Most DIOs reported serving on important institutional committees (89.7%) other than the Graduate Medical Education Committee (GMEC). Of those respondents, the majority (91.3%) indicated such involvement seemed to help with accomplishing DIO responsibilities (see Table 3).
We introduced the idea of competencies with the following statement in the survey: “In light of the current focus on competencies, it is important to know what competencies you see as important for a successful DIO.” Over 95% of respondents selected five competency items as essential from the list of 13 that we provided: professionalism, verbal communication skills, interpersonal skills, leadership skills, and written communications skills (see Table 4). In addition, we gave respondents the option to add to our list in a comment section. We then reviewed all respondents’ comments on competencies for emerging themes; few respondents wrote in additional competencies, none of which was listed more than once. Several commented that the list seemed complete as presented.
The most frequent comments were: required competencies probably would vary according to an organization’s structure; having good support staff was essential if a DIO did not possess a particular competency; and a DIO must be viewed as a leader, expert, and role model. In addition, two respondents’ specific comments seemed noteworthy: “[a] DIO has to be a jack of all trades and a master of many” and “when you don’t know, know who [sic] to ask.”
We asked respondents about the likelihood of their using five specific resources (see Table 5). The majority (83.1%) indicated they would be very likely to use resources such as templates for GME policies, contracts, and affiliation agreements. Over 50% reported that they were very likely to attend DIO-specific training and would use data on DIO demographics. About one third of respondents (32.1%) indicated they would be very likely to attend a DIO certification program, but, of note, several wrote in that they would not like to see such a program mandated. Respondents listed no additional resources in the comments section.
This cross-sectional survey of DIOs had a 66.9% return rate and likely is representative of the views held by current DIOs at the time the survey was completed. The survey responses identified and defined DIOs’ perceptions of minimum DIO experience and training requirements, additional training desired by persons fulfilling the role, committee service viewed as helpful for reinforcing and enhancing the image of an institution’s DIO, professional competencies believed to be essential for successful job performance, and resources DIOs were most likely to use and need for accomplishing their jobs as expected.
Our previous report revealed considerable variability in DIO salaries, titles, reporting titles, responsibilities, time commitment, training, authority, and support. That knowledge led us to conclude that the DIO position was underdeveloped and in need of immediate attention.2 The findings reported here can be used by institutions providing GME, by DIOs, and by other medical education leaders to make informed decisions about how better to develop the DIO position. It appears that DIOs would welcome some standardization of the position. Eighty-two percent of respondents agreed that there should be minimum experience and training requirements set for DIOs. This is especially striking since no respondent suggested that current DIOs should be exempt from the new criteria on the basis of their prior appointment to the position.
The 243 respondents evidenced remarkable agreement on the competencies they deemed essential to success as a DIO. Few wrote in additional competency items, none of these write-ins was listed more than once, and several respondents commented that the list we provided seemed complete. Consequently, it seems reasonable to conclude that the 13 items do cover the most important competencies. Only three of 13 competency items were viewed by less than 50% of respondents as essential: medical knowledge, visa knowledge (immigration requirements), and legal expertise. While just under half endorsed medical knowledge as an essential competency, 59% of all 243 respondents believed experience working in undergraduate or graduate medical education should be a minimum requirement for the position. It appears that experience in a medical education setting is relatively more important to DIOs than medical knowledge. Far fewer respondents endorsed visa knowledge and legal expertise as essential competencies. The justification for this could be that competent support staff can fulfill these responsibilities.
The remaining 10 competency items were viewed as essential by more than 50% of respondents, with five items endorsed by at least 97%: professionalism, verbal communication skills, interpersonal skills, leadership skills, and written communication skills. In addition, approximately one quarter of those listing especially helpful additional training wrote in leadership training, lending more support for the importance of leadership competence. The nature of such training was not addressed, but is a justifiable area for additional study.
Establishing benchmark professional training and experience for persons aspiring to and currently filling a DIO position should be done as soon as possible. The DIO holds a critically important position within ACGME-accredited GME programs. The 13 competencies should become aspects of specific job descriptions, both for persons currently in such roles and for efforts to recruit new DIOs. A final recommendation, and probably one of urgency, is that DIOs and their respective institutions should consider the competencies and minimum training and experience identified here as areas for continuous improvement and targeted training for existing DIOs.
In our previous publication, we noted that 72% of DIOs reported confusion and/or overlap between the DIO and program director roles within their institutions.2 In addition, we report here that nearly half of the respondents indicated they were very likely to use a clear description of DIO versus program director responsibilities. Together, this information supports the need for a clear delineation between the two positions. Doing so should improve operations of medical training programs, enhance the effectiveness of residency training programs, and provide assurances to the public and accrediting agencies that respective institutions are earnest in their commitment to ensuring high-quality physician training.
Residency Review Committees address basic minimum qualifications and responsibilities for program directors. The information that we gathered may be similarly useful to Institutional Review Committee members, particularly in their role of developing and revising institutional requirements, which include the DIO role. Further clarification within the institutional requirements would, in fact, help to distinguish and clarify the role of DIO from that of program director.
Almost half of respondents in this study answered affirmatively when asked if they had received additional training that had helped them meet their DIO responsibilities. Of those, 80% reported attendance at meetings, workshops, or conferences as beneficial. Since this was a write-in item, it is possible that more DIOs would have endorsed specific additional training had it been included in the list we provided. Future research should explore the development of such options and probably approach the task by using either a Delphi study or focus groups to discover the kinds of activities deemed especially useful.
We asked respondents if they served on important institutional committees (other than the Graduate Medical Education Committee) where their involvement helped with the DIO role, and, if so, to list these committees. A majority of respondents reported that service on institutional committees helped with their DIO role, but the list of committees generated was based on write-in responses. It is possible that more committee service would have been identified if the participants had been presented with a list of choices with accompanying explanations rather than an open-ended comment section. Future research could consider the types and nature of committee service and explore how such activities are viewed as enhancing DIOs’ performance.
Since our research demonstrated the DIO role was underdeveloped, and there were issues that diluted or interfered with DIO authority,2 carefully selected committee service may be a means to confront and mitigate such concerns. In addition to being an opportunity for accumulating personal service points, committee service would provide valuable face time for a DIO to explain his or her role and its importance to the institution with regard to ACGME accreditation. Moreover, committee service provides a forum for interacting with a broad spectrum of professionals. In addition, strategically selected committee service might provide a venue for educating others about the importance of medical education activities within the institution and for recruiting other professionals to provide input into GME activities. A final bonus derived from such exposure would be to facilitate the process of acquiring other professionals to serve on GME committees, subcommittees, task forces, and internal review and curriculum and evaluation development committees.
Fifty-eight percent of respondents indicated that they were very likely to attend DIO-specific training. In addition, respondents noted resources that could be developed to assist DIOs. These included GME-specific templates, such as policies, contracts, and affiliations agreements. Other resources deemed helpful by DIOs included job description templates and publication of DIO demographics, such as salaries, degrees, titles, and responsibilities. Organizations and associations interested in the success of GME could use this information to guide resource development.
We believe the generalizability of our study to the broader DIO population is strong, because two thirds of the DIOs we surveyed responded to our questionnaire. The integrity of responses is only as strong as the honesty of respondents; however, we assume that the DIOs who responded had a vested interest in the research findings and likely provided honest answers. In addition, we provided numerous opportunities within the survey instrument for respondents to make comments, thus concerns about the completeness of this survey are mitigated.
One possible limitation of this study is that some individuals identified by the ACGME as the DIO delegated responsibilities of their job to another individual. In spite of this, identified DIOs would have answered questions from their perspectives, which are valid study data. For this reason, we do not consider this a major limitation of the study.
In summary, this article describes minimum requirements, additional training desired, ancillary activities (committee service) viewed as helpful, competencies believed to be essential, and resources DIOs are likely to use. DIOs and their institutions, the ACGME, and other organizations invested in GME can use our findings to better develop the role with the ultimate goal of improving GME outcomes. Future research should assess the effect of efforts at DIO role development on important outcomes, which might include the success of the DIO as measured by internal markers, the accreditation status of programs under the oversight of the DIO, and DIO job satisfaction. The DIO holds an increasingly important position in GME. Better-prepared DIOs could provide the necessary leadership and direction for improving future physician education.
The authors thank Guthrie/Robert Packer Hospital for partial funding in the form of author time (LR) and some supplies for this research, as well as all of the DIOs who completed the survey.
This Research Report is based in part on Riesenberg L. The characteristics of the designated institutional official position in graduate medical education [dissertation]. Lincoln, NE: University of Nebraska, 2004.
2 Riesenberg LA, Rosenbaum P, Stick SL. Characteristics, roles, and responsibilities of the designated institutional official (DIO) position in graduate medical education. Acad Med. 2006;81:8–16.
© 2006 Association of American Medical Colleges
4 Riesenberg L. Editor’s educational corner: Designated Institutional Official (DIO). AHME News. Summer 2001:2.