Are you aware of some of the common ACGME residency program requirements?
Is your program in compliance?
Examples of some Common Program Requirements:
V.A.1.a).(1).(a) “Additional members of the Clinical Competency Committee must be physician faculty members… who have extensive contact and experience with the program’s residents….”
Do you know who the members of the Clinical Competency Committee (CCC) are? More importantly, do they know you? They are the people that judge your progress, standing and promotion. In some cases, faculty may be judging a resident that they have never even met. Do those members of the CCC truly have extensive contact and extensive experience with you?
V.A.1.b).(1).(a) The CCC should “review all resident evaluations semi-annually…”
Does the CCC truly read and review all of the evaluations of all of the residents before or at the time of their semi-annual meeting? Are these the basis of their discussion and decision-making? If the evaluations are not discussed, what is substituted for those formal observations of your performance? Perceptions, gossip, hearsay?
V.A.1.b).(1).(b) The CCC should… “prepare and ensure the reporting of Milestones evaluations of each resident semi-annually to ACGME…. ”
How are your Milestone evaluations written, and who actually decides how you are rated? Have you ever found a less-than-favorable rating, or even a “critical deficiency” with which you disagree? Which is without substantiation? Who marked that rating? Did the CCC body vote on that rating after deliberating objectively on your progress? Or was that rating merely selected by your program director?
V.A.1.b).(1).(c) The CCC should… “advise the program director regarding resident progress, including promotion, remediation, and dismissal.”
Does your program’s CCC review your progress then make a recommendation to the program director, or is it vice versa? Does your program director, instead, present a case of his or her judgment of you at the CCC and proceed as (s)he prefers unless formally overruled?
V.A.2.a) “Formative Evalution. The faculty must evaluate resident performance in a timely manner during each rotation or similar educational assignment, and document this evaluation at completion of the assignment.”
Are you being evaluated promptly by each of your faculty upon completion of each rotation? Do some faculty submit evals months late – long after their likely ability to recall the specifics of your performance? Do some faculty never submit evals? If substantive evaluations are not submitted and shared with you, upon what information are you being judged in the CCC meeting? And how can you improve or deal with any perceived deficiencies if these are not effectively communicated with you?
V.A.2.b).(1) The program must “provide objective assessments of competence in patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practices based on the specialty-specific Milestones;….”
How objective are the assessments of your performance? Are they mere personal opinion which is heavily influenced by the personality or behavior of the attending doing the evaluation? Or are they thoughtful assessments which utilize examples, observations and outcomes to provide a more realistic objective presentation of your abilities and standing?
V.A.2.b).(2) The program must “use multiple evaluators (e.g. faculty, peers, patients, self, and other professional staff)….
Does your resident file (or other sources reviewed by the CCC in your evaluation process) contain multi-disciplinary inputs as called for? And speaking of your resident file, did you even know you had one? You can and should ask to review it.
V.C.1.a).(3).(c) Program Evaluation and Improvement. The Program Evaluation Committee “should participate actively in:… addressing areas of non-compliance with ACGME standards,…”
Has your program informed you that it has a Program Evaluation Committee (PEC)? The PEC exists to audit the program and assure its compliances. It should receive resident concerns and complaints in a confidential manner. What if the PEC primarily consists of the same members as the CCC and program leadership who may themselves be perpetrators of ACGME violations (or entirely ignorant of ACGME requirements)? “We have investigated ourselves and found we have done nothing wrong.” In that case, how could complaints lodged with the dual PEC/CCC members remain confidential? To whom do those complaints go? What are the disincentives for filing an internal complaint against your program when you are unsure that your identity will be protected from those that sit in judgment of you and determine your future?
VI.A.2. and 5. Resident Duty Hours in the Learning and Working Environment. Professionalism, Personal Responsibility, and Patient Safety. “The program must be committed to and responsible for promoting patient safety and resident well-being in a supportive educational environment…. The program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility.”
Are there attendings (or residents, fellows, or staff) in your program who behave in unprofessional ways? Is there yelling, intimidation, belittling? Have you been purposefully embarrassed in front of others: staff, teammates, on rounds, or in conferences? What is the culture of your program? Is it conducive to learning and patient care? Is open communication encouraged? Or is the environment hostile and toxic such that you seek as little communication as possible with certain people? What do you do if the program director, who is responsible for ensuring a culture of professionalism, is one of that culture’s greatest impediments? Unfortunately, there are programs in which the bad actors seem to assume the power positions of leadership. (And should we even get into the topic of duty hours? How many residents are encouraged to misrepresent their hours in order to keep the program “out of trouble?”)
Your program may have some of these problems, all of them, or additional ones. If so, here are some ideas of what you can do. Put your program under the magnifying glass, apply the ACGME’s Common Program Requirements, and see how it holds up.
What/Who is the ACGME?
While the ACGME is surely a well-intentioned agency and group of professionals, with lofty stated goals, principles and program requirements, it is obvious to us that there are programs that escape enforcement and application of those mandates and ideals. Like the medical specialty boards and The Joint Commission, the ACGME is also NOT a government agency, nor is it directly accountable to the public or our elective representatives – although it is funded primarily by taxpayer Medicare dollars paid to residency programs for physician training (about $5,000 per accreditation per year).
The ACGME is a private, non-profit, corporate entity that was formed in 1981 as a coalescence of multiple interests (e.g. the AMA, the American Hospital Association, the American Board of Medical Specialties, et al.) to assume oversight of resident training. While it is categorized as a “non-profit,” as are most hospitals today, that does not mean that there are not large cash flows or extreme salaries involved. Being non-profit merely means that profits are not divvied up to shareholders that own stock, but instead are retained inside the corporation.
The CEO of the ACGME, Mr. Nasca, made $1.2 MILLION in 2015. There are about 18 VPs and other officials under him with average salaries above $400,000 per year. (While full-time physicians gross on average about $294,000 per year, it looks to be a much better gig to be an administrator of a monopolistic non-profit, overseeing captive physicians-in-training… to whom you owe the duty of ensuring the compliances of the programs upon which they depend.) The organization’s assets exceed $62 million. See their IRS Form 990.
Per the ACGME’s annual report, the purported mission, vision, values and philosophy of the organization include claims and ideals such as “…advancing the quality of resident physicians’ education,” a “high-quality, supervised, humanistic clinical educational experience, with customized formative feedback…,” fostering “innovation and improvement in the learning environment…,” “Honesty and Integrity, Excellence and Innovation, Accountability and Transparency, Fairness and Equity, Stewardship and Service, Engagement of Stakeholders.” How well does the ACGME assure that programs meet their requirements for accreditation, as well as comply with the ideals the ACGME promises us it will promote among those that bear its seal of approval?
There are 124,409 active residents and fellows in 9,977 programs which the ACGME oversees, per page 33-34 of their annual report. One might wonder if the monopoly organization is capable of the task for which it is single-handedly responsible, and for which it is handsomely compensated. Being paid approximately $50M per year by the residency programs themselves (primarily via GME funding through Medicare tax dollars), with whom does the ACGME’s allegiances lie? When complaints are received and program violations demonstrated, are the residents given equal consideration to, and standing with, the residency programs?
One might also question:
With 9,977 programs under its watch, how does the ACGME guarantee that all of the many program administrators and faculty get trained in ACGME requirements, prove proficiency, and apply them appropriately? Who watches the watchmen?
How many residents have never seen the basic requirements by which they and their programs are to function and be evaluated?
How many members of the CCC programs around the country (and world) have never formally read or been trained in the requirements with which they must be compliant?
What is the ACGME’s training platform for the tens of thousands of individuals involved in administration and resident education in these 9,977 programs? What is the documentation of their ongoing learning and the guarantee of their proficiency?
What if the ACGME is not capable of the oversight and guarantees that its expensive stamp of approval costs? What if this monopoly accreditation agency’s stamp gives false assurances of program quality and stability, and in some cases, perhaps even provides cover to programs which do harm – shielding them from scrutiny, from liability, and from the need to improve? What if high level administrators scoff in the face of resident complaints by saying, “we’ve had our site visit. Obviously, there’s no problem here!” What if the ACGME is the physician education industry’s equivalent to Moody’s credit rating agency which in 2007 stamped AAA rating status on the many Too Big To Fail Banks (which similarly paid for the rating agency’s stamp themselves) right up to the moment that they were all shown to be failing and bankrupt? Moody’s had the oversight of the US Securities and Exchange Commission (SEC), yet misled the world in the false creditworthiness of the the most prominent institutions in the world’s financial system. What public or Congressional oversight does the ACGME have? (That answer is “none.”) Is it possible that the ACGME is no better than Moody’s at providing accurate ratings? Is there similarly a moral hazard in the educational rating agency, as in the financial rating agency, in which both receive massive cash flows to provide a façade of institutional compliance and health, while others are left to pay the price and bear the consequences of having trusted the false rating?
Our Programs. Our Future. Our Responsibility.
GMECP: Driving education, awareness, and positive change towards systemic improvement for our programs’ residents, faculty, and staff.
*See Dr. Todd Rice’s article from November 5, 2017, The ACGME: an impediment to progress?
ACGME_Common_Requirements .pdf. Revised July 1, 2017.
Whitcomb, Michael. Graduate Medical Education in the United States. Oct 2010. www.macyfoundation.org .pdf link at: JMF.Whitcomb.GME
Medicare Payments for Graduate Medical Education: What Every Medical Student, Resident, and Advisor Needs to Know. January 2013. Assoc Am Med Colleges. .pdf link at: Medicare Payments for Graduate Medical Education 2013
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