Graduate Medical Education Past, Present, and Future: Sponsoring Institutions in Transition

These quotes emphasizing the importance of progress are attributed to 3 physicians born in the 19th century—all well regarded in the history of medical education. Their words predate the creation of the Sponsoring Institution 2025 (SI2025) Task Force the Accreditation Council for Graduate Medical Education (ACGME) appointed to conduct a forward-looking assessment of environment for sponsors of graduate medical education (GME) programs by more than 100 years; yet they speak to the importance of the Task Force's work.

Initially, the role of the Sponsoring Institution was limited to providing basic infrastructure and support for residency and fellowship programs. Over time, the demands of the educational process have brought new authority and responsibilities to Sponsoring Institutions. Considering these changing expectations, the ACGME Board of Directors created SI2025 to understand and plan for these expanding and evolving roles. The work of the Task Force continues the Board of Directors' effort to ensure the ACGME is prepared to advance its mission in anticipated and unanticipated future conditions.

After 9 months of listening to more than 800 respondents representing a diverse group of stakeholders, the SI2025 Task Force distilled 52 key findings that were grouped into 8 thematic categories. There was also consistent expression of 1 additional prominent concern: the evolving definition of the profession of medicine with the related aspect of how professionalism will manifest itself over the next decade. The overall emphasis, expressed by many respondents, was how best to support residents and fellows, as well as increase their understanding of systems-based practice through an interprofessional approach aligned with organization goals, all occurring in a continually evolving health care delivery environment. The goal is to teach residents/fellows to be fully prepared to enter the workforce, with a key component being their experience of this at their own Sponsoring Institution.

With these findings, and in light of 3 major driving forces for health care—commoditization, democratization, and corporatization—the Task Force made 4 recommendations: (1) alignment of Sponsoring Institution accreditation requirements with recent revisions to the ACGME Common Program Requirements; (2) applicable education programing for institutions including faculty and learners; (3) recognition of excellence in innovation that raises the bar and shows the way to the larger graduate education community; and (4) assessing all of these efforts through an appropriate evaluation process.

As noted in the Preface to the Task Force's report, the expectations for improved structure and function of the Sponsoring Institution of the future “often were tempered by comments on pragmatic limitations and uncertainty” (p. 6). No entity has unlimited resources, or exists in a vacuum protected from external forces. Practical considerations in the health care delivery process can diminish the appetite for innovation. Threats of governmental and regulatory agency changes do not provide a backdrop of stability that stimulates innovation. Such limitations and uncertainty may have tempered potential comments.

Further, the report wisely states “the information gathered by the Task Force is subject to unknown bias” (p. 11). This raises the question whether there are other sources of pertinent input, although the list of respondents, while primarily representing medically focused stakeholders, is quite comprehensive. As the initial recommendations are implemented, the SI2025 effort may spark more conversation and input from other sectors.

An unavoidable challenge in an effort such as this is the difficulty of imagining what has not yet happened. The future is often described as “now, on steroids.” This denotes a larger and more powerful manifestation, which is still mired in the roles, relationships, and values of the present, and viewed through the lens of the present. It may be useful to reflect that we are all in a F.O.G., an acronym that reminds us that the Future will have new Opportunities/Options to meet our Goals, which we cannot see at this time. The ACGME Board of Directors continues to address this challenge with a strategic planning approach based on ongoing work to assess approaches relevant in 4 very different possible futures, ranging from total loss of the electrical grid to a fully integrated utopian health system.

A strength of the SI2025 effort is the inclusion of representatives of the osteopathic profession in the cohort of respondents in the listening phase of this project. Some of the institutional aspects of this osteopathic contribution through the Single Accreditation System are documented in this report, including a discussion of the Osteopathic Postdoctoral Training Institute (OPTI). For more than 20 years, this structure has provided academic oversight and resources for GME, coming from colleges of osteopathic medicine and training sites and clinics, without geographic limitation. Considering that only 15% of Sponsoring Institutions are academic medical centers/medical schools (p. 44), the OPTI structure is an example of a resource-sharing efficiency needed for the direction described in SI2025.

No doubt, some readers of this editorial first guessed, and then looked ahead to see who those 3 quoted physicians were. One name may not be familiar to all readers: Andrew Taylor Still, MD, DO, the founder of osteopathic medicine. He represents the osteopathic tradition, which was rooted in his preparation as he became an MD. Sir William Osler represents the allopathic tradition. Charles H. Mayo, MD, represents the uniting bridge foreshadowing the braiding together of both traditions under the Single Accreditation System. Upon reflection, the Sponsoring Institution concept itself has been a constant of both traditions of graduate medical education.

In summary, the role of the Sponsoring Institution is becoming more complex and highly evolved. Both are necessary to enable it to function in a future health care system characterized by commoditization, democratization, and corporatization. Many years ago, the 3 physicians quoted in the introduction pointed out the importance of making progress, and this challenge remains. If we do not strive to improve the training of our future physicians to better care for their patients, who will? The SI2025 Task Force report sets the stage for continuing progress today, and in the future.