Abstract Background This study applied a resilience engineering framework to understand how international graduate medical educations (GME) programs responded to the disruptions caused by the COVID-19 pandemic. Beyond describing early pandemic disruptions, we offer a multi-year, multi-country analysis of how training functions adapted, which elements durably changed, and what program design features may be associated with recovery. Methods We conducted a retrospective longitudinal study of all 180 ACGME International (ACGME-I)–accredited programs across seven countries. Annual surveys were completed over three years (Year (Y)1 = Academic Year (AY)2021–22, Y2 = AY2022–23, Y3 = AY2023–24), assessing clinical experiences, educational activities, telemedicine use, and training modifications. Data were analyzed using mixed-effects and generalized linear mixed models, with exact logistic regression for small strata. Subgroup analyses compared specialty, training type, and World Bank income classification. Studying ACGME-I programs provides a common competency-based context, allowing us to describe trajectories of disruption, recovery, and persistence. Results Of 180 programs, most were residencies (68.3%) and medical specialties (53.3%), with 87.2% located in high-income countries. Clinical experiences were most disrupted in Y1, especially ambulatory continuity clinics (estimated marginal means EMM 1.489) and ambulatory rotations (1.571), both of which recovered by Y3 (1.863 and 1.874; p .05). Educational activities were most disrupted for in-person didactics, which nearly ceased in Y1 (0.784) but improved by Y3 (1.386; p .05) remained stable. Telemedicine use peaked in Y1 (clinical care 1.020; supervision 0.544) and declined by Y3 (0.720; 0.386; both p <.001) but remained in use across programs. Training extensions declined substantially from 43.2% in Y1 to 23.0% in Y3 (OR = 0.11; p =.002). Differences by specialty and country income suggest heterogeneous recovery pathways rather than a uniform “return to normal.” Conclusions International GME programs demonstrated resilience, restoring clinical and educational activities, integrating telemedicine, and markedly reducing training extensions. Our longitudinal, multi-country data move the field beyond single-site, early pandemic reports by identifying which disruptions resolved, which practices persisted, and which gaps remained. Because all programs shared competency-based structures, findings suggest that specific design features may support adaptation. These results refine the prevailing “back to business as usual” narrative in international graduate medical education by showing a selective reversion with durable innovations.
Khoury et al. (Fri,) studied this question.