Shaping Graduate Medical Education: Synthesis of Stakeholder Input on Training Needs for Physicians

Introduction

The Accreditation Council for Graduate Medical Education (ACGME) is the primary accrediting body for graduate medical education (GME) programs and their sponsoring institutions in the United States. Using an evidence-based approach, the ACGME aims to enhance the quality of both medical education and health care in general. This article outlines methods used to generate evidence for the development of GME program requirements in medical specialties and the key findings of those efforts across specialties and stakeholders.

ACGME policy requires that each specialty and subspecialty’s program requirements must be reviewed every 10 years.¹ These reviews generally lead to major revisions to reflect the current and anticipated needs for GME training and the practice of each specialty. The ACGME initiated the current cycle of major program requirement revisions in 2017 with internal medicine under the initiative named Shaping GME.

The review process began with extensive data collection about the current and future practice of the specialties with literature reviews and stakeholder and public input. In addition, the ACGME staff facilitated a process that included:

1. Scenario planning to develop common strategies for the practice of the specialty in 4 different world scenarios set in 2050.

2. Focus groups and interviews of patients and their families, recent GME graduates, and employers of those graduates.

From 2020 through 2024, 10 specialties completed the Shaping GME process. The objective of this article is to compare strategies derived from scenario planning with themes from focus groups and interviews with patients, industry leaders, and recent GME graduates to identify common elements applicable across all specialties in GME.

Scenario Planning

Since 2013, the ACGME has employed “alternative futures” scenario-based planning as the process for strategic planning for the organization.² This approach is suited to situations where there is a rapid pace of change, uncertainty about future operating circumstances, and where control of future conditions is mostly in the hands of others.

For this initiative, 10 specialties (family medicine, pediatrics, general surgery, colon and rectal surgery, vascular medicine, emergency medicine, ophthalmology, dermatology, allergy and immunology, and physical medicine and rehabilitation) engaged in scenario planning to identify strategies for the future practice and training of physicians in that specialty. The 4 scenarios, originally designed for use by the ACGME Board of Directors in 2018, portray an array of future conditions set in 2050 that create uncertainty for health care and medical education.

Participants included members of specialty review committees, program directors from diverse institutional types, recent graduates, non-physician health professionals, public representatives, and associated specialty stakeholders.^3,4 A total of 351 people recruited from these groups participated in scenario planning across the 10 specialties. Workshops spanned 2 and a half days, with small groups assigned to each of the scenarios. The groups synthesized strategies developed across the scenarios into consolidated recommendations for specialty training and practice.

Focus Groups and Interviews

The ACGME retained a communications research firm to better understand how to effectively meet the needs of those whom physicians serve. The firm collected and evaluated public comments regarding care in each specialty to help inform the process of revising its program requirements. The purpose of this process was to identify gaps between performance of physicians in the specialty and expectations.

The firm conducted stakeholder engagement with 3 components:

1. Patient Focus Groups: There were 6 online groups per specialty, each with 3 to 4 participants who had recent experience with care in that specialty. Pediatric sessions included parents of pediatric patients. A total of 176 patients and caregivers participated. These discussions explored recent care experiences, perceptions of specialty care, and physician responsiveness to patient needs.

2. Industry Leader Interviews: Seventy-one executives from community health, payer networks, and strategic consulting discussed future models of specialty care, training adequacy and gaps, and critical competencies for future practice.

3. Recent Graduate Interviews: Sixty physicians within 3 years post-residency discussed transition challenges, training adequacy and gaps, and anticipated developments in the field.

The communications firm recruited volunteers from each category for participation.

Data Synthesis

Each of the 10 specialties that participated in both scenario planning and focus groups/interviews developed a list of strategies from the scenario planning along with a description of physicians in the specialty, which were posted for 45 days to allow for review and comment by the public.⁵ Two independent author groups (group 1, M.E.K., K.M., C.P., and group 2, L.M.K.) reviewed and synthesized these documents identifying strategies that were common across specialties.

The communications firm compiled themes from the interviews and focus groups. The themes identified by industry leaders and recent graduates aligned closely, allowing them to be consolidated into a single list.

The authors reviewed the major strategies from the scenario planning, themes from industry leader and recent graduate interviews, and those from patient input to identify commonalities and produce a final list. Each major strategy was then aligned with ACGME’s 6 core competencies: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Systems-Based Practice, and Professionalism.⁶

Nine major strategies emerged from the scenario planning exercises, completed across the 10 specialties (Table 1):

Table 1.

Major Strategies, Descriptions, and Associated ACGME Competencies Identified by Scenario Planning

Major Strategy	Description	ACGME Core Competency
Comprehensive care in the specialty	Manage routine and complex problems Manage health care issues related to climate change	Patient Care Medical Knowledge
Teamwork, collaboration, and leadership	Effective interdisciplinary and interprofessional collaboration and leadership in care teams	Systems-Based Practice
Emerging and enabling technology	Artificial intelligence Telehealth	Patient Care
Well-being	Patients, residents, and care teams	Professionalism
Education content and process	Competency-based medical education Duration of training Resident role as teacher/educator/mentor	Practice-Based Learning and Improvement
Professionalism, ethics, and diversity	Mitigation of health inequity, disparities, and bias Compassionate, patient-centered, culturally sensitive care Diversity of patients, colleagues, and teams	Professionalism
Communication	With patients and their families With interprofessional/multidisciplinary teams Community outreach and engagement Patient advocacy	Interpersonal and Communication Skills
Outcomes and practice improvement	Continuous quality improvement and use of outcomes data to improve patient care	Practice-Based Learning and Improvement
Health systems and business of medicine	Cost effectiveness, resource stewardship, and financial literacy Practice in a variety of settings, including community-based, resource-limited, and underserved	Systems-Based Practice

Abbreviation: ACGME, Accreditation Council for Graduate Medical Education.

1. Comprehensive care in the specialty

2. Teamwork, collaboration, and leadership

3. Emerging and enabling technology

4. Well-being

5. Education content and process

6. Professionalism, ethics, and diversity

7. Communication

8. Outcomes and practice improvement

9. Health systems and the business of medicine

Seven of these strategies were included by all 10 specialties. Two strategies—well-being and professionalism, ethics, and diversity—were included by 9. Each of the major strategies had additional items to further describe that strategy, which were noted by most of the specialties and are included in Table 1. All 9 strategies were matched to one or more ACGME core competencies, and all 6 ACGME core competency domains were represented in the strategies.

Themes identified from interviews of industry leaders and recent graduates included:

• Newly trained physicians are generally well prepared for practice

• There is variability of training largely due to program resources

• Gaps in training include:

  • Training sites and care environments (outpatient/community-based, underresourced settings)

  • Exposure to new models of care (team-based care, telehealth, value-based care)

  • Interpersonal and leadership skills

  • Business and operational exposure and understanding

  • Lifelong learning and faculty development

The identified gaps were further elaborated by the interviewees and are outlined in Table 2.

Table 2.

Training Gaps Identified by Industry Leaders and Recent GME Graduates

Category	Description
Types of training sites and care environments	Overemphasis on inpatient care, lack of outpatient, continuity, community-based, and underresourced setting exposure Lack of experience within emerging care models such as team-based care, surgical home, value-based care, quadruple aim, and acute treatment sites/hospital at home
Training content	Limited experience with advanced practice providers, quality improvement data, performance metrics, and telehealth
Interpersonal skills	Need for better training in communication, leadership, diversity, and mentoring
Business and operational exposure and understanding	Inadequate training on contracts, billing, health care economics, running a practice, insurance navigation, and referrals
Lifelong learning and faculty development	Need for fostering ongoing curiosity, relevant research engagement, and faculty skills as effective educators and assessors of resident performance

Abbreviation: GME, graduate medical education.

Key themes identified by patients for care from physicians in each specialty included:

• Control: having the desired level of decision involvement when it comes to my care

• Trust: belief in the reliability, consistency, ability, and honesty of a physician that gives me confidence in the choices I have made

• Individuality: being treated as a unique person and having services and communications tailored to my situation

• Quality: strong clinical coordination and performance across the care team

• Simplicity: ease and efficiency that reduces the hassles and barriers to being healthy

• Affordability: providing cost-efficient care options and support solutions so that I can afford the care I need

Themes from the patients, industry leaders, and recent GME graduates were reviewed by the authors and integrated into the 9 major strategies identified by the scenario planning exercise (Table 3).

Table 3.

Major Strategies From Scenario Planning and Associated Themes and Constructs From Interviews and Focus Groups

Major Strategy	Themes From Industry Leaders and Recent GME Graduates	Themes From Patients
Comprehensive care in the specialty	Well prepared to begin practice Remain current with rapid and frequent developments in care	Physicians able to consistently and reliably provide appropriate care
Teamwork, collaboration, and leadership	Work with advanced practice providers Effectively participate in and lead clinical teams	Coordinated, high performance care from all team members
Emerging and enabling technology	Manage patients via telehealth
Well-being
Education content and process	Engender ongoing curiosity and learning Faculty skills as effective educators and assessors of resident performance
Professionalism, ethics, and diversity	Navigating diversity, equity, and inclusion issues that impact patients’ health and care	Personalized, context-sensitive care Physician honesty
Communication	Coaching in communication	Patients able to have their desired level of involvement in their care
Outcomes and practice improvement	Understand and use quality, outcomes, patient experience, and productivity data to modify practice
Health systems and the business of medicine	Training on contracts, billing, health care economics, running a practice, insurance navigation and referrals Exposure to outpatient, community-based, longitudinal, and underresourced setting Working within emerging care models: team-based care, surgical home, value-based care/quadruple aim, and acute treatment sites/hospital at home	Accessible cost-effective care and support services

Abbreviation: GME, graduate medical education.

The 9 strategies were then matched to the ACGME competency domains. Two strategies aligned with Patient Care: Comprehensive care in the specialty and Emerging and enabling technology. Comprehensive care in the specialty also aligned with Medical Knowledge. Two strategies are included in Practice-Based Learning and Improvement: Education content and process and Outcomes and practice improvement. One is included in Interpersonal and Communication skills: Communication. Teamwork, collaboration, and leadership and Health systems and the business of medicine are both aligned with Systems-Based Practice, and Well-being and Professionalism, ethics, and diversity aligned with Professionalism (Table 1).

As a part of its Shaping GME process to provide evidence-based information for the decennial major revisions of specialty program requirements, the ACGME has gathered data from a wide variety of sources. This article focuses on data from 3 of these sources. The integration of data from scenario planning, industry leaders/recent graduates, and patients demonstrates strong convergence across stakeholder groups, regardless of specialty. Most themes could be organized within the 9 strategies identified in scenario planning, reinforcing their relevance.

Importantly, each strategy maps to the ACGME competency domains established in 1999,⁶ reaffirming their continued applicability in current and future GME and clinical practice contexts. The breadth of stakeholder engagement enhances the validity of both the strategies and the competencies.

This study has limitations in that the largest portion of participants in the scenario planning exercise were recruited from groups (review committees, certifying boards, specialty organizations) quite familiar with GME in the specialty. This may have produced some bias. Those recruited as patients, caregivers, and industry leaders would have had a broader perspective on the training and practice of physicians in the specialty.

The scenario planning exercises are resource intensive. Their widespread applicability across specialties has prompted the ACGME to adopt the resulting strategies as a foundation for future program revisions, rather than repeating the full scenario planning process for each specialty. These data have also been made available to the task force currently developing major revisions to the ACGME Common Program Requirements, which apply to all specialties and subspecialties.⁷

These findings are applicable beyond GME. They offer valuable insights for undergraduate medical education (UME), continuing medical education (CME), and continuing certification processes.

Conclusions

Through its Shaping GME initiative, the ACGME has gathered and synthesized a broad base of stakeholder input to inform evidence-based revisions to specialty program requirements. The 9 core strategies derived from this work represent a forward-looking framework for the development of physicians across the education continuum. These strategies not only align with ACGME’s longstanding competency domains but also reflect the real-world expectations of patients, educators, and the health care industry.

We anticipate that this framework will support educators and program directors in UME, GME, and CME in aligning curricula and assessments with the evolving demands of health care delivery.

Editor’s Note

The ACGME News and Views section of JGME includes reports, initiatives, and perspectives from the ACGME and its review committees. This article was not reviewed through the formal JGME peer review process. The decision to publish this article was made by the ACGME.