Linguistic Validity: The Missing Link in the Evolution of Iranian Undergraduate Medical Education Accreditation Standards

Sir, I read with interest the article by Burney and Al-Lamki on the accreditation of graduate medical education (GME) programmes which appeared in the May 2013 issue.1 However, I would like to raise an issue regarding their belief that the way forward for GME in Oman is to seek accreditation through the Accreditation Council for Graduate Medical Education International (ACGME-I).1 Accreditation of medical education at any level is regarded as a national responsibility by international organisations such as the United Nations Educational, Scientific, and Cultural Organization (UNESCO), the World Health Organization (WHO) and the World Federation for Medical Education (WFME). This implies that a national accreditation agency must have a clear mandate, and be authorised by a government entity, to conduct the accreditation. Anchoring the accreditation firmly within the country reflects a fundamental regard for the specific political, socio-economic and cultural conditions, the disease patterns, the characteristics of the healthcare delivery system etc., of the nation and would thus enable the medical programmes to be relevant to the country’s needs. National conditions must be taken into account when designing the standards or criteria used in the accreditation process as the basis for evaluation, and for the decisions on accreditation. I concur with the authors regarding the notions that: (1) Accreditation is a powerful tool in quality improvement and quality control, and (2) In addition to the GME “curriculum” (what is done and why; how it is done and where; how it is assessed and evaluated, using which standards), other issues central to the discussion on accreditation include the institutional culture, its state of readiness for change and other contextual parameters.1 It is in this light that I would like to draw attention to the global standards framework for quality improvement in medical education published in 2003 by the WFME as a pathway to accreditation of GME in Oman.2 This framework ‘trilogy’ covers all three phases of medical education: basic medical education; postgraduate medical education, and continuing professional development [Figure 1]. The global standards framework was developed by an international working party of experts from all regions of the world.2 Recently, Sultan Qaboos University has gone through the accreditation process for basic medical education using the WFME standards framework, and is the first institution to go through this process in the region. For the sake of continuity, is it not more natural that the accreditation of postgraduate medical education should follow the same route? Figure 1: The World Federation for Medical Education framework ‘trilogy’ covering all three phases of medical education. Second, in response to the inherent question regarding GME programmes: does (or rather, should) one size fit all? I will obviously repond: ‘Yes’ and ‘No’! I say Yes in the sense that parameters that are globally agreed through an international organisation sanctioned by the WHO should guide the recognition process; and No in the sense that nation-states or closely-related regional blocks should have the final mandate to accredit (recognise) training programmes. In conclusion, I would like to posit that the road to accreditation (I prefer to use the word ‘recognition’) of GME programmes in Oman should lead to the WFME and not to any other accrediting body. The Oman Medical Specialty Board (OMSB)—the nationally mandated body to accredit GME programmes—could seek accreditation through the WFME’s programme for the recognition of accrediting agencies.3

Objective Health care and health professions education are becoming increasingly global, yet no formal international accrediting body exists for medical education. Among the challenges in developing international standards for medical education is the variation in program models, with some regions offering six-year bachelor’s degrees and others, including North America, customarily requiring a bachelor’s degree prior to admission to a 4-year graduate-level degree program. This study sought to determine the applicability of the USA Liaison Committee on Medical Education (LCME) accreditation standards internationally as the foundation for program development, quality improvement, and program evaluation in a program that follows the North American medical education model in the United Arab Emirates (UAE). Methods Using a qualitative political, economic, sociocultural, technological, legal, and environmental (PESTLE) analysis framework, we systematically assessed the applicability of each of the 93 LCME accreditation elements to the nascent doctor of medicine (MD) degree program at Khalifa University. Results All 93 elements in the most current LCME accreditation standards were deemed applicable internationally in a program developed in accordance with the North American model of medical education. Of these, three elements were deemed applicable with caveats in the legal or regulatory processes required to achieve comparable compliance outside of the USA. No elements were deemed not applicable in an international setting. Conclusions Our analysis demonstrates that the LCME accreditation standards are model-specific and can be effectively applied internationally in programs that follow the North American model of medical education. Countries in which no specialized medical education accrediting body exists can apply the LCME standards and achieve international benchmarks of quality in medical education through rigorous self-assessment and continuous quality improvement.

ACGME, Osteopaths Fail to Reach Deal on Accreditation: 18-Month Negotiations Collapse

Medical school accreditation is recognised internationally as an important quality control process for programmes that lead to the Medical Doctor (MD) degree. Accreditation standards govern the accreditation process which in turn drives educational objectives. Given the power of these standards to shape what becomes valued in the curricula, it is therefore imperative to ensure that core values and ideals of the profession are meaningfully incorporated. As the provision of compassionate care has long been a central medical value, this value should be clearly articulated in MD programme accreditation standards. We conducted a Critical Discourse Analysis of compassionate care within Undergraduate Medical Education (UME) Accreditation Standards governing North American medical schools since 1957. We explored how and to what extent the written language of the accreditation standards incorporated compassionate care. References to compassionate care in the UME Accreditation Standards were few and far between. Historically, a statement of 'The Objectives of Undergraduate Medical Education' published by the Association of American Medical Colleges (AAMC) was referenced for the first and only time in the 1957 standards, describing the development of attributes such as the provision of compassionate care as a basic objective of UME. Thereafter, there was infrequent mention of this value. Terms that could potentially incorporate aspects of compassionate care were identified, yet these were explicated in ways that limited connection to compassion. Instead, the term 'care' has increasingly been used instrumentally (ie acute care, chronic care). The relative absence of language pertaining to compassionate care in accreditation standards is troubling as compassion is integral to good medical care. This absence is particularly important to attend to in the current era of competency-based training where we must be explicit about all important curricular objectives lest essential values and practices be unintentionally lost.

Interpersonal Social Work Skills for Community Practice

Editorials6 September 2011The July Effect: Fertile Ground for Systems ImprovementFREEPaul Barach, MD, MPH and Ingrid Philibert, PhD, MBAPaul Barach, MD, MPHFrom University Medical Center Utrecht, 3508 GA Utrecht, the Netherlands, and Accreditation Council for Graduate Medical Education, Chicago, IL 60654. and Ingrid Philibert, PhD, MBAFrom University Medical Center Utrecht, 3508 GA Utrecht, the Netherlands, and Accreditation Council for Graduate Medical Education, Chicago, IL 60654.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-155-5-201109060-00352 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail A decade after the publication of the Institute of Medicine report To Err Is Human(1), health care still is considered a low-reliability industry associated with significant preventable patient harm. An editorial describing the experience of 2 physicians, father and son, during their first night of call separated by 30 years offers sobering insight into the preventable harm and terrors experienced by rookie physicians as they confront their first patients (2). It highlights why academic health centers brace themselves for the arrival of new trainees and describes an almost unchanged experience, despite the passage of time and the institution of systems to improve the safety and quality of clinical care and learning in teaching hospitals (2).Despite these systems, significant risk for patient harm in teaching hospitals is a persistent problem, largely because of the lack of safeguards surrounding inexperienced new physicians when they are first entrusted with major clinical responsibilities. Policies, guidelines, and checklists help raise awareness and prevent some harm, but they appear to fall short of helping create an ultrasafe system (3). Despite unprecedented levels of spending, preventable medical errors abound, uncoordinated care still frustrates patients and providers, and health care costs continue to rise (4).High reliability—or consistent performance at high levels of safety at all period—is a hallmark for other high-risk industries, such as aviation and nuclear power (5). Reliable patient care is the ultimate responsibility of the attending physician and the clinical microsystem. Clinical microsystems provide a conceptual and practical framework for thinking about the organization and the mindful delivery of safe care (6, 7). Medical education, from the first year of medical school through the end of residency training, requires learners to assume graded responsibility and autonomy in clinical practice while the trainees engender trust in their attending physicians (8). Ideally, the attending physician holds quality of care constant while balancing the amount of supervision and autonomy he or she gives the learner. Patients trust that the teaching faculty members are taking care of them, watching out for their welfare, and coordinating the clinical care delivered by all members of the team. Patients would not consent to care if they knew that the opportunities for residents to learn come at the expense of their welfare and life.The superb systematic review by Young and colleagues in this issue (9) adds evidence to the long-held suspicion that in practice, the quality of care in teaching hospitals decreases at the start of the academic year. Patients and physicians have suspected this, but individual studies often offered inconclusive findings. Now we have the evidence. The review clearly traces the worsening in patient quality and safety by new interns and residents as they advance toward mastering patient care. Higher-quality studies have consistently found greater evidence of a true "July effect" throughout training.The finding is sobering. The public expects safe, high-quality health care and wants its teaching hospitals to lead the way: in generating and applying new knowledge, in teaching the next generation of health professionals, and in demonstrating high scores on publically reported quality and safety measures. The evidence from closed-claims studies comparing medical errors in teaching and nonteaching settings does not bear this out (10).Clearly highlighted by the review, and potentially even more disturbing, is that the debate over the existence, magnitude, and impact of the July effect spans 20 years. Even if one interprets Young and colleagues' comments that "unpublished studies may be more likely to have negative results," the existence of this phenomenon seems incontrovertible and unsettling. Alarmingly, Young and colleagues note that effective interventions will benefit from better information about the causes and magnitudes of harm in a variety of clinical settings and that until efficient models are developed, "addressing the effects of changeovers will probably require considerable resources." Thus, the July effect can be added to patient outcomes that require further study or have solutions that are considered out of financial reach for a nation that already spends more than 16% of a sizable gross domestic product on health care. Members of the medical and education communities may acknowledge the July effect as a topic requiring further study; a problem with an unfunded mandate; or, worse, a necessary tradeoff in institutions where learners participate in care. None of these are acceptable.We should accept that Young and colleagues' review provides the best available evidence and that effective interventions requiring implementation and robust evaluation exist. "Good" science involves more than evidence of effect; it requires innovative research methods, including action research, observational methods, and improvement science methods to better understand how to socialize and support new physicians during large cohort turnovers. These new methods can help shed light on the relationships and interactions between trainees and their teachers and between patients and the technologies that support this interaction. When cohort turnover studies are de-coupled from practice and are poorly reconciled with the practical, material, and temporal arrangements of delivering health care services, they miss the organizational, political, and emotional processes of learning and their effect on the socialization of trainees (11).Young and colleagues' review identified clinical inexperience, inadequate supervision of trainees functioning in new clinical roles, and loss of "systems knowledge" due to team turnover and departure of the experienced, "systems-literate" clinicians as the mechanisms that cause these outcomes. The relevant empiric work has been done. Needed now is the courage to apply existing data on the effectiveness of interventions in these areas to attenuate or eliminate the July effect. The solutions—such as enhancing supervision, reducing the tempo of the uptake of clinical responsibilities in the first weeks of service, avoiding overnight responsibilities during that period, coupling experienced providers with inexperienced ones in a buddy system, and implementing even more involved interventions (for example, staggering the start dates of trainees over the year)—will greatly enhance individual learning, performance, and patient safety. Simulation, team training, and better "on-boarding" of new trainees centered on the clinical microsystem will help transfer knowledge from departing trainees. Many of these interventions already are standard approaches currently included in the Accreditation Council for Graduate Medical Education's accreditation standards, and the enhancements to the supervision standards to be implemented in July 2011 are particularly relevant (12). These interventions require no future "test of concept" studies; they require political will and financial support for implementation and evaluation.Ensuring safe care in teaching hospitals in July cannot wait any longer. It will require the ability to pool data from local tests of change. Ideally, identical interventions will be implemented across several settings, and the studies will be powered to ascertain the effectiveness of the change and to ensure sufficient organizational breadth for generalizability across different teaching institutions. Finally, future work should address the dearth of data on the effect of the changeover in the ambulatory setting. The effect among outpatients may be more subtle; data already suggest that harm is common (13), and less than one half of ambulatory patients receive the health services indicated to optimally manage their health (14).Reliable quality and safe patient care throughout the academic year will require a multipronged approach, one that recognizes the need to immerse trainees in a new clinical environment but with seasoned mentorship, close supervision, and graduated clinical responsibilities. The complex interrelationships among the July effect, handoffs of clinical care, excessive work hours, sleep deprivation, and increased medical errors highlight a profound need for a robust and resilient systems approach to mitigate the chaotic healthcare settings in which trainees must perform and survive. It is time to move beyond the "counting and control model" to one that enables and supports dedicated trainees struggling to manage the ever-growing complexity of their new social and technical environments. We need to better understand how best to protect patients and providers during cohort turnovers while developing a culture where trainees feel psychologically safe to speak up, admit error, challenge poor practices, and learn to be accountable for their actions (15).Paul Barach, MD, MPHUniversity Medical Center Utrecht3508 GA Utrecht, the NetherlandsIngrid Philibert, PhD, MBAAccreditation Council for Graduate Medical EducationChicago, IL 60654

We describe the accreditation of medical education programs that lead to the Doctor of Medicine degree in the United States and Canada. We identify select accreditation standards that relate directly to the preparation of medical school graduates, as required for the supervised practice of medicine in residency training and for developing the skills of self-directed, independent learning. With standards that promote flexibility and encourage innovation, the Liaison Committee on Medical Education utilizes a continuous improvement model for the accreditation of undergraduate medical education with standards that promote flexibility and encourage innovation. The standards focus on curricula to meet learning objectives that address the current context of medical care. In undergraduate and graduate medical education, the relevance of the hospital as the predominant learning environment is challenged; in continuing medical education, traditional lectures are called into question for failing to change physician behavior and improve health care outcomes. To improve medical education from undergraduate through continuing medical education, all the relevant accrediting agencies must collaborate for success.

ACGME Letter on Hurricane Katrina

The impact of an accreditation system on the quality of undergraduate medical education in Saudi Arabia

Implementing an innovation, such as offering new types of patient-physician encounters through the patient-centered medical home (PCMH) model while maintaining Accreditation Council for Graduate Medical Education (ACGME) accreditation standards (e.g., patient encounter minimums for trainees), is challenging. In 2009, the Group Health Family Medicine Residency (GHFMR) received an ACGME Program Experimentation and Innovation Project (PEIP) exception that redefined the minimum Family Medicine Resident Review Committee requirement to 1,400 face-to-face visits and 250 electronic visits (1 electronic visit defined as 3 secure message or telephone encounters). The authors report GHFMR residents' continuity clinic encounters, specifically volume, from 2006 through 2013 via pre- and post-PCMH implementation. They discuss the implications for leaders of high-performing practices who desire to innovate while maintaining accreditation. Post-PCMH residents had 20% more overall patient contact. The largest change in care delivery method included a large increase in secure messages between patients and residents. Pre-PCMH residents had more face-to-face encounters; however, post-PCMH residents had more contact for all types of patient care encounters (face-to-face, secure messaging, and telephone) per hour of clinic time. The ACGME PEIP exception, allowing the incorporation of the PCMH, facilitated an increase in patient access and immersed residents in primary care innovation (namely, practicing in a PCMH model during graduate medical education training). The next steps are to assess the effect of the PCMH on resident learning and clinical outcomes and to continue residents' access to training that keeps pace with today's health care delivery needs.

This issue of ‘Really Good Stuff’ (RGS) marks the 6th year of the feature in Medical Education and a quick review of introductions I have written in the past reveal that I have maintained a fairly constant plea – that is, to have more of the world's medical schools represented in the journal, beyond the U.S., Canada, and the UK. I am pleased to report that this issue of RGS is beginning to strike a balance and include many more medical schools from around the globe. In particular, I want to highlight the work of a group of authors who took part in the International Fellowship in Medical Education (IFME) programme offered by the Foundation for Advancement of International Medical Education and Research (FAIMER). The FAIMER fellowship programmes for medical educators include The Institute and the IFME programme. The intent is to create a new educational pathway that will allow international medical educators to become outstanding local resources for improving medical education. The 5 reports that were selected for publication in this issue were submitted individually, but I have learned that the authors devoted considerable time during their FAIMER Fellowship to working on their projects and writing up the results. More information about the Fellowship programme is available at http://www.faimer.org. I chose to highlight these reports to encourage everyone to consider the projects they are working on and to think about whether others might benefit from learning more about them. Medical Education is truly an international journal. There are different educational programme structures, accreditation standards, licensure requirements, and political climates for every reader. Consequently, a topic that would be of critical importance in one country may not seem new or innovative to another reader. However, please keep in mind that by featuring a variety of approaches to address universal issues in medical education, we can all gain a better understanding of our medical education colleagues around the globe and RGS can provide as broad a perspective of really good stuff as possible. The majority of the submissions are still focused on undergraduate medical student education, but there are hopeful signs that more postgraduate and continuing professional development activities will be appearing in future issues. I am looking forward to working with the new editor of Medical Education, John McLachlan, and continue to be grateful for the excellent support and guidance I receive from Julie Brice and Liz Baker of the journal staff. As always, I encourage you to send us your good stuff.

Currently, accreditation in medical education is a priority for many countries worldwide. The World Federation for Medical Education’s (WFME) launch of its 1st trilogy of standards in 2003 was a seminal event promoting accreditation in basic medical education (BME) globally. In parallel, the WFME also actively spearheaded a project to recognize accrediting agencies within individual countries. The introduction of competency-based medical education (CBME), with the 2 key concepts of entrusted professional activity and milestones, has enabled researchers to identify the relationships between patient outcomes and medical education. The recent data-driven approach to CBME has been used for ongoing quality improvement of trainees and training programs. The accreditation goal has shifted from the single purpose of quality assurance to balancing quality assurance and quality improvement. Although there are many types of postgraduate medical education (PGME), it may be possible to accredit resident programs on a global scale by adopting the concept of CBME. It will also be possible to achieve accreditation alignment for BME and PGME, which center on competency. This approach may also make it possible to measure accreditation outcomes against patient outcomes. Therefore, evidence of the advantages of costly and labor-consuming accreditation processes will be available soon, and quality improvement will be the driving force of the accreditation process.

The Australian Medical Council (AMC) is an independent national standards body for medical education. It accredits the medical schools and their programs in Australia and New Zealand. In the accreditation of medical education in China in recent years, Chinese medical educators drew upon the accreditation procedures of the AMC. This paper presents the AMC procedures and the insight the Chinese medical educators have into them, aiming to enlighten the Chinese medical educators regarding the procedures of medical education and to advance the accreditation of medical education in China. Key words: Australian Medical Council; Medical education; Accreditation; Procedures

Context and setting In response to the Association of American Medical Colleges' (AAMC) Medical Schools Objective Project (MSOP) and Liaison Committee on Medical Education (LCME) accreditation standards, institutions are challenged to develop and disseminate educational objectives for the undergraduate medical education programme and to ensure their use as programme planning and assessment tools. Concerns over the level of faculty and student awareness of new educational objectives prompted our institution to develop a campaign to increase awareness and use of new objectives. Why the idea was necessary We employed traditional strategies for developing and disseminating our new educational objectives. We asked many faculty members to participate in their development; we asked all faculty to review and approve them; we discussed them with administration staff at meetings; we distributed them widely using electronic mail and posted them on the Office of Curriculum and Medical Education website. Despite these efforts, conversations among administrators, faculty and students raised concerns that many in our academic community remained unfamiliar with the new educational objectives document. What was done We utilised a longitudinal trend study to investigate the impact of a 24-week campaign designed to increase awareness and use of our institution's new educational objectives. This campaign contained 4 elements: listen to the institution; develop a theme that resonates; sweep people in, and build infrastructure. During the 24-week campaign, we listened to the institution's voice (i.e. discovered where innovation was already taking place in the organisation and who was behind it) by building on the creativity of faculty members who had drafted the educational objectives document. We developed a resonating theme by generating the SP2IC2ES mnemonic, with each letter representing 1 of 8 educational objective themes (Scientific foundations of clinical practice; Professionalism; Problem-solving and clinical decision making; Information management and critical thinking; Communication; Clinical skills; Economics of medicine and health care delivery systems, and Social, community, and cultural contexts of health). We swept people in by using PowerPoint presentations, electronic communications and poster displays, and we built a sustainable infrastructure by creating electronic icons for each SP2IC2ES theme. A 9-item questionnaire was administered to a convenience sample of faculty and students pre- and post-campaign. Data were analysed using spss. Pearson's chi-square was used to test for differences on dichotomous variables; the Mann–Whitney U-test was used for Likert scale variables. The null hypothesis was rejected for P < 0·05. Evaluation of results and impact The campaign produced a significant increase in student and faculty awareness of the educational objectives and the SP2IC2ES mnemonic. A total of 59% of faculty responders planned to use SP2IC2ES in their teaching, compared with 29% before the campaign (P = 0·001). The relationship between faculty who planned to use SP2IC2ES in teaching and faculty who reported that the campaign had had at least a moderate impact on their knowledge of the educational objectives was also significant. In conclusion, a campaign approach contributed to both increased awareness of a medical school's educational objectives and enhanced use.

This article analyzed the relationship between undergraduate medical education and physician accreditation system in 11 countries and regions, and emphasized not only their guiding effect on undergraduate medical training objectives and models but also their influence on the assessment and quality evaluation in medical schools when they were closely combined hoping to offer revelation and reference for related medical education reform in China. Key words: Undergraduate medical education; Medical licensure examination; Physician accreditation system