The ACGME Single Accreditation System: Alterations in the Force of Graduate Medical Education

Abstract

The Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) disturbed the gravitational forces of medical education when they entered into a historic agreement in August 2014. This agreement resulted in a 6-year journey to a single accreditation pathway for all residency programs and nearly all fellowship programs in the United States. It brought together the 2 traditions of medicine in the country for the first time in more than 100 years, unifying a critical phase of medical education for all physicians in the United States. In this commentary, the authors briefly describe the Single Accreditation System and relate their perspective on the factors leading to this profoundly important event and its impact on the ACGME, AOA, and medical education.

In this issue of Academic Medicine, Dr. Mark Cummings ¹ articulates concerns about the impact of the decision made by the American Osteopathic Association (AOA) to give up unilateral authority over osteopathic graduate medical education (GME) to participate in oversight of all GME as a member organization of the Accreditation Council for Graduate Medical Education (ACGME). In this commentary, we provide our perspective, based on our engagement in this process from conceptualization to completion, on this momentous change in oversight of GME in the United States.

To paraphrase the words of medical educator Larry A. Green, MD, the ACGME “disturbed the force” in August 2014 when it chose to work with the AOA and American Association of Colleges of Osteopathic Medicine (AACOM), along with its 5 existing member organizations, ²,* to unify accreditation of GME programs within the ACGME. The 6-year effort resulted in the Single Accreditation System (SAS) for all residency and most fellowship programs in the United States, fully implemented as of June 30, 2020. This “disruption of the force” might be likened to gravitational waves brought about in the universe by disruptions or significant celestial body movements that ripple through space-time, are measurable in distant circumstances, and have variable effects. ³ As the waves brought about by the creation of the SAS course through the educational universe, their impact will be determined by where you sit in that universe.

There are multiple dimensions or perspectives from which to understand the impact of the waves brought about by the creation of the SAS. We begin by exploring the antecedent circumstances that led the AOA to seek the creation of a unified accreditation model. Next, we describe the primary event, the SAS. We then explore the impact of the SAS on previously AOA-approved programs and opportunities for graduates of colleges of osteopathic medicine for residency training. We also consider the impact of the SAS on both the AOA and ACGME and on GME. Finally, we speculate about the further impact of the SAS on the medical profession’s social contract with the public, professional self-regulation, and professional interactions.

Factors Driving the Creation of a Unified Accreditation Model

There were 2 major factors that drove the AOA to approach the ACGME to discuss unifying accreditation. The first was the imbalance between the AOA’s growing undergraduate medical education (UME) output and the capacity and attractiveness of AOA-approved GME programs. Expansion of UME output (by both DO- and MD-granting schools) has occurred in the context of the Medicare Balanced Budget Amendment (1998) “caps” on Medicare reimbursement for GME positions. Over the next 2 decades, it became increasingly difficult to expand GME programs in GME-naive institutions (i.e., those that had no existing cap). For existing AOA-approved programs, expansion was often further limited by institutions’ educational capacity (patient numbers, service portfolios, and faculty). In contrast, existing ACGME-accredited programs more frequently were based in larger institutions in the community and in large academic medical centers with long histories of commitment to GME, where the marginal cost of program expansion usually was balanced through service provision expansion. Furthermore, there was a surplus of GME positions in ACGME programs compared with numbers of domestic MD graduates. Indeed, the majority of DO graduates were choosing to matriculate into ACGME-accredited programs at the time of the creation of the SAS in 2014.

The second factor was the movement of the ACGME to establish the first systematic element of competency-based medical education, the Milestone Project. ⁴ In ACGME-accredited programs, each trainee is evaluated every 6 months on a developmental trajectory that is specialty- or subspecialty-specific, as established by peers in each discipline, and receives specific feedback based on that assessment to guide their individual competency development. This resulted in eligibility standards for residents moving from program to program (or from outside the ACGME system into ACGME-accredited programs) that placed additional burdens on graduates of AOA-approved programs. In addition, the ACGME embarked on a clear path ^5,6 that would further separate the nature of accreditation oversight by the ACGME from that of the AOA.

These factors, and a recognition that both challenges were nearly impossible to mitigate, led the AOA to enter into discussions with the ACGME to unify GME accreditation. The alternative for the AOA was to continue on a course of progressive separation of the GME systems and to have no influence on the dominant educational system where the majority of DO graduates would be educated.

When the AOA approached the ACGME, the ACGME faced a decision. As the majority of graduates of colleges of osteopathic medicine were already choosing ACGME-accredited programs, the ACGME did not need to take action and could have permitted the circumstances to drive change by evolution. The ACGME chose a different path, however; a path driven by its value-based perspective of responsibility to the profession of medicine and service to the public through its mission to enhance health and public health through education and accreditation. It chose—in collaboration with the AOA and AACOM, as well as the AAMC, AMA, ABMS, AHA, and CMSS—to create the circumstances under which the osteopathic tradition could be sustained while giving all MD and DO graduates access to all GME programs as we moved forward together on the journey to outcome-based, competency-based education. Significant changes and additions to governance, standards, and background of volunteers were required to create the structure of this accreditation model within the ACGME. Dramatic change in the previously AOA-approved programs was required to achieve ACGME accreditation—and to make the SAS a reality.

The Single Accreditation System

The SAS is the extension of accreditation by the ACGME to all residency and nearly all fellowship programs in the United States, coupled with modification of the ACGME, its governance, volunteer structure, and standards to incorporate the osteopathic community, through its organizations, into the ACGME. The AOA and AACOM are now member organizations of the ACGME, nominating to the ACGME Board of Directors. AOA board certification is recognized as an acceptable credential for faculty and program directors, the traditions of osteopathic medicine are formally recognized through creation of 2 new review committees, and committee membership on specialty review committees has been expanded to include members nominated by the AOA. All residents are now eligible to apply to all programs. All programs are eligible to apply for Osteopathic Recognition, including programs accredited solely by the ACGME before the SAS.

Impact on Previously AOA-Approved Programs

In the run-up to creation of the historic memorandum of understanding ⁷ among the ACGME, AOA, and AACOM, considerable effort was undertaken to understand the impact of the SAS effort on the stakeholders. Committees were formed in the large specialties to compare standards. The result was a recognition that while the standards were very similar, the processes of accreditation differed. The ACGME had recently implemented the Next Accreditation System, ⁶ which included the Clinical Learning Environment Review (CLER) ⁸ and milestones. ⁴ In recognition of the significant adaptation required, AOA programs were given the opportunity to apply (and receive feedback from the residency review committee as to deficiencies identified) as many times within a 5-year window (2015–2020) as necessary to achieve ACGME initial accreditation. Educational sessions and courses were sponsored by both the ACGME and AOA to prepare program directors and faculty for these efforts. The AOA funded consultants to assist programs directly in restructuring their programs and with the application process. These efforts produced a high success rate in program accreditation. In excess of 95% of programs applying to the ACGME achieved initial accreditation. Of 711 total program applications, 680 (95.6%) were accredited, 25 (3.5%) were withdrawn, and 6 (0.8%) were pending decisions as of September 24, 2020. ⁹

It is true that a significant number of AOA programs chose not to apply. Historically, AOA-approved programs had a voluntary closure rate approaching 10% per year. ¹⁰ Further, stand-alone osteopathic internship programs were among the largest groups of programs that did not apply for ACGME accreditation. These positions were often “retasked” at the institutional level to other programs.

One measure of the impact of the SAS on previously AOA-approved programs is the number of programs ultimately accredited. ACGME can only act on programs that apply. We can, however, also look at other outcomes. Since the transition began, the number of positions in the formerly AOA-approved programs that are now accredited by the ACGME has grown significantly. In 2015, the more than 1,000 programs solely approved by the AOA enrolled 8,647 residents and fellows. ¹⁰ In the 2019–2020 academic year, the subset of 680 of these programs that applied for and achieved ACGME accreditation enrolled 10,462 residents and fellows. ⁹ In other words, there were 21% more residents being trained in a smaller number of accredited programs based on the osteopathic tradition.

Impact on the AOA, the ACGME, and Medical Education

In our estimation, the SAS is a manifestation of success of both the AOA and ACGME. The SAS is a manifestation of the importance of the osteopathic tradition in the preparation of physicians to serve the public, as well as evidence of the maturity of its organizations to assure the continuity of the educational continuum for graduates of colleges of osteopathic medicine. As the osteopathic community has intentionally increased its UME output to approximately 25% of the domestic output of physicians, ¹¹ the AOA bore the responsibility to ensure that the opportunities for those graduates were as diverse as feasible. The AOA recognized the limitations of a separate system at the GME level, worked effectively to assure the continuity of its traditions and principles in GME through codification of Osteopathic Recognition, and now actively participates in the activities of the ACGME.

For the first time in more than 100 years, the 2 traditions in U.S. medical education have been unified at the GME level. From the ACGME’s perspective, the organization has gained 2 member organizations. The SAS has given it opportunities to provide consistency of educational frameworks and to introduce competency-based principles and outcome-based accreditation principles for all residency programs in the United States, as well as better to fulfill its role of governance and accountability for GME in the social contract. ¹² Further, many osteopathic GME programs have been located in rural areas. Through the SAS, the ACGME also gained opportunities to reaffirm its mission to serve the public by expanding support for GME in rural and underserved areas.

Both the ACGME and AOA were challenged to demystify and confront biases, seize opportunities to learn, and to embrace this once-in-a-century opportunity to unify the profession. We believe the ACGME and AOA are each better due to this effort.

Impact on the Social Contract, Professional Self-Regulation, and Professional Interactions

The creation of the SAS demonstrates that the medical profession’s seemingly static oversight organizations, which are responsible for professional self-regulation granted through the social contract, can and perhaps must evolve to meet the needs of both the profession and the public. Seemingly incompatible entities, when faced with a changing reality, can choose to adapt while maintaining and even enhancing their effectiveness on their journey to excellence. Rather than closing doors or saying no, we can choose to open more doors and say yes, expand opportunities, and in the process, better serve the needs of the public.

In our opinion, the success of the SAS should challenge each of us charged with participation in the social contract–based gift of professional self-regulation to reexamine our structures and consider new and more effective ways to achieve our mission of service to the American public and the medical profession. It is time for us all to put existing institutionalized barriers behind us, identify opportunities to work together in creative value-based ways to advance medical education in the 21st century, and underpromise and overdeliver to the profession and the public, who deserve our best efforts.

Acknowledgments:

The authors wish to acknowledge with appreciation the leadership of the osteopathic educational community, the member organizations of the ACGME, and the Board of Directors of the ACGME in making the Single Accreditation System possible. The authors wish to applaud the staff of the ACGME, the members of the residency review committees, and the osteopathic program directors and faculty whose diligence and commitment to excellence made the Single Accreditation System a reality.