Perspectives on the US Graduate Medical Education Accreditation System in the Context of the Current Policy Climate

Abstract

Visual Abstract.

Introduction

In the United States, the Accreditation Council for Graduate Medical Education (ACGME) provides oversight for residencies and fellowships, accrediting 13 762 programs with a total of 167 083 trainees in academic year 2024-2025.¹ On April 23, 2025, President Donald J. Trump signed an executive order entitled “Reforming Accreditation to Strengthen Higher Education.”² This order specifically mentions the ACGME, with the White House’s “Fact Sheet” calling the current accreditation system “broken” and alleging “unlawful discrimination,” failure to “ensure quality,” and prioritizing “ideology over quality medical training.”³ The order proposes “resuming recognition of new accreditors to foster competition.”³ A look at our current accreditation system’s advantages and challenges may shed light on whether reform is needed and if competition from accreditors would be beneficial.

Background

In 1910, the Flexner Report set the stage for the Council of Medical Education and Hospitals of the American Medical Association to create the first standards for graduate medical education (GME). Specialty-specific residency review committees followed in the 1930s under the oversight of the Coordinating Council of Medical Education.⁴ In 1981, the American Medical Association, the American Board of Medical Specialties, the American Hospital Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies established the ACGME as an independent, not-for-profit accrediting body designed to protect both the public and trainees.^5,6 Accordingly, the mission of the ACGME is “to improve health care and population health by assessing and enhancing the quality of resident and fellow physicians’ education through advancements in accreditation and education.”¹

After requests by osteopathic students and institutions, in 2014 the ACGME began a process to become the sole accreditor for all US allopathic and osteopathic GME.^7,8 Osteopathic programs meeting high standards that demonstrate commitment to teaching and assessing osteopathic principles and competencies may apply for the ACGME Osteopathic Recognition designation.⁷ This Single Accreditation System⁷ now allows all medical school graduates to have the opportunity to train in equally standardized programs,⁸ with uniform accreditation and transparency, increased collaboration, less cost, improved efficiency, consistent standards, and maintenance of osteopathic specialty recognition.⁶ Though accreditation is voluntary, programs must be ACGME accredited to receive federal funding through Medicare. Absent training in an accredited GME program, physicians may be unable to achieve board certification or obtain an unrestricted license to practice medicine.

Strengths of a Single Accrediting Body

The current Single Accreditation System was designed to provide clear competency-based standards for GME training. Socially accountable postgraduate training and accrediting bodies may provide equitable access to GME for DO and MD students within an environment of safety and support for learning, professional development, and population-aligned patient care. A single, centralized, well-regulated accrediting body ensures continuity and quality standards consistent with societal expectations, optimal patient experiences, and appropriate stewardship of resources.⁹ By holding each GME program to their respective specialty and subspecialty accreditation standards, the US public and specialty certification bodies can be assured that the minimum standards for competence have been met. Without this consistency of accreditation, quality of training could be jeopardized, thus affecting patient care.

Downsides to the Current System

Although the ACGME maintained recognition for osteopathic trainees, there were objections to the formation of the Single Accreditation System. A single gatekeeper structure has universal standards and an inflexible training model, the effect of which can be particularly evident in rural and underresourced settings.¹⁰ Some osteopathic programs have struggled to meet ACGME accreditation standards and data show a reduction in osteopathic GME positions.^11,12 One author noted that by joining the ACGME, the American Osteopathic Association traded their direct relationship with residents and institutions to gain “critical GME opportunities.”¹³ Other criticisms include increased costs, administrative burden, and increased competition for GME positions.^14,15

Competition and Commoditization

The ACGME is a not-for-profit entity providing accreditation as a process critical to the safety of all individuals who seek health care in the United States. Without price regulation, a for-profit single accrediting body could dictate their price for overseeing quality review. Introducing multiple new GME accreditors could involve lengthy and costly processes. Sponsoring institutions could choose to seek less expensive and/or less robust accrediting bodies, if given the option.

The closure of prominent training programs provides cautionary tales of what can happen if GME becomes a commodity rather than a service. Hahnemann University Hospital, caring for the people of Philadelphia since 1848, closed after a for-profit entity purchased it and then declared bankruptcy. GME training positions were auctioned to the highest bidder. This was ultimately deemed illegal and the positions were reallocated.¹⁶ In theory and if enforced, ACGME program requirements ensure that institutions do not compromise educational standards to maximize profit (or margins). However, it is unclear if oversight by a separate and unified accrediting body can ensure that profit motives do not outweigh education.¹⁷

Accountability

The ACGME plays no role in allocation of residency positions by institutions into various subspecialty programs: it oversees the ability of the program and institution to meet standards for accreditation. A primary source of funding for GME in the United States is taxpayer dollars via Medicare, contributing $16.2 billion in 2020 alone.¹⁸ In 2014, a thorough independent review concluded that the “critical missing piece in GME governance is the stewardship of the public’s [financial] investment.”¹⁹ The panel recommended creating a program that directly linked GME with Medicare; was appropriately staffed and regulated yet independent; had members with expertise in physician education, accreditation and certification, and health care economics; and gathered input from a wide range of stakeholders including patients.¹⁹

Although there are shortcomings with transparency in funding utilization, many mechanisms exist to demonstrate accountability in GME trainees acquisition of competencies within the current system, including the accreditation process itself, board certification and maintenance of certification programs, state licensure, public representation on governing boards of accrediting bodies, and public reporting processes (see Table).

Table.

Graduate Medical Education Accountability Mechanisms

Accountability Mechanism	Purpose	Current Use
Accreditation process	Evaluates, reviews, and accredits training programs to ensure they are held to the same standards	The ACGME Single Accreditation System provides competency-based standards for GME training
Board certification	Ensures the public that physicians have the requisite knowledge and skill in their specialty	The American Board of Medical Specialties is the main certifying organization, overseeing 24 distinct medical boards
Maintenance of certification (MOC)	Ensures the public that board-certified physicians maintain their knowledge and skill	MOC pathways vary based on specific board requirements
State licensure	Validates basic competence to practice medicine	States require a minimum amount of GME training that must be completed to be eligible for a license
Public representation	Gives voice to public interest	The ACGME has significant public representation through the Council of Public Members, the Board of Directors, and Review Committees
Public data	Facilitates transparency and informs the public	An extensive public data collection is available through the ACGME and is intended as a reference for policymakers, program directors, institutional officials, and the public25

Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; GME, graduate medical education.

Note: Table adapted (and updated) from: Committee on the Governance and Financing of Graduate Medical Education; Board on Health Care Services; Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Eden J, Berwick D, Wilensky G, eds. National Academies Press (US); 2014:109.

Ideology

Lastly, a brief look at the subject of “ideology” in health care is warranted. Ideology is “a form of social or political philosophy in which practical elements are as prominent as theoretical ones. It is a system of ideas that aspires both to explain the world and to change it.”²⁰ Medicine, in its raw form, is both a science and an art, having evolved as a profession over the course of time to first do no harm. When ideology in medicine supersedes science, medicine itself is under threat.²¹ Nonetheless, we must recognize the social contexts in which we live and practice medicine. Societies are fluid, ever changing over time, and just as our social constructs change, our perceptions of the world change, too. In medicine, we are fortunate to have science as a grounding force on which to stand, and accrediting organizations across the world strive to uphold this foundation.²²

Summary

Graduate medical accreditation must continuously evolve and adapt to maintain effectiveness and ensure safe, competent graduates.²³ Though opportunities exist for improvement, we should recognize that accrediting bodies joined forces for a reason: to ensure that all physicians were held to the same standard of quality outcomes. Readers are strongly encouraged to learn more about the current accreditation system. Actively participate in local, regional, and national groups that support GME, such as health care system GME departments, state medical societies, and program directors associations. Attend educational webinars and conferences such as the ACGME Annual Educational Conference. Volunteer and support GME trainee representation on committees: each ACGME Review Committee has at least one trainee representative and 2 residents are on the ACGME Board of Directors.²⁴ Advocate for excellence in training by maintaining the socially responsible, science-based, high standards of our profession.