ACGME-I History

Being a doctor today brings complexities not faced by physicians in times past. Information and evidence for how we help our patients keeps growing; technologies urge procedures never possible before; the list of treatments available grows longer. Patients have access to much more medical information and expect the highest of quality. Economic pressures further challenge a doctor’s capability to serve as many patients as is feasible, while still providing the best care to each individual.

How does a physician assimilate the knowledge, skills, and pragmatics of helping today’s patients?

It is the mission of ACGME International (ACGME-I) to assist in this development. Its mechanism is to work with countries’ medical educators at the critical educational time of graduate medical education (GME), the period of time immediately following the conclusion of medical school, but prior to an individual’s serving in an independent fashion to help patients. The ACGME-I carries values developed by its parent organization, the ACGME, and works with those who request services to tailor GME to the needs and resources of those countries.

Medical education in the United States underwent radical transformation over 100 years ago, after an independent report (the Flexner Report) found extreme inconsistencies in the standards of US medical schools. People in need of medical help had no ability to assess whether the doctor providing care was good or bad.  The consequent changes focused initially on what was essential for medical school education-an academic environment, dedicated teachers, sufficient hands-on experience with patients, and laboratories which provided the underpinning of evidence based medicine for the times.  As knowledge expanded, the need for continuing education in the form of specialty training evolved. One arbiter of quality was the “certification” movement, in which individuals who had completed further education were judged by selected peers. The other arm for insistence on quality was the “accreditation” movement, which centered its quality assessment on the places that trained these individuals. Today, the former is called “board certification” (of individuals) and the latter is called “accreditation” (of training programs and institutions).

The ACGME is the main accreditor of GME programs in the United States. In large part, those seeking board certification by the analogous agency American Board of Medical Specialties (ABMS) must have completed a residency or fellowship in an ACGME-accredited program. Since its inception, the ACGME has centered on a specific type of GME that it believes helps create the foundation for doctors that serve society. The following are some examples of principles that underpin its accreditation model:

• emphasis on more than book knowledge-
  Though “cognitive knowledge” is of tremendous importance, a physician needs more, including good examination skills, communication skills, a systematic approach toward continuous learning and self-assessment, and a team approach to caring for patients. Tying all together the spirit of professionalism and selfless responsibility to patients’ needs, requires concerted emphasis in educational programs for physicians
• critical mass of dedicated faculty members, who provide the necessary supervision when appropriate, and who take an active role in the formation of tomorrow’s physicians
• evaluative process not only by faculty members, but by all of those with whom the training physician interacts to include self-assessment
• graduated responsibility culminating in an ability to practice independently
• emphasis on patient safety, quality assurance, and clinical outcomes, and a learning environment which incorporates this knowledge into resident’s/fellow’s education
• emphasis on each resident’s/fellow’s own education, as opposed to provision of service
• emphasis on the well-being of the resident/fellow

In essence, physicians who train in an accredited program should be assured that by training in such an environment they will be able to serve society’s needs in a patient-centric fashion. Habits inculcated during residency, such as life-long learning and professionalism, are just as important outcomes as is an accumulation of knowledge. The “end product” is physicians who serve society with an allegiance to patients, a true sense of vocation, and a commitment to quality care and caring.

Why ACGME-I?

ACGME-I arose consequent to petitioning by governments and institutions that the ACGME extend its accreditation model internationally. The first pilot project was in Singapore in 2009. Five years into this path, Singapore educates physicians in 15 specialties and 10 subspecialties, at three separate sponsoring institutions.

Though still at the early stages, there is evidence of the benefits of ACGME-I accreditation. The National University Health System in Singapore faced three major strategic concerns prior to ACGME-I accreditation:

1. The educational mission was broad, spanning disciplines and specialties, but lacked structure and accountability.
2. Patient-centered management would require clinicians with broad experience in managing clinical complexities.
3. Institutional systems and policies could easily lead to an excessively longitudinal approach to clinical quality education.¹

The Institutional and Advanced Specialty requirements laid out by the ACGME-I addressed all three concerns through educational structure, practice-based learning and improvement, and systems-based practice, as well as the opportunity to rotate between hospitals.

Specific outcomes research that will more clearly define its effectiveness is currently being conducted.

In addition to Singapore, the ACGME-I now accredits programs and/or institutions in Abu Dhabi (six institutions and seven specialties), Qatar (one institution and 14 specialties), and Lebanon (one institution), and is in exploration with more countries, including Oman, Haiti, Trinidad and Tobago, Ecuador, and Panama.

As inquiries are received, the ACGME-I initiates dialogue by first understanding what the individual country/institutional needs are. If sufficient interest exists, a team from the ACGME-I visits with the appropriate individuals on-site prior to initiation of the accreditation process. The opportunity for education of program directors, faculty members, and administration is provided as well.

Once the accreditation process is initiated, verification of meeting requirements includes review of resident data, surveys of residents and faculty members, review of information provided by those responsible for specific aspects of accreditation, and on-site evaluations to ensure accuracy of submitted material. The ultimate authority granting accreditation is a peer-driven process by physician educators without personal conflicts of interest with those seeking accreditation.

The ACGME-I seeks to improve the health of societies by ensuring that doctors who care for individuals are well-trained in all aspects required of competent physicians. The ACGME-I acknowledges that, though much in education is neutral to location, individual countries have specific cultural, as well as disease-demographic differences for which one size does not fit all. As such, the learning process moving forward with international accreditation is one for which dialogue is essential; in which respect for the state of current medical education must be understood; and where at every turn, the needs of specific societies must be met.