Teaching hospitals in the United States are subject to regulatory oversight by multiple regulators and accreditors. Each of these oversight bodies operates with the aim of assuring the public of the quality and safety of care through various sets of requirements and related, high-stakes evaluations. In the past decade, the Accreditation Council for Graduate Medical Education (ACGME), as an accreditor for graduate medical education (GME), has committed to continuous improvement of residency and fellowship education. These improvements have been facilitated through increased engagement with the GME community, and by forecasting the evolution of health care for the coming decade. Through a shared understanding of these areas, the ACGME will guide institutions that sponsor GME programs toward accreditation standards that are meaningful in today's environment, and will endure into the future.1

The SI2025 report in this supplement to the Journal of Graduate Medical Education represents the latest effort by the ACGME to attain this goal. Through a discussion of more than 50 observations on the future of health care and GME drawn from conversations with stakeholders across the United States, the report identifies democratization, commoditization, and corporatization as 3 major drivers of changes in the United States health care system. To address these findings, the SI2025 report outlines ways in which ACGME—through the institutional accreditation process and other mechanisms—can stimulate integration of GME and the clinical environments in which residents and fellows are educated.

Here in Rochester, New York, many of the changes described in the SI2025 report already are underway. Strong Memorial Hospital is the flagship of a 6-hospital network that includes nursing homes and home care services, and more than 2000 faculty members and affiliated community physicians. Today, nearly 500 000 patient lives are being cared for by this network. Strong Memorial Hospital also is a university-owned teaching hospital with a deep commitment to GME, which provides an environment in which to accomplish the “Triple Aim”2 by leveraging health care professions and settings. This effort to collectively improve quality, cost, and access is reinforced through financial risk-sharing arrangements with public and private insurers. While this presently constitutes a small percentage of Strong Memorial's payer contracts, we expect that risk-sharing arrangements will grow, as health care evolves. Thriving in this new environment requires active engagement and new approaches for all members of the health care team, particularly teachers and trainees.

The current design of resident and fellow education presents challenges that must be overcome if the community is to align GME with evolving aspects of health care delivery in our teaching hospitals and health systems. There are numerous challenges. The GME experience of many residents involves rotating through a number of clinical environments without being appropriately anchored in high-functioning health care teams. In addition, residents are not often included in quality improvement efforts that address the biggest challenges facing health systems and hospitals. Most residents and fellows are not yet taught to understand the risk-sharing arrangements that can affect teaching institutions' ability to provide care to the populations we serve, including accountable care organizations, bundled reimbursement, and similar patient care and financing arrangements. Concomitant with the assumption of financial risk is an imperative to enhance the design of patient care to enhance effectiveness and efficiency. Redesigning health care models will require Sponsoring Institutions to engage residents and fellows in rethinking how we deliver care across a complex continuum of services, with inpatient care as 1 element in that continuum.

Achieving greater integration of GME and health care delivery will require increased faculty engagement. Residents and fellows often adopt the behaviors they observe in their faculty. In today's health care environments, faculty physicians across the United States are asked to change their practice habits. In addition to changes associated with use of electronic health records and quality performance metrics, faculty faces the imperative of increased transparency in outcomes metrics. One of the hallmarks of teaching hospitals in the United States is the high proportion of subspecialty-based medical practice, whereas emerging models for effective and efficient patient care emphasize the physician as a member of a multidisciplinary team. This requires teaching faculty to adapt their teaching style.

These changes may create stressful conditions for teaching faculty. In navigating the course charted in the SI2025 report, Sponsoring Institutions will need to develop new and more effective tactics to engage and support faculty in ways that align health care system design with a commitment to GME in this new paradigm. This realignment will be necessary if faculty are to be essential agents of change in the complex and accelerating evolution of health care. They must model the behaviors we want to see in trainees to transform the health care system.

The SI2025 report discusses many of these changes, and provides a convincing view of consumer and market demands that will define health care over the next decade and, likely, beyond. If commoditization, democratization, and corporatization of health care are driving forces, as identified in the SI2025 report, then we must maximize the value of residents' and fellows' experiences to prepare them for their future practice. Applying the lessons of SI2025, teaching hospitals can work with the ACGME to ensure graduates of residency and fellowship programs are prepared to meaningfully participate in, and lead, the impending transformations in health care. This is a key factor in ensuring this transformation is permanent.

1 Accreditation Council for Graduate Medical Education. ACGME 2014 Strategic Plan Summary. April 2015. https://www.acgme.org/Portals/0/PFAssets/PublicationsPapers/Strategic%20Plan%20Summary.pdf?ver=2015-11-06-120707-670. Accessed November 17, 2017.

2 Institute for Healthcare Improvement. IHI Triple Aim Initiative. http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx. Accessed November 17, 2017.