To the Editor: Lost in Translation-International Accreditation Through Virtual Site Visits.

Abstract

The COVID-19 pandemic has ushered in the widespread use of virtual platforms in graduate medical education (GME), including teaching and assessment activities, residency interviews, and more recently, accreditation processes.1,2 In the February 2021 issue of the Journal of Graduate Medical Education, Al-Bualy et al outline the challenges and benefits of remote accreditation.2 Their rationale for favoring virtual visits includes reducing cost and administrative burden as well as minimizing disruption in clinical duties of faculty and residents. Notwithstanding these clear advantages, as medical educators also practicing in the international setting, we are cognizant of the importance of contextual and qualitative input afforded only by in-person visits.Though important compliance checks of GME standards may be completed using online platforms, seeing the full picture of the clinical learning environment, the role of residents, and the institution's support of the educational mission just cannot be accomplished through the screen. It is in the degree of familiarity between residents and hospital administrators, the tone of interactions among faculty and clinical department leadership, and the state of call rooms that site visitors pick up subtle cues of the institutional value placed on GME. The international arena adds additional challenges with social and cultural factors that impact the implementation of competency-based medical education.3 Recognizing these contextual influences in a virtual visit may not be possible. Additionally, language barriers and cultural differences in expressivity are more easily overcome through personalized interactions, allowing less to be “lost in translation.” Another advantage of face-to-face site visits is the “boots on the ground” effect—the undeniable impact of the presence of site visitors on senior administrative leaders. In countries where accreditation is novel, the scrutiny and commitment of these seasoned clinician educators on display in hallways, boardrooms, and clinical spaces during the site visit serve to spotlight the value and work of their local GME peers. Finally, we believe the value of in-person site visits contributes substantially to fostering cross-national familiarity between the Accreditation Council for Graduate Medical Education and local educational stakeholders. International accreditation goes beyond completing a checklist or the wholesale importation of Western-based protocols; it is a transformative process that requires bilateral understanding to enable local adaptation and meaningful education reform.There is much to be learned from our colleagues in Oman, whose insights may encourage a more cost-effective, “value-based” accreditation process.2 As the pandemic has prompted self-awareness and reflection, perhaps a hybrid approach to accreditation services may be the best path forward. Limiting in-person visits to new applications and programs with concerns, while continuing online visits for renewals for institutions/programs in good standing, might be one approach. We agree with our Omani colleagues that the recruitment and training of international field representatives is an important next step. Individuals who are knowledgeable of regional, cultural, and social norms can provide valuable insights for both the Accreditation Council for Graduate Medical Education-International (ACGME-I) and local educators. Such training would also help build international expertise and truly promote the ACGME-I's mission of advancing medical education and population health worldwide.