International Residency Program Directors on Implementing Educational Transformation: A Qualitative Study of Their Experiences and Strategies for Overcoming Challenges

Academic medicine constantly evolves and transforms, shaped by technological and educational innovations, regulatory requirements, and population health. Educational leaders are often at the forefront of these transformations. As competency-based medical education is becoming the global standard for postgraduate training, a large cadre of clinician educators is needed to implement effective teaching, supervision, and assessment of medical trainees.¹  Among clinician educators, program directors (PDs) are accountable for the leadership and implementation of many aspects of postgraduate training. In addition to their patient care duties, PDs have multiple responsibilities, including trainee recruitment, teaching, faculty development, program administration, and change management. These diverse roles and day-to-day challenges make PDs particularly vulnerable to stress and burnout, leading to high rates of PD attrition.^2–4  Studies estimate that one-third to half of PDs have been in the role for less than 3 years.^3–5 

Understanding how PDs perceive and manage the stress of educational transformation may help minimize PD turnover in change management processes. Most studies addressing this topic have been conducted in the United States and are Western-centric—less is known about the challenges faced by PDs in international institutions, where the transformation to competency-based frameworks is relatively new. Qatar, Singapore, and the United Arab Emirates (UAE) were the first countries to transition their postgraduate programs from time-based, apprenticeship models to competency-based medical education and successfully receive accreditation from the Accreditation Council for Graduate Medical Education-International (ACGME-I).^6,7  These nations offer unique opportunities for research on health care education, as they have been in the forefront of globalization, innovation, and rapid infrastructure development in recent decades.^8,9  In each of these countries, the educational transition was government-mandated and occurred within a brief time frame, with the burden of reform falling on educational leaders and teaching faculty.^6,7  While early perceptions of the change process were positive, with 76% of educators agreeing that the educational transition was worthwhile and 77% intending to remain in academic medicine,^10,11  studies showed that those in leadership roles (PDs and associate PDs) were significantly less likely to report an intent to stay in academic medicine.¹¹  Long-term analysis of PDs in these international programs did, indeed, find a high rate of attrition, with 80% of programs changing PDs since inception.⁴ 

The purpose of our study was to better understand how international PDs perceive and manage the challenges related to implementing competency-based medical education as part of their educational leadership roles.

We conducted a qualitative study employing a phenomenological approach^12,13  to explore the lived experiences of PDs and understand how they manage challenges at a time of educational program transformation. We followed the Standards for Reporting Qualitative Research.¹⁴ 

We interviewed current and former PDs in Qatar, Singapore, and the UAE. Singapore programs received initial ACGME-I accreditation in the 2010–2011 academic year, followed by Qatar and the UAE in 2013–2014. Although other countries in Asia, Central America, and the Middle East have since attained ACGME-I accreditation, we selected these countries because they were the first international locations to successfully adopt ACGME-I standards and have the longest experience with competency-based medical education.

Education in these international programs models US training structure, with similar PD roles and expectations, but required significant adaptation to local contexts. PDs were purposively nominated by study investigators (S.A., H.I., D.S.) working in each country, and contacted via phone or email. Using a snowball sampling method, additional PDs were recruited. We sought participant diversity in terms of gender, geography (Singapore vs Middle East), specialty, and tenure as PD (current vs former). Participants were either the first or second to hold the PD role. Our interviews were conducted within 8 years from initial ACGME-I accreditation in Singapore and 5 years in Qatar and the UAE. All participants provided informed consent. No compensation was provided.

This study was approved by the institutional review boards of Johns Hopkins University School of Medicine, Weill Cornell Medicine-Qatar, National University of Singapore, Massey University of New Zealand, and Tawam Human Research Ethics Committee in the UAE.

The interview guide was developed following a comprehensive literature review⁹  and iteratively revised by investigators (S.A., J.C., H.I., D.S.) with extensive experience in US and international medical education. The interview script was piloted for process, clarity, and comprehension on an associate PD in one of the countries studied. This interview was not included in the final analysis.

From September 2018 to July 2019, 33 participants (30 by phone and 3 in person) engaged in one-on-one, semi-structured interviews in English (guide provided as online supplementary data) by one investigator (D.D.). Audio-recorded interviews ranged from 30 to 45 minutes. Participants were asked to share accounts of their experiences as PDs, with a series of open-ended questions to elicit multiple perspectives, including challenges experienced and management strategies employed. Data collection and analysis occurred concurrently, allowing for iterative adjustments of the interview guide, and continued until theoretical saturation was reached. Pseudonyms were used and data de-identified by assigning transcripts confidential study numbers.

All interview transcripts were transcribed verbatim and checked against the recordings for accuracy. Two investigators (D.D., H.I.) independently performed a line-by-line open coding on the transcripts and initial codes were recorded. Then, thematic analysis was conducted,¹⁵  identifying recurring concepts and patterns of everyday interactions and sense-making that reflected coping strategies. Themes were categorized through constant comparison in the process of refining the categories. Discrepancies were resolved through in-depth conversations. Through consensus, the coding scheme was established and then applied to all transcripts. The codes were discussed and further refined with co-authors in monthly videoconference meetings. To enhance trustworthiness, typed transcripts were sent to 5 participants (15%) for confirmation and further input. An audit trail¹⁶  was maintained via member checks with interested participants and through a checklist of data entry and analysis with all authors. We performed all data management, coding, and analysis manually.

Throughout the process, the team reflected on how our positions as medical educators and our experiences and relationships could influence data interpretation. To minimize individual bias, we regularly engaged in group discussion and emails to share, confirm, and challenge each other's interpretations.

We interviewed 33 PDs, of whom 16 (48%) were female (Table 1). We identified 5 themes of how PDs managed challenges in implementing educational reform (Table 2).

All participants expressed that the PD role was stressful and that they initially felt underprepared. They embraced a variety of knowledge and skill-building strategies to learn and adapt, including formal medical education courses, professional development at workshops and conferences, informal learning from colleagues, and on-the-job training, often through trial and error. Participants admitted that the learning curve was steep, and unforeseen challenges provided opportunities to refine their skills.

Participants also noted how making mistakes contributed to continuous learning and self-development.

The desire to improve their skills inspired several participants to pursue formal degrees in health professions education.

Most participants provided narratives of continuous learning and personal development as strategies for overcoming inexperience and achieving success.

Many PDs shared that this was their first leadership and change management role. They were simultaneously expected to implement a new Western-based educational model while respecting local culture and norms. Adjustment, innovation, and realignment were central to managing the expectations of all major stakeholders, through local cultural wisdom and awareness and negotiating with administrators and accreditors for change.

The challenges and struggles of change management also resonated with another PD:

In addition, willingness to adapt to local realities by engaging with accreditors and regulators helped PDs overcome the structural and cultural barriers to implementing their programs in the local context. One participant talked about dealing with culturally sensitive issues in training, citing the example of reproductive health and, specifically, abortion training: “There were a few things which were not applicable for us, for example [pregnancy] terminations. Terminations are illegal so we don't have a section [in our curriculum] on termination. So the communication with ACGME-I would be—listen this is not applicable for us.” (No. 29)

Therefore, we note in this theme how PDs managed change when adapting program accreditation requirements to their local structural, societal, and cultural contexts.

Instead of being the lone problem-solvers, all participants expected obstacles and challenges, and acknowledged the need to seek help and expertise from colleagues and institutional leaders.

This illustrates the importance of alliance making and support building, as well as internal and external team building and collaboration.

These outreach strategies helped PDs optimize resources and build bridges with partners to implement and run successful training programs.

PDs discussed the importance of maintaining meaningful relationships with all relevant stakeholders, including residents, core faculty members, program coordinators, senior department and institutional leaders, patients, accreditors, and regulators. As PDs, they had to lead these maintenance efforts with effective communication to support and nurture diverse relationships. Communication strategies included regular formal and casual meetings, informal chats, or any instances which provided the PDs opportunities to interact with the stakeholders. For example, one participant shared how informal interaction, such as organizing social events, contributed to relationship building within the program.

PDs reported that maintaining these interactions helped them negotiate challenges, which otherwise would have been difficult to resolve. One participant shared the importance of support from educational and clinical leadership to resolve conflicts.

Relationship building and maintenance at every level with stakeholders supported communication and conflict mitigation provided the PDs with the necessary resources and motivation to optimize performance.

All participants stressed the importance of, and reliance on, intrinsic qualities which helped them overcome adversity. Qualities included commitment to the residents and the program, enthusiasm, perseverance, and flexibility. Identifying and strengthening these attributes helped them manage hardships. For example, one PD, who had inherited a complex environment and a difficult program, knew that streamlining the program would not be easy. He noted the importance of maintaining a positive attitude and a vision.

Strong interpersonal skills were considered essential by many of the participants. One PD noted:

PDs also commented on being kind to faculty and residents:

Participants were cognizant that their personal traits and attitudes were important determinants of building social capital and for their success as PDs.

This study of lived experiences examined how PDs in international postgraduate training programs overcame challenges in the transition to competency-based medical education. We found that continuous learning, willingness to make adjustments, reaching out to program stakeholders, building meaningful networks, being relationship-focused, and identifying intrinsic qualities are critical strategies for PDs as they negotiate structural, cultural, and personal barriers to engage in meaningful and successful program implementation.

PDs in our study frequently noted the power of connectedness, to their institution and to their colleagues, as an important factor in their professional lives. Other studies have highlighted the importance of positive interpersonal relationships to the PD role. In a survey of Canadian physicians, feeling valued by colleagues contributed greatly to job satisfaction.¹⁷  A study of emergency medicine PDs found that those who had mentors were more likely to remain in their positions.¹⁸  Accordingly, sharing a sense of mission and belonging to a community of educators were strongly valued by the PDs in our study. The development of international PD specialty societies may provide additional opportunities for collegiality and networking and may further improve career satisfaction.

The commitment to continuing professional development is notable, particularly as some of the more senior PDs sought formal degrees in education. The administrative and leadership skills of PDs are unique and can take several years to master.¹⁶  Studies, however, have shown that PDs in the United States view the role as a mid-level position and are prepared to leave the job for better administrative opportunities.¹⁶  The investment in further education and professional development among the PD participants in our study may reflect a higher status of the PD role in international academic medicine. Longitudinal studies of international PDs are needed to determine if the role offers long-term career satisfaction, or merely serves as a stepping-stone for promotion to more prestigious positions.

We are encouraged that the PDs who were interviewed reflected positively on their roles, even though all admitted that the role was challenging and there was a steep learning curve. This conflicts with the high PD attrition rates observed in these countries,⁴  and this study provides potential strategies for PD retention. To foster continuous learning and self-improvement, academic institutions can offer mentoring opportunities for PDs, along with professional development programs in educational leadership, focusing on communication skills, networking, and negotiation techniques. In addition, PDs can be taught how to best invest in building and maintaining relationships with all stakeholders by holding regular meetings and using both formal and informal communication channels. In addition, recognizing and developing their intrinsic qualities and attitudes can help PDs achieve success in managing their roles. Other interventions to support PD success may include cultural competence training to help manage and negotiate regulatory standards that may not adhere to local norms or customs.

Our study has some limitations. It is based on unique experiences of a group of PDs from Singapore, Qatar, and the UAE, and may not be generalizable to educators in other settings. There may be cultural differences between these countries that affect how PDs viewed their experiences. Our sample size may have been too small to detect differences based on PD specialty or prior experiences. Our surgical population was particularly small. Also, as PDs primarily focused on positive aspects of their tenure, there may be recall bias, particularly among the former PDs. Despite such limitations, our study offers a unique and important glimpse into the lived experiences of PDs implementing successful educational program reform in an international context.

International PDs were able to share their experiences of overcoming challenges and barriers to successfully implement and maintain educational transformation.

The authors would like to thank Thurayya Arayssi, MD, Weill Cornell Medicine-Qatar, Siok Ching Chia, BS, National University Hospital, and Amanda Bertram, MS, Johns Hopkins University School of Medicine, for their assistance in executing the study and all the program directors who participated in the study for their valuable time and invaluable perspectives.