Transparency in Plastic Surgery Program Accreditation Open Access

The Accreditation Council for Graduate Medical Education accredits postgraduate medical education programs throughout the country, with a specific review committee (RC) for each specialty. The purpose of the Plastic Surgery RC is the accreditation of all integrated and independent plastic surgery training programs as well as fellowships in hand surgery and craniofacial surgery in the United States. What the RC does not do is certify individual plastic surgeons, only plastic surgery programs. Individual plastic surgeons are certified via a separate process through the American Board of Plastic Surgery. The processes and methods of the Plastic Surgery RC may not be universally known to everyone in the specialty and, given relatively recent actions by the RC that resulted in significant changes in the landscape of plastic surgery training, it can be useful to understand how the Plastic Surgery RC gathers information, analyzes data, and takes a variety of actions.¹ 

The Plastic Surgery RC has 10 voting members composed of plastic surgeons (both allopathic and osteopathic), a public member who is not a physician, and a plastic surgery resident member. There are also 2 nonvoting ex-officio members and staff from the ACGME. There is a physician chair of the committee, a physician vice-chair, and an ACGME staff member who is the executive director. Voting committee members serve a 6-year term with the exception of the resident member who serves a 2-year term. Nominating organizations include the American Medical Association, the American College of Surgeons, the American Osteopathic Association, and the American Society of Plastic Surgeons; each organization manages nominations to the committee, and prospective members apply through these organizations. The committee meets at least twice yearly to review residency programs and plastic surgery fellowships accredited through the ACGME, inclusive of the independent and integrated plastic surgery residency programs, as well as fellowships in hand surgery and craniofacial plastic surgery. Of note, hand surgery and craniofacial surgery are the only subspecialties in plastic surgery that are voluntarily accredited by the ACGME. Other plastic surgery subspecialties such as microsurgery, aesthetic surgery, and gender-affirming surgery (among others) are not currently participating in ACGME voluntary accreditation.

While the Plastic Surgery RC has several duties, the accreditation of programs accounts for the majority of their work. As most people involved with plastic surgery training programs know, there are multiple sources of data that programs are asked to provide to the ACGME on a regular basis. Programs submit comprehensive updates each fall summarizing all aspects of their training program from the prior academic year.²  In this annual update a tremendous amount of information is submitted, including program curricular changes, personnel changes, scholarly activity updates for residents and faculty, and updates on diversity and recruitment processes, just to name a few. Additionally, residents and faculty in every plastic surgery program around the country are asked to complete the anonymous annual ACGME survey that typically comes out in late winter. The RC also reviews outcomes data, such as graduate case log minima reports and the outcomes from the first attempt at the certification examinations (written and oral).

The information collected by the ACGME, whether it is through surveys or updates, is critical for the Plastic Surgery RC to understand the climate and the learning environment of each program.³  At its most basic level, the RC has a duty to ensure that all plastic surgery training environments are safe, ethical, and provide all the requisite training experiences in plastic surgery. The RC uses all available data to determine substantial compliance against the program requirements published for each specialty.² 

It is worth mentioning the annual ACGME survey and its role in the accreditation process. Understandably, this survey can generate some anxiety for a program and its personnel. Some domains on the survey are objective and easily understood, while others are subjective and more nebulous. Additionally, most plastic surgery training programs have a wide variety of clinical and educational experiences, and the structure of the survey and the responses provided to programs can make it difficult or even impossible to determine if a single person or a single rotation is driving any suboptimal responses. These limitations of the ACGME survey are not lost on the Plastic Surgery RC. However, the annual survey as a constant across all programs can serve as both a bellwether for impending issues for an individual program and a useful gauge of the pace of progress from already-identified issues. In particular, the survey results can quite often be the earliest indicator of an issue in a program that warrants a closer look.

All plastic surgery programs are reviewed annually, and large amounts of information are considered in order to make an annual accreditation decision. Ahead of each of the RC meetings, programs under review are assigned to 2 RC member reviewers, one primary and one secondary. These volunteer committee members spend many hours analyzing all information provided to them, and they each generate their own, often expansive, independent reports. It is important to note that the 2 reviewers do not communicate or collaborate with each other during these reviews. This is important to minimize bias and maintain impartiality.

With each report, reviewers summarize the program in question and make recommendations for a new accreditation decision. An accreditation decision may simply be a continuation of a status, a new status, new or extended citations, or an increase/decrease in resident complement. Sometimes no changes or actions are recommended, but this is rare. While recommended actions can quite frankly be anxiety-producing for program directors and administrators in the training program in question, they are fundamentally designed to enable, and in some instances empower, the program to improve the learning environment. Just as all our trainees benefit from both positive and critical feedback to adjust their learning arc, so too do programs benefit from curricular and learning environment improvements. Ultimately, the Plastic Surgery RC would much prefer to see a program make recommended improvements rather than levy increasingly stringent accreditation decisions.

The 2 program reviewers make recommendations for action to the larger RC, and then the committee collectively votes on components of the accreditation decision. Of note, individual RC members who have even a semblance of a conflict of interest are recused from any of these discussions. These conflicts can include current affiliations with the program in question, residing in the same state as the program in question, or even having recently served as a visiting professor at the program.

For programs that appear noncompliant against program requirements, there are 2 categories that corrective actions take as voted on by the committee: (1) Areas for Improvement (AFIs); and (2) Citations. AFIs are not always tied to a specific program requirement and do not have a bearing on the type of accreditation assigned to a program (more on that below). AFIs are used by the RC to alert a program about a potential issue, somewhat akin to saying, “This is not a gravely concerning aspect of the program, but we would recommend an adjustment or an improvement in _____.” AFIs do not require a response from the program but are tracked year to year. Citations are a more formal recommendation for action. These are mapped to specific ACGME Common Program Requirements and/or specialty-specific program requirements. Citations may have a bearing on the type of accreditation status assigned to a program, and if the committee determines that previously issued citations have not been satisfactorily addressed within a specific time (typically 1 year), then further and sometimes more stringent action is recommended by the committee.

Following the reports from the primary and secondary reviewers, the entire committee discusses the program in detail, and an accreditation status is voted upon by the entire committee who have voting rights. Shortly after the meeting, this status is communicated to the reviewed program by email. There are multiple status types that can be applied to each program. New programs applying for accreditation will typically receive the Initial Accreditation status. In this status, a program has demonstrated compliance with applicable requirements, however, it is prohibited from requesting a permanent resident complement increase. This status typically lasts for 2 years. If a new program maintains all the proper standards, it is typically transitioned to what is called Continued Accreditation Without Outcomes. In short, this means that the program is in good standing but has not collected data for enough years to determine final outcomes including graduation rates and board pass rates. This status only lasts as long as the duration of the training program plus 1 year, typically 7 years total for plastic surgery programs (not inclusive of the time spent on Initial Accreditation).

The most common accreditation status provided to a program is Continued Accreditation. A program with this status has demonstrated substantial compliance with common and specialty requirements, and it is permitted to request a permanent complement increase. There is also the opportunity to innovate around individual program requirements, meaning the program can develop unique methods for recruitment, evaluation, and educational components as specified in the detail requirements. An accreditation status of Continued Accreditation with Warning is given to programs that have not demonstrated substantial compliance with requirements. There is no time limit for which this status can be applied to a program, and ongoing noncompliance with requirements can further jeopardize the program’s accreditation status.

The 2 most concerning accreditation status types are Probationary Accreditation and Withdrawal of Accreditation. In order for a program to be placed on Probationary Accreditation, a site visit must be done. It is helpful to understand the basics of site visits as these can be intense events, somewhat akin to an audit. Site visits take place at various times during the accreditation process. Since the end of the COVID-19 Public Health Emergency in May 2023, site visits are mostly now done virtually rather than in person, although randomly selected in-person visits are just now resuming. They are purposely done by ACGME personnel, Accreditation Field Representatives, who are not members of the RCs. Field Representatives all have terminal degrees and extensive experience in GME; they perform this work at various sponsoring institutions and programs throughout the country; and they are trained to perform site visits for all specialties. The site visit focuses on the program requirements, and Field Representatives are provided information from the ACGME Accreditation Data System in preparation for the actual visit. During the site visit they will interview a wide range of people associated with the program, including but not limited to administrators, residents/fellows, and faculty members. Following the site visit, a comprehensive site visit report containing all the data collected, a description of compliance against program requirements, and the information provided to the Field Representative through the interview process is compiled and then provided to the RC members for their review at the next RC meeting. This site visit report is reviewed in detail, and subsequent accreditation action is determined. These subsequent actions can include a removal of the warning status or a transition to Probationary Accreditation. Probationary Accreditation has substantial implications for the program reviewed. That program cannot request any complement expansion or exceptions to any program requirements, and furthermore, a program may hold the status of probation for only 2 consecutive accreditation decisions. After that, they must demonstrate substantial compliance or be withdrawn.

Finally, the most dreaded but thankfully the rarest accreditation type is Withdrawal of Accreditation. Like Probationary Accreditation, a site visit must be done prior to this status being conferred. It should be noted that the RC, and by extension the ACGME, does not have the authority to tell sponsoring institutions to terminate the employment or appointment of plastic surgery trainees upon the withdrawal of its accreditation. However, sponsoring institutions typically will not want to continue employing residents in a program that has no accreditation, and similarly, residents will not want to continue training in a program without accreditation. Therefore, trainees from a program that has had withdrawn accreditation typically are no longer employed by the sponsoring institution, although there are requirements that the sponsoring institution and the program help individual trainees find a new accredited program.

As detailed above, it can appear that if a program has problems, there is a stepwise progression from Initial Accreditation or Continued Accreditation to the point of Withdrawal of Accreditation, and in most cases, it does happen in a stepwise fashion as described. However, the Plastic Surgery RC does have the ability to move directly to Withdrawal of Accreditation (called expedited withdrawal of accreditation) if it finds that there is very clearly a lack of compliance with regulations or if it determines that there is a dangerous or unsafe interpersonal or educational environment. Many people in the plastic surgery community will recall this happening just a few years ago to 2 training programs simultaneously. Without delving into particulars, for both programs, the Plastic Surgery RC determined fundamentally that these were not healthy or safe training environments, and following site visits, moved directly to withdrawal of accreditation. The amount of deliberation and the amount of pain felt by Plastic Surgery RC members during and after this process cannot be understated. These decisions are not taken lightly, and a monumental amount of thought and hours are spent considering these actions.⁴  It is also worth noting that, following this withdrawal of accreditation for these 2 programs, the Plastic Surgery RC worked diligently with the American Board of Plastic Surgery and the American Council of Educators in Plastic Surgery to help these impacted residents find training programs elsewhere. To the credit of these organizations and to the residents themselves, every person affected by this action was able to transfer to another program to continue their residency training.

While much of the actions of the Plastic Surgery RC is not readily visible to residents and faculty members, the RC works diligently to ensure that the welfare and safety of both plastic surgery trainees and plastic surgery training programs are at the forefront of all that it does. Individual Plastic Surgery RC members are your colleagues and friends, and they all have a demonstrated track record of advocacy on behalf of learners and educational programs. Programs that receive critical feedback or actions from the RC can, very understandably, feel persecuted for what may be perceived to be small problems. This is not unique to program accreditation: one’s initial reaction to getting critical feedback from a colleague or a supervisor in the operating room can be defensiveness. And, in other aspects of life when we get candid critical thoughts from friends or loved ones, we often can initially think, “What did I do?” or “Why me?” or “Why now?” However, these situations can be a golden opportunity for improvement if we have a trusting relationship with the person providing critical feedback. Similarly, because the Plastic Surgery RC is composed of colleagues, programs and their personnel can trust that these recommendations have every plastic surgery learner’s best interest at heart, and that forms the foundation for recommended changes.

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.