Introduction

Health systems across the globe are undergoing historic transformations driven by physician shortages, aging populations, and health disparities within and among nations.¹ To better meet citizens' health care needs, government regulators are calling for greater transparency and accountability from their medical education systems. Some nations have restructured their graduate medical education (GME) systems to outcomes-based education.² Since 2012, academic medical centers (AMCs) in the United Arab Emirates (UAE), Lebanon, Oman, Qatar, and Saudi Arabia have transitioned to the competency-based framework of the Accreditation Council for Graduate Medical Education-International (ACGME-I).³ There are currently 11 institutions with 81 programs in the Middle East with ACGME-I accreditation.⁴

ACGME-I mandates that each accredited institution appoint a designated institutional official (DIO).⁵ The DIO is an essential position in the GME system as the individual ultimately responsible to lead and ensure appropriate oversight of all GME programs at the sponsoring institution. A study from the United States identified wide variability in DIO responsibilities and roles across the United States.⁶ The DIO role may be equally complex in international settings, where there is a diversity of cultural contexts, practice models, and health system governing structures. With the adoption of international accreditation standards, individuals appointed as DIOs often are expected to actively participate in the transformation of an institution's educational culture. DIOs tasked with this role may have variable preparation and guidance.

To our knowledge, there are no published studies on international DIOs' perception of their role. To address this gap, we examined the characteristics, roles, and responsibilities of institutional GME leadership in ACGME-I accredited AMCs in the Middle East, assessed DIOs' preparedness for these roles, and identified professional development needs for this group.

Methods

Results

Of 16 DIOs of ACGME-I accredited institutions in the region, 11 responded (69% response rate). All responding DIOs were physicians, 64% (7 of 11) were women, 91% (10 of 11) held leadership roles prior to becoming DIO. Most DIOs were responsible for less than 10 GME programs. The vast majority (91%, 10 of 11) spent up to 30 hours per week on DIO-related duties. Additional DIO characteristics are shown in table 1.

table 1 Characteristics of Designated Institutional Officials (DIOs) in the Middle East

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DIO Roles and Responsibilities

The various roles and responsibilities of DIO respondents are shown in table 2A. All DIOs indicated having additional responsibilities beyond those specified in ACGME-I standards (table 2B). All DIOs maintained patient care activities and participated in clinical teaching, and 91% (10 of 11) had a role in continuing medical education (CME) and faculty development in their institutions.

table 2a Designated Institutional Official (DIO) Roles and Responsibilities

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table 2b Other Designated Institutional Official (DIO) Roles and Responsibilities (Not Required by ACGME-I)

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DIO Minimum Requirements, Challenges, and Accomplishments

Respondents reported the most useful experiences and qualifications were leadership and management training (table 3A), and the most useful committees were the medical executive and program director committees (55% [6 of 11] and 45% [5 of 11], respectively). Of note, the ACGME annual conferences were rated as useful by 64% (7 of 11) of DIOs, while none of the participants rated compliance, board of directors/trustees, finance, and house staff committees as useful. Specific resources DIOs reported they were likely to use included templates for GME policies, contracts, and affiliation agreements.

table 3a Designated Institutional Official (DIO) Needs

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DIOs in the Middle East feel well supported and prepared to carry out their duties effectively. When asked about essential requirements for the DIO role, the most common responses included having an MD or equivalent degree, experience in a GME setting, and ACGME conference attendance. Core competencies for successful job performance were professionalism, verbal communication skills, and interpersonal skills (all rated as essential by 91% [10 of 11] of DIOs; table 3B).

table 3b Essential Requirements for Designated Institutional Officials

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Review of the qualitative responses revealed that a common area for professional development, reported by 46% [5 of 11] of respondents, entailed budgeting and the financial aspects of GME. The most frequently described accomplishment was the establishment of accredited training programs, described by 55% [6 of 11] of the respondents.

Discussion

To our knowledge, our study is the first to explore the characteristics, roles, and needs of international institutional GME leaders in institutions that have transitioned to competency-based medical education and attained ACGME-I accreditation. The majority of DIOs are women less than 55 years of age who actively participate in patient care activities and clinical teaching. In addition, most assumed their DIO role within the last 10 years and oversaw less than 10 GME programs. This is consistent with the relative newness of ACGME-I accreditation internationally, and the limited number of GME opportunities in the Middle East region. The predominance of female DIOs in this study seems contrary to the large body of existing literature documenting gender inequity in academic medicine.⁷ Although most studies focus on Western contexts, international studies confirm gender disparities in the recruitment, retention, and advancement of women, with significant underrepresentation in academic leadership positions.^7,8 The promotion of women faculty to this educational leadership role is a step toward gender diversity, equity, and inclusivity in academic medicine in the Middle East.

The majority of DIOs in this study held leadership and education roles prior to assuming the DIO position and felt well prepared for their GME leadership responsibilities. This may be an important factor, as research has shown that program directors who previously held other educational leadership roles felt better prepared and reported greater job satisfaction.⁹ It is reassuring that the DIOs surveyed feel supported by their program directors and hospital leadership, as studies have linked low satisfaction with colleague relationships with high turnover in educational leaders.¹⁰ In addition, the majority of DIOs reported their institutions were well informed about their role, although nearly half of respondents did not have a job description. This may represent the significance of accreditation activities that have increased institutional awareness of the DIO role and GME governance structures, supported by the fact that 73% of DIOs reported that their role was driven by ACGME-I requirements, a remarkable testament to the role of accreditation.

Despite differences in geographic location, program composition, and national health care infrastructure and regulations among the countries represented in the study, the results show consistencies in perception and shared experiences among responding DIOs. All items in the DIO responsibility scale reflected the responsibilities of the majority of respondents, suggesting uniformity in ACGME-I role definitions.

All DIOs reported having additional non-ACGME-I mandated roles in clinical and administrative domains. When asked about essential competencies for success in the DIO role, the majority of respondents identified competencies related to professionalism and interpersonal communication skills as most essential, highlighting the importance of personal attributes over technical skills. There also was a consistency among DIOs in identifying essential qualifications or experiences required for the DIO role—being a physician and having experience in GME. It is interesting that almost all respondents felt that attendance of the ACGME Annual Educational Conference was essential to the role, and this conference also was the most popular professional development need identified by respondents.

The majority of DIOs surveyed agreed that templates for policies, contracts, and affiliation agreements would be beneficial to their roles and that DIO job descriptions and training would be helpful. Additionally, a majority of respondents identified the most challenging aspect of their role to be related to budgeting and/or GME financing, while listing the attainment of accreditation of their programs or institutions as their biggest accomplishment. This represents an opportunity for the international GME community to facilitate opportunities for networking on GME-related issues, discuss and disseminate successful innovations in GME, develop collaborative professional development resources, and share best practices.

Our results should be viewed in light of limitations. First, our data include only institutions in the Middle East that have achieved ACGME-I accreditation, although we believe some of our findings may be relevant to educational leaders working in other competency-based education systems in the region. Second, the small sample size limits the ability to detect statistically significant differences in responses and may limit generalizability. Third, the cross-sectional design of this study does not provide the ability to make causal assumptions or assess longitudinal change. Finally, there may be added factors that may not have been fully addressed in our survey, including institutional culture and DIOs' individual personality.

Conclusion

DIOs in the Middle East reported they feel well supported and prepared to carry out their duties effectively and are involved in ACGME-I mandated responsibilities, as well as additional activities, such as patient care, teaching, and administrative roles. The findings suggest added areas for continued development and facilitation of the DIO role, including the dissemination and sharing of resources and professional development opportunities. As the ACGME-I continues to expand its international accreditation activities, further studies could identify specific professional development needs for an increasingly diverse DIO community.