The Role of ACGME-International in Enhancing Opportunities of Residents for Advanced Subspecialty Training

The Accreditation Council for Graduate Medical Education-International (ACGME-I) is a US-based 501(c)(3) not-for-profit organization that provides accreditation services for graduate medical education (GME) programs and institutions outside of the United States. The organization was created in 2009, when the Accreditation Council for Graduate Medical Education (ACGME) was asked to provide services to improve GME programs in Singapore. At the time, the feasibility or desirability of developing global standards for GME programs that could be applied across a wide range of countries was unclear. Over the past 15 years, ACGME-I has gradually grown, and now provides accreditation services across 3 continents encompassing a diversity of medical practices and cultures. At the end of 2023, ACGME-I accredited 22 Sponsoring Institutions in 12 countries, and 188 programs in more than 45 specialties. In any given year, there are more than 3000 residents or fellows enrolled in ACGME-I-accredited programs. ACGME-I's growth has continued despite the multiple challenges of operating in a global setting, adding over 30 programs over the last 2 academic years alone. ACGME-I has learned from every engagement with colleagues in medical education in other countries. The organization also has gained considerable expertise in application of both the assurance and quality improvement functions of an accreditor. These functions must be executed with respect and sensitivity to local culture and context. These perspectives and values are the essential elements of professionalism as an international accreditor and have been reciprocated by all those we have had the privilege of meeting.The mission of ACGME-I is to improve health care in the countries where we are engaged by advancing and improving a structured approach to GME. In addition to the cultural and geographic diversity of our accredited institutions, ACGME-I has also engaged institutions across a wide range of "maturity" of the GME enterprise. Some ACGME-I-accredited institutions are at an early stage in their GME journey, while others have had successful training programs for many decades. The value of the services that ACGME-I provides therefore varies widely from institution to institution and may include developing a structured GME framework and supporting infrastructure, improving the clinical learning environment, driving robust program quality improvement, enhancing the environment of inquiry and scholarship, or innovating in medical education.1There is one value, however, that is universally noted across all ACGME-I-accredited institutions: the potential to improve and expand training opportunities for residents and fellows, both within and external to the local Sponsoring Institution. This value is aligned with an emerging concept that GME training in the future should become more global and that there likely is great benefit in sharing educational resources across institutions, programs, and borders.2,3 Consistent with this emerging perspective, a major goal for ACGME-I is to enhance the educational opportunities for residents and fellows, all with a goal of enhancing the preparation of residents and fellows in order to serve the population.One of the major mechanisms by which ACGME-I facilitates training opportunities for its residents is through its eligibility rules for fellowship training. This is accomplished in 2 ways: opportunities within the ACGME-I network of accredited fellowship programs, and in a relationship between ACGME-I and ACGME (US) program requirements.The ACGME-I Subspecialty Foundational Requirements (Section III.A), which are applicable to all of our fellowship programs, explicitly state that graduates from ACGME or ACGME-I residency programs are eligible for fellowship positions.4 ACGME-I fellowship programs may consider other candidates if approved by the Sponsoring Institution's Graduate Medical Education Committee, but they must consider ACGME/ACGME-I candidates as eligible. While the number of fellowships within the ACGME-I network is relatively small, it is growing. Thus, our framework promotes mobility of trainees within the network as a means to enhance training opportunities.In 2019, the Common Program Requirements for fellowships in the United States were modified to reference ACGME-I training.5 Specifically, all review committees were given the option to include language stating that residents from programs "with ACGME-I Advanced Specialty Accreditation" were eligible for fellowship; all specialties except neurological surgery include such language.6It is important to clarify the reference to "advanced specialty accreditation," as it is a term that may not be familiar to US-based program directors. Unlike in the United States, the ACGME-I program requirements are split into Foundational and Advanced Specialty requirements; the former is essentially a modified version of the Common Program Requirements, and the latter are the specialty-specific requirements. In the United States, requirements that are specific to a specialty and those that are common to all programs are included in one document. ACGME-I, however, separates these into 2 documents (Foundational and Advanced Specialty), and each program is assessed separately in each domain. Doing so provides a stepwise approach to accreditation in which programs can opt to initially focus on the common elements of program structure, such as developing the role of the program director or establishing an assessment framework, and then subsequently focus on the specialty-specific aspects of training, such as providing specific clinical rotations. This framework has potential to provide opportunity for programs in early developmental stages to focus their effort on achieving foundational accreditation only; individuals from such programs would not be eligible for fellowship in the United States, as their program would not have achieved advanced specialty accreditation yet.Programs accredited by ACGME-I are required to use the ACGME-I Milestones in the same way as US-based programs. Following input from a wide range of stakeholders across ACGME-I-accredited institutions, a revised version of ACGME-I Milestones (version 2.0) is currently being implemented across all international programs. This revised version is nearly identical to the Milestones used in ACGME (US) programs, which should facilitate the transfer and initial assessment of ACGME-I residents when they begin fellowships in the United States.7There are 3 main caveats when considering fellowship opportunities across borders. First, the trainee must be aware of local licensure and visa requirements. In the United States, for example, Educational Commission for Foreign Medical Graduates certification is required to obtain a training visa, and most states require it in order to obtain a training license. Practically, this also means that United States Medical Licensing Examination examinations are required to pursue fellowship in the United States. Second, the implications for physician board certification vary widely. Across the world, there are many bodies that certify physicians, and each determines their own eligibility rules that are subject to change at any time. The ACGME-I framework is designed intentionally to be transparent, rigorous, and free of conflict of interest, so that each certifying body may make its own informed decisions on eligibility for its examination. Third, residents who seek fellowships in ACGME or ACGME-I programs should understand that the process of obtaining positions is structured, under the leadership of the program director, and often includes a selection committee. In some programs, the competition for positions may be great. Neither ACGME-I nor ACGME (US) have any role whatsoever in the selection of candidates.In the 3-year period from 2019 to 2021, 85 residency graduates matriculated directly to subspecialty fellowships in the United States after completion of an ACGME-I-accredited residency program. The largest core specialties were anesthesiology, internal medicine, pediatrics, radiology, and orthopedic surgery. Smaller numbers were seen from emergency medicine, family medicine, neurology, otolaryngology, psychiatry, and surgery.The subspecialties in which fellowships were obtained are listed in the Box. These fellowships were located in 47 Sponsoring Institutions across the United States, 23 of which accepted more than one ACGME-I resident for matriculation into fellowship.These preliminary data reflect considerable diversity in multiple domains, representing 35 subspecialties across 47 US institutions over just a 3-year period. This is encouraging, as it implies that ACGME-I graduates are being recognized as viable candidates for fellowship training in the United States across a range of specialties in many institutions. In the future, as numbers of trainees accumulate, ACGME-I will evaluate educational outcomes of these trainees and provide that information to the field.The primary limitation of these data is that the practice type or location of graduates after completion of their US fellowship programs cannot be determined. ACGME-I does not have the mechanisms in place to obtain this information from individuals after graduation from our programs. Establishment of a process for voluntary reporting of such information may be an area of future work. Anecdotal information from one ACGME-I-accredited institution suggests that most individuals return to their home country to practice; however, a more systematic review is needed.It is not appropriate at this time to report the distribution of fellowship matriculants by subspecialty or institution, given that the absolute numbers are small. Over time, we anticipate that institutions will publish their experiences on the educational outcomes of their graduates, including data on advanced subspecialty training and location of practice.We have described the framework through which ACGME-I accreditation may enhance subspecialty training opportunities for the graduates of those programs. The experience from the first 3 years following implementation of changes to ACGME Common Program Requirements is positive. Over time, we expect that as fellowship programs in the United States and elsewhere gain experience and familiarity with ACGME-I residency graduates, educational relationships will form across institutions and the opportunities for exchange of trainees will grow.The ACGME News and Views section includes data reports, initiatives, and perspectives from the ACGME and its Review Committees. The decision to publish the article is made by the ACGME.