the need for international accreditation. Those who cannot accept change, however inevitable it is, and those with the pride/patriotism who question the wisdom of relying on developed countries as accreditors of developing countries. They ask why the developed countries themselves never seek international accreditation from each other. The third group is those who cannot see any obvious benefits to be accrued. However, despite these concerns, international accreditation has several benefits.

Various programs and colleges in Oman, medical and otherwise, are seeking accreditation from one of the three countries: the USA, Canada, and the UK.¹ However, even with accreditation of the training and the education given, the degrees provided by the accredited colleges and programs are still not at par with the accreditors’ own, and in many cases trainees are not recognized as being fully trained or qualified enough to sit specialty examinations. The UK has been the most generous about recognizing internationally accredited foreign training and allow foreign trainees to sit their specialty examinations. The USA and Canada have now started responding to the need for recognizing foreign medical specialty training and have started accrediting them. The Accreditation Council for Graduate Medical Education (ACGME) formed an international arm, ACGME-International (ACGME-I), for this purpose and the Royal College of Physicians and Surgeons of Canada (RCPSC) has established similar body.^2-5

While these are major steps forward, there are still problems. For example, being accredited by ACGME-I does not entitle one to sit for the American Board of Medical Specialties (ABMS) examination. However, we hope the situation will gradually improve. The ABMS has opened an international section (ABMS-I), and they are negotiating with a consortium of Gulf country educators to start a special overseas American Board examination for accredited programs. However, this would not be recognized as on par with the ABMS certification.

Preparation for international accreditation involves a lot of effort and sacrifice.⁶ Thankfully, for the Oman Medical Specialty Board (OMSB) these sacrifices were not as radical as they could have been since the training programs were based on the Canadian system of medical residency training for at least six years prior to the beginning of negotiations with the ACGME-I for the American accreditation. However, the switch from one international accreditor to another may still involve a significant change, including a change in the duration of training or individual rotations. Additionally, some rotation requirements of international accreditors may be inappropriate for particular countries. For example, the situation in Oman is such that pediatric medicine is geared for the care of children up to age 13 years; however, ACGME-I insists on pediatric residency training extending to those aged up to 18 years. While it may be a cultural interference to put a substantial emphasis on training for adolescent medicine (13–18 years old) in pediatrics residency, it may be of potential healthcare benefit as this age group gets minimal medical attention.

International accreditation is not only important in postgraduate medical education, but in the whole continuum of medical education. In Oman, undergraduate medical education has been seeking international accreditation long before postgraduate training. The most recent is the College of Medicine and Health Sciences at Sultan Qaboos University in Muscat, which has received international accreditation from the World Federation for Medical Education (WFME) in association with the Association for Medical Education in the Eastern Mediterranean Region (AMEEMR).⁷ Furthermore, the WFME has standards for accreditation for all three sections of the continuum of medical education (undergraduate, graduate, and practicing physicians).⁸ Each of these three sections of the continuum is accredited using nine standards for each, therefore stressing the importance of accreditation throughout medical education and practice.

While Oman is seeking accreditation with the ACGME-I, Saudi Arabia is seeking accreditation with the RCPSC. Abu Dhabi and Qatar are working with the OMSB to seek accreditation for their postgraduate medical education programs from ACGME-I. At the same time, they are seeking recognition of the ABMS-I to allow their trainees to sit for the American Board examination; the main impediment being that ABMS-I is not recognize as on par with ABMS. Nevertheless, this does not belittle the importance of international accreditation of training graduate medical doctors.⁹

The accreditation process involves not only a review of the training center, but also of the facilities, number of cases, faculty qualifications, assessment process, curriculum, quality assurance processes, patient safety, and trainees working hours.¹⁰ It all mounts up to the ultimate goal of ensuring that trainees are thoroughly equipped to meet the needs of healthcare in their country.

There are several benefits of international accreditation, but the accreditation standards and norms have to be adapted so that they reflect social accountability. Thus, international accreditation must contribute not only to healthcare but also to social accountability of medical education, the demands of the stakeholders, and the country at large. As long as accreditation standards adapt to reflect a country’s social needs, they can be accountable to meet the needs of that society.¹¹

What should the focus of international accreditation include? According to the recent changes in Canadian guidelines, accreditation should concentrate on the promotion of quality improvement and the sharing of ideas and best practices amongst and between the different programs, which can be enhanced through accreditation.^12,13 Accreditation is a sign of quality and an important consideration in the decision making of consumers.¹⁴ The educated e-consumers clearly go for an accredited institution with a reputation of quality assurance for their healthcare delivery. A major benefit of international accreditation is the resultant creation of international standards of medical care which leads to improved patient care.

Achieving accreditation requires commitment to quality improvement and monitoring the results thereof. Perhaps the primary benefit to be accrued from the accreditation process is the internal check of the training programs that precedes. The institution, trainers, and residents all have to ensure that they can demonstrate conformance to the international accreditor’s standards in their training program.¹⁵ This alone can lead to major improvement in the training of residents, even before the accreditor visits. Kennedy et al,¹² explained that accreditation is highly effective in identifying problems in programs and successfully solving those problems.

More institutions worldwide are recognizing the importance of international accreditation and the standardization of training and similarity of the curriculum. In the Bologna Declaration, educators from various parts of Europe developed standardized medical training to allow easier movement of doctors between countries.¹⁶ Globalization of medical training would address the growing challenges of global healthcare delivery. Subsequently, international accreditation could result in uniform training and education standards for future physicians worldwide.

Current uniform training as dictated by international accreditation involves competency-based training or outcome-based medical education. For this, the RCPSC introduced the CanMEDS Competencies while the ACGME-I uses Core Competencies. Both are aimed at outcome-based medical education.¹⁷

International accreditation has evolved with changes in the practice of medicine over the last 15 years, and there is now a greater emphasis on patient safety. This was accelerated in 1999 following the release of a report from the Institute of Medicine entitled, "To Err Is Human".¹⁸ It pointed out that several thousands of patients die every year in the USA. Thus, patient safety was added to the postgraduate medical training and the standards of international accreditation.¹⁹

ACGME-I stresses patient safety in all its three accreditation categories: Sponsoring Institution, Foundational Program, and Advanced Specialty Program. All three categories involve several standards known as requirements.⁴

The Sponsoring Institution accreditation involves a commitment of the sponsoring institution (e.g., OMSB) to graduate medical education (GME) as set by the ACGME-I institutional requirements. Institutions sponsoring the residency programs are expected to adhere to these requirements, and compliance is measured through a periodic review of the institution.

The Sponsoring Institution accreditation must be achieved before moving to the other two levels, which must be achieved in sequence. The Foundational Program accreditation assesses compliance of the GME programs to the common requirements of the educational infrastructure needed for all specialty programs. This includes systematic evaluation of the program personnel, faculty and residents, adherence to established resident selection processes and duty hours policy, and the availability of appropriate resources, including the faculty: resident ratio and requirements for Program Directors.

The Advanced Specialty Program accreditation reviews the GME program’s compliance with the specialty-specific requirements. These include educational infrastructure, specialty-specific curriculum, clinical and educational resources, and experiences that are essential in the discipline as outlined in the requirements.

Some of the current requirements of ACGME-I had already been implemented by OMSB in its training programs. Thus, the shift to ACGME-I accreditation was relatively less difficult. These requirements included: a) commitment to GME by OMSB and the Training Centers; b) CanMEDS competency-based curricula; c) Program Education Committee administrative structure; d) trainers’ qualification; e) assessment and evaluation systems for residents, trainers, rotations, and the program; f) availability of educational resources such as training centers, libraries, simulation centers; and g) resident and faculty development programs. Also, OMSB has an established local Accreditation Committee that conducts periodic reviews of all OMSB Postgraduate Medical Education (PGME) programs and takes the role of Internal Review Committee.²⁰ Members of this committee were trained by the RCPSC.

OMSB also had a Quality Assurance for PGME Committee that developed Quality Program Training Standards (P Standards) for OMSB residency programs that were updated every two years. In 2014, Training Center Standards (T Standards) were added, and both P and T Standards were revised to align with the ACGME-I Institutional Requirements, Foundational Program Requirements, and ACGME core competencies. Furthermore, OMSB undertook the additional actions in its preparation for ACGME-I accreditation including having a Designated Institutional Official (DIO) with responsibility and authority to oversee and monitor all OMSB GME programs. To enhance liaison with the training centers, a PGME office and PGME Committee were also created at each training center, and Associate DIOs were appointed to assist the DIO. Finally, a Graduate Medical Education Committee (GMEC) was formed with membership from the leadership of the sponsoring institution, Training Centers, DIO, associate DIOs, GME programs, resident representatives, and appropriate subcommittees.

OMSB through the DIO conducted various steps to educate the staff, trainers, and residents. The DIO sent multiple memoranda to all trainers and residents with information regarding the ACGME-I accreditation process and the steps undertaken by OMSB. Additionally, the DIO had several meetings with individual program directors and Program Education Committees. An ACGME-I awareness campaign was also conducted in the Training Centers and at periodic retreats.

Following the internal review of existing processes, policies, and procedures, in addition to the accreditation campaigns, OMSB requested and underwent mock site visits from ACGME-I for the sponsoring institution and four of its programs (internal medicine, obstetrics and gynecology, psychiatry, and family medicine). The mock site visit reports helped to identify areas of noncompliance and possible ways to resolve these.²¹

OMSB acquired a resident database management system, New Innovations, to record resident training and activities. Appropriate training was carried out to ensure its effective use.

The international accreditation of residency training programs helps to improve healthcare systems in meeting population needs by assessing and advancing the quality of resident physician education and addressing emerging healthcare issues.⁹ International accreditation provides reassurance to institutions that the training provided meets international standards, that graduates of the program are of international caliber and are prepared to serve the Omani society in their healthcare needs. Graduates of ACGME-I accredited training programs also have increased opportunity for further training abroad as fellows. International accreditation may also ultimately provide graduates the opportunity to take international certification examinations, such as ABMS-I, when available. It also strengthens the commitment of the sponsoring institution and the training centers to provide quality education to the future medical specialists.¹⁷ It is our hope that these specialists will serve our future generations with confidence and willingness to evolve with the changing healthcare needs of the Omani society as they have acquired life-long learning skills.