In Reply to van Zanten et al.

Abstract

We thank van Zanten and colleagues for their interest in our review. Both the Educational Commission for Foreign Medical Graduates (ECFMG) and the World Federation for Medical Education have important influence over medical education on a global scale. We agree that for global accreditation to work, there must be a form of standardized process for approving the local accreditors and ultimately, the medical schools. Our core argument, however, is that this always carries an inherent danger of silencing important nuances in local needs and resources that affect training models. 1 We hope we have raised awareness about assumptions that are inherent in concepts, such as “standardization.” 2 Standardization is a common theme in both medicine and medical education, which may in part be driven by the biomedical paradigm of evidence-based medicine. Proponents of standardization in global standard development emphasize its role in improving quality in both training and patient care and facilitating movement of health professionals. However, as stated by Timmermans, “standardization may seem to be politically neutral on the surface, but in fact, it poses sharp questions for democracy.” 3 Standardization has been criticized for driving a loss of identity and social power and being vulnerable to implementation gaps. 3 Sefton describes the tensions inherent in meeting specific local community health needs while addressing international requirements or standards. 4 Our position is not to eliminate global efforts, such as those in accreditation and curriculum design, but to recognize the complexity and subtleties between local priorities and global differences. We acknowledge the articulated benefits of the new system proposed by the ECFMG. However, we argue that the unanticipated and unintended effects of power relations must be consciously examined, reported, and corrected. As stated in the ECFMG’s 2010 announcement, “the efficacy of such a requirement depends on a universally accepted accreditation process.” 6 Achieving a “universally accepted” accreditation process is likely impossible. For this reason, we argue that we must track which institutions/regions do not end up participating in the new system and, most importantly, why they do not. 5