In the United States, disparities in health outcomes are driven by various population- and area-based factors, including social drivers of health and geographic access to care.1,2 The health care system may contribute to reducing these disparities by ensuring access to cost-effective care that is satisfactory to patients and health care professionals.3,4 Progress in reaching this goal is limited by the scarcity of physician services in many rural and urban areas, with hospital closures and physician retirements putting additional pressure on strained resources.5-8 Graduate medical education (GME) is a major contributor to the professional formation of physicians, and the literature has shown that physicians' selection of practice locations is strongly influenced by the GME programs they complete.9,10
Consistent with its mission 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,11 the Accreditation Council for Graduate Medical Education's (ACGME's) accreditation model is responsive to societal needs. Recent circumstances have underlined the need for the ACGME to clarify its role in facilitating sponsoring institutions' and residency and fellowship programs' preparation of physicians to address the needs of medically underserved areas and populations (MUA/Ps). While the number of first-year US residency positions is increasing, this growth has not kept pace with the increasing number of eligible applicants for these positions.12 Health system leaders, policymakers, and the public increasingly view GME as an important component of educational pathways that advance diversity, equity, and inclusion in the medical profession and health care. The successful transition to a single accreditation system for GME in the United States has provided new opportunities to collaborate with allopathic and osteopathic medical educators in efforts to advance the ACGME mission.13
In this context, the ACGME Board of Directors requested in 2018 that the ACGME convene a work group to study GME and MUA/Ps and to make recommendations for the organization.
The MUA/P and GME work group included ACGME staff and Board of Directors members as well as external representation from the GME community, public, and resident members. The group met in May, June, and July 2018 to hear presentations from experts on GME financing and accreditation in rural and urban underserved areas. The work group discussed initial considerations for GME and MUA/P before traveling to Washington, DC; Jackson, Mississippi; New York, New York; Tulsa, Oklahoma; and Portland, Oregon, for regional visits from August to November 2018.
During these visits, work group members interviewed 124 GME stakeholders to discuss local contexts for health care and GME, the current need for resident and fellow education in MUA/Ps, challenges to building educational and health system capacity, and opportunities for the ACGME to join sponsoring institutions, programs, and others in efforts to address those challenges. Participants in the visits included residents, fellows, program directors, faculty members, designated institutional officials (DIOs), health system and education leaders, medical students, interprofessional health care team members, legislators, health services researchers, policymakers, and representatives of organizations with an interest in GME and MUA/Ps.
Following these discussions, the work group held additional meetings to develop and finalize an accreditation framework with recommendations to enhance physician workforce development in communities that face substantial shortages of practicing physicians in various medical specialties and subspecialties.
The accreditation framework for MUA/Ps and GME aims to encourage the development of GME that results in greater access to and availability of health care in MUA/Ps. The framework is divided into 4 sections outlining initial actions to (1) enhance ACGME support; (2) engage with ACGME review processes; (3) understand ACGME compliance challenges; and (4) facilitate effective institutional oversight and administration (Figure).
I. Enhancing ACGME Support
The work group recommended the creation of a programmatic unit with dedicated ACGME staff to organize and support the implementation of the accreditation framework. The framework calls for the formation of a permanent advisory body for work on GME in MUA/Ps. To facilitate learning about GME and MUA/Ps, the work group proposed that the ACGME should enhance relevant systems, data collection practices, and educational activities.
II. Engaging With ACGME Review Processes
The work group identified collaborative efforts to include specialty review committees, the Institutional Review Committee, and ACGME staff members as critical to facilitating the development of GME that enhances health care in underserved communities. In recognition of the ongoing work to address physician shortages through law and policy, the framework recommends that the ACGME attempt to align its requirements, policies, and procedures with those of governmental agencies and other organizations where possible. The work group recommended that the ACGME take steps toward monitoring, evaluating, and sharing national and regional progress in GME development.
III. Understanding ACGME Compliance Challenges
The work group's conversations with stakeholders revealed a number of organizational, common, and specialty-specific barriers to creating and maintaining ACGME-accredited sponsoring institutions and programs. The framework recommends that the ACGME should promote dialogue and learning that results in a better understanding of compliance challenges in areas such as program director and faculty appointments and retention, curriculum, educational experiences, participating sites, and supervision.
IV. Facilitating Effective Institutional Oversight and Administration
The work group's visits across the United States offered an opportunity to study multiple successful institutional models for overseeing and supporting GME. The framework encourages the ACGME to promote the sharing of knowledge concerning institutional GME structures, processes, and outcomes among DIOs, program directors, institutional and program coordinators, and others. The framework calls upon the ACGME to streamline accreditation application processes and remove administrative barriers to support GME development in MUA/Ps.
In May 2019, the ACGME Board of Directors approved the accreditation framework for MUA/Ps and GME. The ACGME programmatic unit for MUA/P and GME was established with the arrival of its first director, Laney McDougal, in spring 2020. Appointed in the ACGME departments of Accreditation, Recognition, and Field Activities as well as Sponsoring Institutions and Clinical Learning Environments, the director collaborates with ACGME staff, review committees, and the ACGME Council of Review Committee Chairs to implement the framework.
The ACGME's Rural Track Program (RTP) designation process14 was the first project completed under the framework. This process, which is designed to be consistent with the rules and regulations of the Centers for Medicare & Medicaid Services, defines a structure for educating residents and fellows in rural areas for more than 50% of the duration of their ACGME-accredited programs. As of January 2023, 13 ACGME-accredited programs have obtained designation as RTPs, and reports identifying RTPs are now available on the public website of the ACGME Accreditation Data System.15 The MUA/P and GME team is building on these changes and providing leadership on how to improve GME location data to accurately and reliably measure the presence of GME in rural and underserved areas and populations (rural data enhancement project), in alignment with Section I of the framework.
The ACGME appointed an advisory group for MUA/Ps and GME, which held its first meeting from December 1 to 2, 2022. The charge of the advisory group has 3 components:
To develop assessments related to GME and MUA/Ps (eg, contribute to the development of a set of working definitions for MUA/P that will be used in programmatic activities)
To engage and collaborate with GME stakeholders on issues of relevance in MUA/Ps (eg, contribute to the development of publicly available ACGME data relevant to MUA/Ps; contribute to the ACGME's understanding of relevant policy discussions and considerations for GME and MUA/Ps in collaboration with ACGME policy staff members)
To contribute to learning relevant to ACGME accreditation and MUA/Ps (eg, contribute to the development of educational programming for DIOs and institutional coordinators through the National Learning Community of Sponsoring Institutions)
The advisory group has begun to fulfill its charge by making initial suggestions to the ACGME for learning and collaboration that will be pursued at future meetings.
MUA/P in 2023 and Beyond
The early implementation of the accreditation framework for MUA/Ps and GME has opened new lines of communication among GME stakeholders and new opportunities for the ACGME to learn with the GME community, organizational and governmental partners, and the public. The ACGME will continue building its stakeholder engagement through conferences, data project focus groups, and community-building.
At the 2023 ACGME Annual Educational Conference, the MUA/P and GME team held a panel session featuring members of the MUA/P Advisory Group and Dr. Randy Longenecker of the Rural Training Track Collaborative. In this session, panelists discussed relevant topics, such as challenges related to training in rural and underserved settings; retention of graduates to practice in areas of need; recruitment of those underrepresented in medicine; developing relationships with the Indian Health Service, Tribal, and Urban Indian (I/T/U) communities; and available funding and resources for developing programs in MUA/Ps. The Annual Educational Conference provided additional opportunities for engagement in MUA/P through a first-ever MUA/P interest group facilitated by the panelists, as well as a focus group for program directors, DIOS, and institutional coordinators to provide input into the rural data enhancement project.
The MUA/P and GME team will take the information learned from the Annual Educational Conference and project focus groups into consideration and discussion with the MUA/P Advisory Group for development of the rural data enhancement project as well as developing opportunities for community-building and educational programming. Additional updates and opportunities for engagement will be discussed at the National Learning Community of Sponsoring Institutions meeting in fall 2023. The MUA/P and GME team will continue to support new RTPs and other program development in areas of high need.16
The ACGME would like to thank the members of the 2018-2019 work group and the graduate medical education stakeholders they interviewed for their contributions to the development of the MUA/Ps and GME framework. A full listing of individuals is provided as online supplementary data.
Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its Review Committees. The decision to publish the article is made by the ACGME.