ACGME Initiatives in Concert With Institute of Medicine Recommendations

The recently released report from the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education1 provides the opportunity for all engaged in the graduate medical education (GME) effort to pause and reflect on our work, its effectiveness, and the strengths and weaknesses of our collective efforts in meeting society's needs. Indeed, with the very real pressures exerted on teaching institutions, and their faculty, residents, and students, we may lose sight of our core purpose. That purpose was clearly articulated by Thomas Percival, when he described the 3 elements of medicine as a profession: the commitment to excellence, the commitment to altruistic service, and the responsibility to prepare the next generation of physicians to serve the needs of the public, not their own or those of the profession.2 These 3 principles separate a profession from a guild.

The net result of our collective efforts should be the preparation of the next generation of physicians to serve the American public. In this fashion, we accomplish a social good, and maintain the implicit social contract. A key element theme of the IOM report, that should not be lost, is the assumption that we provide a social good, while at the same time, a growing proportion of opinion leaders voice a need for the GME enterprise to be accountable for the public funds it receives. It must be our responsibility to continually earn both the right to self-govern the preparation of the next generation of physicians, and to receive public support for that effort by meeting society's needs.

In its chapter on governance, the IOM report identifies the strengths and weaknesses of the current GME governance model.^{1(pp107–129)} Its strengths lie in professional peer oversight of the content and outcomes of graduate physician education, along with the efforts of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) certifying boards in allopathic medicine, and the American Osteopathic Association in osteopathic medicine. Directions taken by ACGME in response to the public calls for increasing emphasis on key elements of systems-based practice, practice-based learning and improvement, and interprofessional education as identified in each specialty through educational Milestone development, with the objective to increase public confidence that these “new physician competencies” are being addressed. Ongoing ACGME efforts seek to also enhance physician understanding of the importance of meeting the “Triple Aim”: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Specific focal areas include added emphasis on communication and interpersonal skills, achieving value through good stewardship of health care resources, and a focus on quality and safety, reduction of health disparities. All are intended to give the public confidence that the GME community is striving to address society's needs.

The structures put in place through the ACGME's Next Accreditation System (NAS), the Milestones Project,3 the Clinical Learning Environment Review (CLER) Program,4 along with the move to a Single Accreditation System for all of American GME,5 are tangible demonstrations of the ACGME and GME community's commitment to excellence, altruism, and the preparation of the next generation of physicians to serve the public. The NAS is designed to promote innovation. Programs in good standing are permitted to deviate from detailed process standards to facilitate innovation. They will be stimulated (through the 10-Year Site Visit) to adapt and create new local solutions to clinical care needs, while assuring the public of the quality of the educational outcomes achieved. Milestones assure residents, faculty, and the public that educational outcomes are maintained and/or enhanced, and the focus on outcomes allows for structural flexibility to adapt and innovate. While these efforts are directed at the program, the concurrent review of the institutional learning environment through CLER efforts will motivate, through self-reflection and peer comparisons, salutary evolution of the clinical and patient care environment in teaching institutions. The reach of these efforts will be enhanced through meaningful collaboration with the Liaison Committee on Medical Education, the Accreditation Council for Continuing Medical Education, the ABMS, and other partners to enhance the learning environment for students, residents, faculty, and other health professionals.

The ACGME's strategic planning process has identified the importance of research geared to demonstrate not only the validity of the Milestones as a formative developmental tool, but also to identify and validate the key elements of the Milestones and attributes of the learning environment and program that are predictive of positive clinical performance after graduation from residency training. This research, and evidence-based revision of standards based on this research, will continually bolster the trust of the public in the efforts of the GME community.

Currently beyond the reach of impact by ACGME is the important effort to reshape the physician workforce. Due to the real limitations of antitrust statutes, the ACGME would require legislative relief to participate in interventions that would lead to specialty or geographic redistribution of residency positions. However, ACGME can and does facilitate the accreditation of new programs, such as the Federally Qualified Community Health Center Teaching Health Center program funded by the Health Resources and Services Administration.6 The ACGME will continue to provide on its website and its annual Data Resource Book extensive demographic information that can be used by researchers and those engaged in setting public policy to understand the nature and magnitude of the GME effort.

ACGME can and will appeal to those responsible for institutional GME program and position distribution decisions to ask that local, regional, and national workforce needs be taken into account as they make individual institutional decisions regarding program size and specialty mix.

The IOM committee has made significant recommendations regarding the funding, mechanisms, and distribution of funding for GME. The recommendations regarding elements for program accountability for use of funds and oversight and planning for the national GME effort deserve extensive review and discussion within and outside the profession. While the specific recommendations present many challenges, the sentiment that change and accountability is required must be understood and accepted. We must preserve the public trust, we must solidify GME funding in order to accomplish this vital dimension of the social contract between the profession and the public, and we must devise systems that actively link our efforts in GME to the needs of the American public. It will take all of us to accomplish this task. Our residents and the American public deserve no less than our best efforts.