We read Dr. Nasca's article on the Accreditation Council for Graduate Medical Education's (ACGME's) early response to the COVID-19 pandemic and found much to applaud.1 We appreciate the ACGME's effort to create a flexible system that places the decision-making power with those directly impacted and seeks to alleviate administrative burden. Nevertheless, our institution's experience deciding where we fit along the proposed continuum of the “Three Stages of GME During the COVID-19 Pandemic”2 has generated interesting observations we would like to share in the spirit of process improvement.
The COVID-19 pandemic has produced unequal and asynchronous regional effects. The ACGME's early guidance was almost entirely focused on areas experiencing high infection rates. For these institutions, the progression from “business as usual” to “all hands on deck” was a sensible one. For other parts of the country, maintenance of “normal operations, including continued satisfaction of all relevant accreditation requirements,”2 has been problematic despite low rates of COVID-19 infection. The effects of this disconnect are illustrated by our institution's experience.
Augusta University Medical Center, the main teaching hospital of the Medical College of Georgia (our sponsoring institution), is a medium-sized 400-bed referral center that was stretched by the number of COVID-19 patients in the emergency department, intensive care units, and designated floors, but never truly overwhelmed. Other vital training venues, including ambulatory clinics and operating rooms, were nearly shut down early on, only gradually recovering their volumes after several weeks of limited activity. As we debated what “Stage” we would designate ourselves within the ACGME framework, there were differing opinions among the GME leadership, particularly on the implications of declaring ourselves Stage 3.
From the institution's perspective, Stage 3 seemed disingenuous when our clinical burden was so low compared to hospitals in hard-hit cities like New York. From the perspective of our GME programs, Stage 3 was attractive as justification of a greatly altered learning environment. For the small number of programs with increased clinical activity, the desire to move to Stage 3 was unambiguous. For a greater number of programs, the absence of patient care was threatening the ability to provide adequate educational experiences. Many of these programs also advocated for Stage 3 designation, as it seemed to validate that the program's deficiencies were beyond their control, even if the situation did not strictly meet the definition of this stage. Finally, from the perspective of individual learners, some thought an institution-wide declaration of Stage 3 could be viewed as a license to forget structured educational programming.
The above discussion highlights 2 problematic aspects of the ACGME's pandemic response. First, the declaration can only be made at the institution level. This created considerable consternation because, of our nearly 50 programs, only a small number clearly met the ACGME criteria for Stage 3. Those programs were fearful that if our institution did not declare itself to be in Stage 3, they may suffer future accreditation repercussions. Their program directors perceived Stage 3 declaration as a way to provide “cover” for appropriately suspending educational activities to accommodate care of COVID-19 patients. On the other hand, directors from the greater number of our training programs, experiencing substantially decreased clinical activity, expressed concern that a declaration of Stage 3 would appear dishonest and reflect poorly on our overall GME program. Because the effects of the COVID-19 pandemic vary so much by location, and even by training programs within a sponsoring institution, it may be better if the Stage 3 declaration could be determined at the program level rather than at, or in addition to, the institutional level.
The second issue is that the ACGME's pandemic response framework is geared primarily toward sponsoring institutions with increased clinical demands. Even in hospitals with large numbers of COVID-19 cases, segments of their GME programs found themselves with little opportunity to continue their traditional training paradigms due to the shutdown of elective procedures and ambulatory settings. These program directors had to quickly modify their curricula, including creation of home-based reading programs, online didactic lectures, and web-based conferences to keep their learners progressing toward clinical competence without seeing patients. The ACGME acknowledged that decreased clinical activity is a real phenomenon in its forceful statement on furloughs,3 but there remains significant concern that programs suffering a dip in key indicators may incur citations in future accreditation cycles. We suggest that the ACGME consider a separate category in their system to address the clinical activity slowdown scenario and to provide more reassurance that their accreditation would not be in jeopardy due to such circumstances.
We are confident that the ACGME will continue to address the needs of residents, faculty, programs, and sponsoring institutions as the COVID-19 pandemic unfolds. We are hopeful that by discussing our own challenges with implementing the ACGME's COVID-19 staging system, efforts to render the system more widely applicable will be enhanced.
