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Perspectives

Meeting ACGME Standards Under a Unified Accreditation System: Challenges for Osteopathic Graduate Medical Education Programs

Cummings, Mark PhD

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doi: 10.1097/ACM.0000000000001458
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Abstract

In February 2014, the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine signed a memorandum of understanding (MOU) to create a single accreditation system, under the ACGME, for graduate medical education (GME) in the United States.1 This MOU was the culmination of a series of joint discussions that began in January 2012.2 The osteopathic profession’s motivation to form a common GME accreditation system was largely to preserve osteopathic medical students’ access to ACGME specialty and subspecialty programs, prompted by the ACGME’s decision to no longer recognize AOA-approved GME training for entry into ACGME-accredited residency and fellowship programs.2

The osteopathic profession did not enter into discussions with the ACGME from a position of strength, however, and agreeing to a common GME accreditation system did not come easily. The initial MOU presented to the AOA Board of Trustees in July 2013 was rejected.3 In the end, the AOA gained ACGME recognition of osteopathic manipulative medicine as a specialty, with its own Review Committee (RC) and accreditation standards, and minority membership on various ACGME committees. The AOA agreed to close its GME system in 2020 and to have its GME programs without dual accreditation (i.e., accreditation by both the AOA and ACGME) seek accreditation through the ACGME.1

In this Perspective, I will discuss the challenges that hospitals with osteopathic GME programs face in obtaining ACGME initial accreditation and consider options for addressing them. Many of these challenges stem from differences between the standards of the AOA and ACGME accreditation systems and will require hospitals with established osteopathic GME programs to make difficult choices based on educational and financial realities to comply with ACGME requirements. These challenges will also be faced by hospitals that viewed the MOU terms as making it advantageous to secure new osteopathic GME programs.

Terms of the MOU

According to the terms of the MOU,1 between July 1, 2015, and June 30, 2020, current AOA-approved GME programs (hereafter, AOA or osteopathic programs) without dual accreditation are expected to complete and file an application for ACGME accreditation. After filing the application, these programs will automatically receive “preaccreditation status,” which means that an osteopathic program has started the process of applying for ACGME accreditation while maintaining its AOA accreditation. Preaccreditation status does not connote “initial accreditation,” which is recognition that the program is in substantial compliance with ACGME standards.

Once an AOA program submits an ACGME application, two outcomes are possible. One is that the osteopathic program will receive a letter of notification (LoN) stating that it is in substantial compliance and merits ACGME initial accreditation. The second is that the program will not achieve initial accreditation status with its first application. Under this circumstance, the program, which will maintain its ACGME preaccreditation status and its AOA accreditation, will receive an LoN listing citations from the RC that prevented the program from achieving initial accreditation. The program will then be obligated to submit an updated and complete ACGME application for reconsideration in responding to the citations noted in the LoN.

Current AOA programs must receive ACGME initial accreditation status before June 30, 2020. Any program that has not achieved initial accreditation by this date will lose its AOA accreditation and ACGME preaccreditation status and become defunct, unless the ACGME agrees to other considerations.

Challenges in Achieving ACGME Accreditation

It is overly optimistic to assume that all current AOA programs will migrate to the ACGME system and meet a new set of accreditation standards within a five-year period. Osteopathic programs operate in a GME system with a structure markedly different from that of the ACGME. Osteopathic standards are written to support training in community hospitals, not academic health centers. They place little emphasis on faculty development or the research productivity of program directors and faculty. Notions of core faculty, ratios of residents to faculty, and percentages of protected and compensated time for program directors and faculty are evident in only a few osteopathic specialties’ accreditation standards. Historically, the osteopathic profession has depended heavily on the voluntary contributions of staff physicians without protected time to support its GME programs. In addition, resource requirements for hospitals that wish to start an osteopathic residency are less stringent and less expensive than those for ACGME-accredited programs (hereafter, ACGME programs).4

As the accreditation landscape changes, osteopathic programs can therefore expect to encounter a number of challenges, as described below, as they work toward achieving ACGME initial accreditation.

Minimum number of residents

The minimum number of residents required to qualify as an AOA or ACGME program varies widely by specialty (see Table 1), with the higher numbers required by the ACGME for many specialties presenting challenges on several fronts. First, some osteopathic programs designate their preliminary interns (postgraduate year 1 [PGY-1]) as residents and include them in the total number of approved residency positions. For example, in the AOA system, anesthesiology is a four-year residency, and a program’s number of approved residency positions covers trainees in all four years of training.5 In ACGME standards, however, anesthesiology requires successful completion of an ACGME PGY-1 year, but it is considered a three-year residency and mandates a minimum of nine residents in the program (three in each year).6 As of January 2016, there were 13 AOA anesthesiology programs; of these, 8 (62%) had two or fewer residents in each year.7 Other AOA specialties that consider PGY-1s as residents and include them in their minimum program size include neurology and psychiatry.8

Table 1
Table 1:
Minimum Numbers of Residents for AOA-Approved Versus ACGME-Accredited Residency Programs, by Specialty, 2016a

The two largest specialties in osteopathic GME, family medicine and internal medicine, have minimum program sizes that are considerably smaller than those of comparable ACGME programs (Table 1). A recent analysis indicated that at least 41% of AOA internal medicine programs in 2015 were approved for fewer than the ACGME’s minimum of 15 enrolled residents.9 More than three-quarters of osteopathic family medicine residency programs (202/261; 78%7) are approved for at least 12 residency positions, but many fall short of meeting the ACGME’s requirement of having at least 12 on-duty residents, either because of a lack of funding or their inability to recruit residents to fill all of their approved residency positions.7 As part of its heritage, the osteopathic profession has long promoted the development of small family practice residency programs (6–9 AOA-approved positions) in rural communities to address critical local health care needs. These small programs are at a high risk of closing by 2020 unless they coalesce with another accredited program.

Osteopathic obstetrics–gynecology (OB/GYN) programs face similar challenges. As of January 2016, the AOA had 36 OB/GYN residencies, of which 2 were dual accredited and 3 were recently AOA approved. Of the other 31 programs, 13 (42%) were approved for fewer than the ACGME minimum of 12 residents, and 16 (52%) were funding fewer than 12 positions.7

Hospitals that transition their osteopathic programs to the ACGME system are expected to have sufficient scope, volume, and variety of clinical cases in the specialty to adequately train higher minimum numbers of residents. Smaller hospitals with less than the ACGME minimum numbers of residents in their programs may find it difficult to increase their program sizes and still have an adequate amount of clinical material for training additional residents.

Federal cap on resident numbers

Established hospitals—that is, hospitals with osteopathic GME programs and an established Medicare resident limit (federal cap number)—face difficult choices. It can be assumed that these hospitals currently operate at, if not over, their fixed federal cap number of residents. In adding new residency positions to qualify for ACGME accreditation, established hospitals will not receive additional reimbursement for increases beyond their federal cap.10 The choices open to them to expand their programs to meet ACGME minimum sizes are limited: They can absorb the cost of additional residents, reduce or eliminate other AOA programs to create fewer yet larger residency programs, or withdraw from GME altogether. It can be expected that programs that provide the highest value to the hospital and have the greatest potential to meet ACGME standards will be favored—most often primary care residencies.

Fellowship programs

Osteopathic fellowships began as a result of limited acceptance of DOs into ACGME fellowship programs. Osteopathic hospitals seeking to offer a wider range of clinical services needed to develop a cadre of osteopathic subspecialist physicians. Moreover, generalist osteopathic physicians wanted to acquire additional training and credentials. As of January 1, 2016, the AOA had 261 fellowship programs, the majority of them in subspecialties of internal medicine (n = 131; 50%) and family medicine (n = 40; 15%).7 Yet only 44% of the AOA-approved fellowship positions in 2015 were filled11 (see Table 2), primarily because of a lack of funding.

Table 2
Table 2:
Approved and Filled Positions in AOA-Approved Graduate Medical Education Programs, 2014 and 2015a

The contrast between the requirements contained in the AOA and ACGME accreditation standards is especially evident at the fellowship level. The AOA standards were developed for hospitals using a limited number of DO subspecialists to fulfill the roles of program director and faculty. They emphasize educational outcomes and lack the specificity found in the ACGME fellowship standards.

As an example, consider the differences in standards for internal medicine fellowship faculty and program directors. The AOA’s one-size-fits-all “Common Basic Standards for Osteopathic Fellowship Training in Internal Medicine Subspecialties”12 require each fellowship program, regardless of size, to have at least two certified physicians in the subspecialty, inclusive of the program director. While mention is made that the program director must have compensated dedicated time, the percentage of time is not specified. For faculty, there is silence regarding minimum numbers, committed time to the program, and compensation.

In ACGME internal medicine subspecialty fellowship standards, it is the norm for 25% to 50% protected and compensated time to be mandated for the program director, depending on program size. These standards also include the position of key clinical faculty (KCF), a committed subspecialty physician who on average works with the program director and dedicates at least 10 hours per week to the fellowship.13 Each internal medicine subspecialty mandates a minimum number of KCFs and, for larger fellowship programs, a KCF-to-fellow ratio. The minimum number of KCFs is three for cardiology and gastroenterology and two for pulmonary medicine, for example.14–16

Required companion residencies

Osteopathic specialty accreditation standards do not include requirements for the presence of other accredited specialty residency programs at the same sponsoring institution. In contrast, ACGME standards for pathology, orthopedic surgery, anesthesiology, OB/GYN, urology, and neurological surgery residencies and for transitional-year programs all mandate the existence of certain other ACGME programs. Compliance with the companion residency requirements for 3 of these programs represents a special hardship for osteopathic compliance.

For instance, the ACGME neurological surgery standards require the sponsoring institution to also have ACGME programs in anesthesiology, diagnostic radiology, internal medicine, neurology, pediatrics, and surgery either at the primary clinical site or a participating site.17 However, the sponsoring institutions of all 11 AOA programs in neurological surgery lack a complete set of these ACGME-accredited residencies.7

For orthopedic surgery, the ACGME standards require the program sponsor to also participate in ACGME programs in general surgery, internal medicine, and pediatrics.18 None of the institutions that sponsor the 44 AOA orthopedic surgery residencies also sponsor 1 of the AOA’s 21 pediatrics residency programs (of which 14 are dual accredited).7

For urology, the ACGME standards require an ACGME-accredited PGY-1 preliminary program in general surgery.19 However, all AOA urology and general surgery programs are five-year categorical programs. To comply with the ACGME standards, institutions transitioning their AOA urology and general surgery programs will need to expand their approved positions—and potentially faculty and resources—in general surgery if they wish to continue to offer the full continuum of urology training. They may also need to reduce their approved urology positions to avoid overall resident count increases and federal reimbursement considerations.

Additional costs: Personnel, infrastructure, and curricula

Hospitals with osteopathic programs can expect to incur additional costs to maintain their GME accreditation.4 Compared with AOA standards, the ACGME requires greater expenditures in human and physical resources, which will drive up program costs and factor into hospitals’ decisions regarding the number and size of GME programs they are willing and able to support.

Faculty.

In hospitals with osteopathic GME, the hospital CEO typically negotiates a compensation amount with the staff physicians who serve as program directors and faculty. Unless dictated by AOA standards, financial support for the teaching faculty varies according to institutional culture. (Historically, uncompensated voluntarism has been a notable feature of osteopathic GME faculty.) ACGME standards, however, set minimum requirements for faculty numbers and compensation. In orthopedic surgery, for example, the ACGME standards stipulate a minimum of three faculty members, including the program director, each of whom devotes at least 20 hours per week to the residency program.18 The AOA standards include no mention of protected and compensated time for the program director and faculty.20 In internal medicine, the ACGME standards require 50% salary support for the program director and a minimum of four core faculty who dedicate an average of at least 15 hours per individual per week to the residency.21 The AOA standards state only that the program director must have compensated dedicated time to administer the training program; there is no mention of core faculty.22

Staff.

The majority of ACGME specialties require a dedicated program coordinator for each residency. AOA standards are silent on this issue. As noted above, AOA residencies tend to be small, making it possible for program coordinators to service more than one residency. To comply with ACGME specialty standards, hospitals with AOA programs will need to hire more coordinators and expand office space.

Infrastructure.

Investments in infrastructure will also be required to meet certain ACGME specialty standards. For example, general surgery standards stipulate that hospital resources must include simulation and skills laboratories,23 and orthopedic surgery standards call for a dedicated space to facilitate basic surgical skills training18—features not commonly found in community hospitals with AOA programs. The inpatient facilities required for ACGME neurological surgery programs are even more extensive.17

Curricular differences.

Curricular differences in AOA and ACGME standards will likely necessitate that osteopathic programs send residents for outside rotations that cannot be claimed on the hospital’s cost report for federal reimbursement. As an example, ACGME general surgery standards mandate a formal transplant experience to include patient management,23 an experience not required in an AOA general surgery residency.24 For emergency medicine residencies, the ACGME requires five full-time equivalent (FTE) months, or 20% of all emergency department encounters, to be dedicated to the care of pediatric patients, with 50% of the five months in an emergency setting.25 AOA standards stipulate a minimum of two months in pediatrics.26 In anesthesiology, the ACGME mandates a minimum of three FTE months in pain management,6 while AOA standards only specify that residents should have progressive exposure to chronic pain management.5

Finally, family medicine program standards for obstetrical training have different emphases. Not only do ACGME standards require the residency to provide 70% salary support to the program director, but the program also must have physician faculty providing and teaching maternity care, including deliveries.27 Residents need to document two FTE months dedicated to participating in deliveries (at least 40 newborn patient encounters, including well and ill newborns) and providing prenatal and postpartum care. The AOA standards, in contrast, include three FTE months of women’s health, but there are several pathways to satisfy this requirement.28 While the standards mandate obstetrics (ambulatory and in-hospital), they are not time-specific, nor do residents have to participate in a set number of deliveries.

In general, the specificity of curricula contained in ACGME accreditation standards is inherently different from the flexibility evident in osteopathic GME. Compliance with the stricter ACGME standards will come with additional costs to hospitals with AOA programs.

A Spate of New AOA Programs

An unforeseen consequence of the MOU was unprecedented growth in the number of new AOA programs between 2013 and 2015, especially in family medicine and internal medicine. As of January 1, 2016, the AOA reported 261 family medicine residencies, of which 58 programs (with 844 new positions) were approved between 2013 and 2015—a 28.6% increase in programs in three years.7 For internal medicine, there were 146 programs, of which 39 (36.4%), with 855 positions, were created between 2013 and 2015.7 There was even a bump in general surgery: Of 61 programs, 9 (17.3%), with 165 approved positions, were added in that three-year span.7

The sudden rush to sponsor osteopathic GME was prompted by a variety of considerations. Hospitals new to GME (hereafter, new GME hospitals) realized that the present circumstances—that is, the terms of the MOU—offered them a new opportunity to become a teaching hospital and build a high federal cap number. The common strategy they followed was to apply for AOA rather than ACGME accreditation because AOA standards were easier to achieve, the AOA approval process was considerably faster, and AOA programs cost less to initiate and operate.4 Their immediate goal was to recruit as many residents as possible to create a high federal cap number to maximize federal reimbursement. Whereas family medicine and general internal medicine residencies have been low-priority choices of graduates from Liaison Committee on Medical Education–accredited medical schools for some time,29 the osteopathic profession has had the problem of too many graduates and too few AOA programs. In short, a new GME hospital’s chances of recruiting a full complement of residents to build a high federal cap number were much better if it started with AOA rather than ACGME primary care programs.

When applying for ACGME accredita tion, these new AOA programs will receive preaccreditation status, and new GME hospitals will thereby gain years of breathing space to work on meeting the criteria for ACGME initial accreditation. By the time a new GME hospital’s osteopathic programs achieve ACGME initial accreditation, the hospital will have moved its programs beyond the planning stages, have an established GME track record, and be well on its way in establishing a federal cap number. Once ACGME initial accreditation is achieved, these hospitals will be able to recruit international medical graduates and U.S. medical graduates into their programs.

This chosen pathway toward ACGME accreditation via the AOA is not without its challenges, however. The ACGME will encounter a bevy of applications from newly established AOA residencies at hospitals with limited GME experience that face many of the same issues as AOA programs at established hospitals. As noted above, minimum program size is one such concern. Of the 39 new AOA internal medicine residencies, for example, 11 (28%) were approved for fewer than 15 residents.7 Also, with the sudden surge in new AOA programs that are currently limited to recruiting only DO graduates, there will be a day of reckoning for each program in determining whether it can generate a sufficiently high federal cap number to sustain the program financially over the long term. One ominous sign is that although there was 14% growth in new residency programs in the 2015 AOA Match compared with the 2014 AOA Match, the percentage of residency positions filled dropped from 66% to 60%11 (see Table 3).

Table 3
Table 3:
AOA-Approved Graduate Medical Education Programs, 2014 and 2015a

Looking Ahead: Will AOA Programs Make a Successful Transition?

On paper in 2015, the AOA had the potential to bring 1,248 programs and nearly 15,000 GME positions into the ACGME system (see Tables 2 and 3). It is unrealistic to assume that all of these programs will make the transition, but the question open to speculation is, What percentage will be successful? To gain a better understanding of the situation, positions in internship, residency, and fellowship programs need to be considered separately.

Internships

The traditional osteopathic internship is a legacy of the past, when all DOs in the AOA GME system completed an internship prior to starting residency training. Even though that policy has changed, many established hospitals (n = 1217) have continued to retain a high number of intern positions despite declining demand: In 2015, only 44% (568/1,293) of AOA-approved intern positions were filled11 (see Table 2). As established hospitals struggle to add new residency positions to meet ACGME program minimums and remain close to their federal cap numbers, they may decide to reallocate positions in traditional internships—and their federal funding—to other programs. The ACGME system supports a sufficient number of transitional, preliminary (PGY-1) internal medicine and surgery positions, as evidenced by the number of unfilled PGY-1 slots (198/398; 50%) in the 2015 National Resident Matching Program Main Residency Match.30 Even when osteopathic graduates are fully integrated into the ACGME system, the number of additional PGY-1 slots needed will be considerably less than the current 1,293 AOA-approved traditional intern positions.

Residencies

Osteopathic residencies come in two varieties: those that are only AOA accredited and those that are dual accredited.

Of the 866 AOA programs approved as of January 1, 2016, 155 (18%) were dual accredited.7 In nearly all of the dual-accredited programs, the number of AOA-approved positions was carved out of the ACGME-approved number. Compliance with GME unification will be easy for these overwhelmingly primary care residencies: All that is required is that they drop their AOA accreditation.

The number of AOA-only approved residency and fellowship positions at osteopathic hospitals can only be seen as inflated. Historically, hospitals with osteopathic GME programs requested and received AOA approval for a larger number of positions than they intended to fund. This helps explain high vacancy rates in AOA programs overall—in 2015, 7,623 (60%) of 12,720 residency positions were filled11 (see Table 2)—and in even the most highly competitive and popular residencies, such as orthopedic surgery (74% filled in 2014) and emergency medicine (71% filled in 2014).31 The confounding situation for the osteopathic profession is that its established hospitals operate at or above their federal cap numbers and collectively maintain an excess number of approved but unfunded residency positions, and yet a sizable number of these hospitals will still need to add or fund unfilled slots to meet ACGME minimums. Most established hospitals will need to right-size programs they want to retain by adding new residency positions, cut back or eliminate other residencies, and transfer federal funding over to cover the new slots and end up with larger programs in fewer specialties. In hospitals without dual-accredited programs, the total number of GME slots transitioning to the ACGME system may be the same or fewer, but it is likely that the total number of programs will be smaller and include fewer programs in non-primary-care specialties.

Fellowships

As hospitals with osteopathic fellowship programs contemplate applying for ACGME accreditation, they will need to closely analyze criteria for specialized laboratory services, protected and compensated time for the program director and faculty, curricular requirements and the need for outside rotations, research requirements for fellows, and ambulatory facilities. They will need to weigh whether the additional expenses incurred in meeting ACGME standards can be offset by the economic and clinical benefits the fellowship brings to the institution. Given the high number of unfunded and/or unfilled fellow positions (see Table 2), it is likely that some hospitals will conclude that they lack the human, physical, educational, and financial resources for their fellowships to make the transition.

Conclusion

Only time will tell how many freshly minted AOA programs at new GME hospitals will achieve ACGME initial accreditation. Another unknown is how many programs and specialties at established hospitals will transition to the ACGME system. In adapting to unified GME accreditation, osteopathic training institutions have been put in the position of needing to reassess their existing GME programs and make critical decisions about their future.

At the hospital level, the financial goal in GME is to break even, at minimum, and to avoid having the programs become a financial drain. The major challenges facing hospitals with osteopathic training programs in the coming years are anticipating and addressing the factors that make GME more expensive—and more faculty- and staff-intensive—under ACGME accreditation while continuing their roles as teaching hospitals offering quality in medical education. Those hospitals that successfully transition AOA programs to the ACGME system will provide osteopathic graduates with new opportunities to participate in GME programs that meet a single set of educational standards, making them eligible for entry into ACGME residency and fellowship programs. Yet an unknown but sizable number of existing AOA programs likely will not complete the transition because of a lack of program adaptability, limited educational resources, financial constraints, and inconsistencies with ACGME standards. With the rapid growth in the number of new medical schools (both DO and MD granting),32 the loss of these osteopathic programs will only heighten pressure on the ACGME to guarantee a sufficient supply of GME positions to train the next generation of physicians.

Acknowledgments: The author would like to acknowledge the prepublication comments of Donald Sefcik, DO, MBA, Thomas Gentile, MSA, Jon Rohrer PhD, DMin, and Marion Cummings, PhD. Special thanks go to Jennifer Campi for her editorial expertise.

References

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