Abstract
In July 2014, the American Osteopathic Association House of Delegates endorsed the establishment of a new, single graduate medical education accreditation system in collaboration with the Accreditation Council for Graduate Medical Education and the American Association of Colleges of Osteopathic Medicine. Since that time, the osteopathic medical community has made substantial headway in the transition to the new system. This article provides an update on the transition.
In 2014, the American Osteopathic Association (AOA), the Accreditation Council for Graduate Medical Education (ACGME), and the American Association of Colleges of Osteopathic Medicine (AACOM) signed a historic agreement to establish a new, single accreditation system for graduate medical education (GME).
1 Such a system offers several benefits to the osteopathic medical profession, including the preservation of osteopathic access to ACGME training, enhanced visibility of osteopathic medicine, and evidence of a consistent quality of GME training.
2 It creates a consistent method of evaluation for programs and residents and provides an opportunity for greater unity in advocating for funding support of GME and better alignment with policymakers’ expectations.
The agreement set the transition period to begin July 1, 2015, and be completed by June 30, 2020. During the transition period, AOA-accredited programs that wish to continue their training programs must apply to the ACGME for accreditation under the single accreditation system. This article provides an overview of the accommodations made by the ACGME and the AOA to facilitate this transition, as well as an update on the accreditation status of AOA programs.
The osteopathic postdoctoral community has made substantial headway in the transition to a single accreditation system. The ACGME system was adjusted to enable it to accredit osteopathic programs and sponsoring institutions. After a rigorous review process, 50 osteopathic physicians (ie, DOs) were selected to be new members of the ACGME review and recognition committees; 4 DOs were added to the ACGME Board of Directors; a senior vice president of osteopathic accreditation was hired for the transition to the single accreditation system; and 2 new osteopathic committees were formed: the Osteopathic Principles Committee and the Osteopathic Neuromusculoskeletal Medicine Review Committee.
In addition to its organizational changes, the ACGME has made substantial changes in its policies and procedures to create the single accreditation system. An important and very beneficial change has been instituted by the ACGME Review Committees over the past year. At the direction of the ACGME Board of Directors, review committees are proposing changes to their standards to recognize AOA board certification in addition to American Board of Medical Specialties (ABMS) board certification for graduating residents as one of the outcome measures for programs.
3
Another change has been an accommodation on the preliminary year requirements. Several specialties require a preliminary postgraduate year before entering into a residency program. Under the ACGME standards, programs must accept only applicants who have completed the first year in an ACGME program.
4 To facilitate the transition, the 9 ACGME review committees that require a preliminary year of training have stated that ACGME programs accepting applicants enrolled in AOA-approved prerequisite programs will not jeopardize their accreditation status. This affirmation averted a potential problem in which DO graduates of AOA internship programs might not be able to enter second-year residency positions.
The ACGME made accommodations to address the Common Program Requirements statement that qualifications of the program director must include “current certification in the specialty by the American Board of [relevant ABMS board],
or specialty qualifications that are acceptable to the Review Committee [italics added].”
4 All review committees for which there are AOA training programs have stated that AOA board certification is an acceptable qualification for program director.
In addition, as a result of an analysis by the AOA showing that internship programs with 1 sponsoring residency program produce competent graduates, the ACGME Review Committee for Transitional Year changed their requirements to require only 1 residency sponsor to support an internship program.
5 This decision is particularly important because many AOA programs are smaller and in more rural locations than their ACGME transitional year counterparts. Preservation of rural training programs facilitates the provision of health care services to rural communities.
The AOA has modified its policies as well. In July 2015, the AOA Board of Trustees approved a policy to regulate the actions of AOA training programs during the transition. Known as Section X of
The Basic Documents of Postdoctoral Training,
3 this policy was later modified to establish firm deadlines for filing ACGME applications in order to accept trainees. The revised policy requires training programs 4 years or longer to submit an ACGME accreditation application by January 1, 2017. Programs 3 years in length must submit an ACGME application by January 1, 2018.
The AOA also established a new policy to address the states that require an AOA internship year for licensure. Specifically, a DO who successfully completes an osteopathic-focused track in an ACGME-accredited year-1 program that has received osteopathic recognition will be deemed by the AOA to have completed an AOA-approved year-1 program for the purposes of satisfying state licensure requirements (Resolution B-9 [A/2015]—AOA Approval of OGME-1 Training).
During the transition to the single accreditation system, many DOs will start their graduate training in an AOA-accredited program and complete an ACGME-accredited program. Because this change could adversely affect board certification eligibility, the AOA Board of Trustees approved that DOs graduating from such programs would be eligible to sit for an AOA certifying board with no additional application requirements. This rule applies to DOs who begin training in an AOA-accredited program that subsequently transitions to ACGME accreditation. This benefit would also apply to trainees who started training in a dually accredited program that dropped its AOA accreditation (Resolution B-8 [M/2016]—AOA Specialty Certification During Transition to the Single GME Accreditation).
Under the single accreditation system, an allopathic physician will be able to complete a program with osteopathic recognition. Thus, the AOA Board of Trustees directed the AOA Bureau of Osteopathic Specialists to develop the necessary policy modifications to allow allopathic physicians who successfully complete an osteopathic track to be eligible for AOA board certification.
In the single accreditation system, every accredited training program must reside in an accredited sponsoring institution (hospital, consortium, etc). A sponsoring institution must submit an application for accreditation before its residency programs file applications. Likewise, a residency program must submit and achieve initial accreditation before its fellowship program may apply.
There are several accreditation terms used in the single accreditation system. Pre-accreditation means that the AOA-approved program has submitted its application for ACGME accreditation. Pre-accreditation is not an accreditation status but rather indicates that the program and its residents are eligible for benefits agreed upon by the AOA, the ACGME, and AACOM. Only programs that were AOA approved by July 1, 2015, are eligible for pre-accreditation. Continuing pre-accreditation means that the program’s application was reviewed and not found in substantial compliance with the accreditation standards; the program is eligible to revise and resubmit its application without being subject to additional application fees. Applications found in substantial compliance with ACGME standards are granted initial accreditation. Sometimes, a residency program may be reviewed and found in substantial compliance with the accreditation standards before its sponsoring institution is granted accreditation. In those instances, the residency program is given the status of initial accreditation contingent upon sponsoring institution initial accreditation. To receive federal funds under Medicare, the program must maintain its AOA approval until it receives ACGME initial accreditation.
The AOA’s transition to the single accreditation system began with 1244 AOA-accredited training programs on July 1, 2015. Of these, 177 were dually accredited, meaning they had both AOA and ACGME accreditation. We are now approximately 20 months into the transition; as of February 27, 2017, 617 (50%) of all AOA-accredited programs have achieved ACGME accreditation or submitted an application for ACGME accreditation, including:
These data include programs that joined ACGME programs through an approved complement increase and AOA programs that combined resources to submit a single ACGME application.
Since July 1, 2015, 440 AOA programs have submitted applications for accreditation (
Table 1). The largest numbers of applications were from internal medicine (56), family medicine (55), surgery (general) (54), emergency medicine (51), and orthopedic surgery (41).
As specified earlier, the AOA Board of Trustees established a requirement that training programs 4 years or longer in length must submit a single accreditation system application by December 31, 2016, in order to accept residents in 2017.
3 This requirement protects residents from entering training programs that may extend beyond 2020 if the programs have not engaged in the transition process.
At the start of the transition, there were 355 AOA-accredited programs of 4 or more years in length. As of February 2017, 285 (more than 80%) are ACGME accredited or had submitted applications, of which 65 (18%) achieved initial accreditation or initial accreditation contingent through the single accreditation system. Fourteen programs (4%) closed. The 3 most frequent reasons for program closure were (1) the program did not want to pay the accreditation fee, (2) the program never had trainees, and (3) the program planned to close before the single accreditation system was announced. An additional 28 programs (8%) have announced closure in the future. Of these, 14 are combined programs, which are not eligible for ACGME accreditation because combined programs are approved by the relevant specialty certifying boards and not the ACGME. (One exception to this rule is that the ACGME accredits combined internal medicine/pediatrics programs.) The closed and closing programs represent approximately 1% of the training positions in the 2016 AOA Match. The remaining 28 programs (8%) are planning their next step.
A similar requirement to enter into the new accreditation system will affect the 3-year training programs at the end of 2017, and many of those programs are in the primary care specialties. The AOA, the ACGME, and AACOM are working together to develop policies to protect residents if their training program does not successfully transition to the ACGME accreditation system.
The future of distinctive osteopathic graduate medical education lies in ACGME-accredited programs with osteopathic recognition. Once a training program has achieved ACGME accreditation, it may apply for osteopathic recognition, meaning that it has the commitment as well as the capacity and resources to train residents in the osteopathic approach to patient care. The criteria for osteopathic recognition were developed by the Osteopathic Principles Committee and are available on the ACGME website.
7 Allopathic physicians must satisfy prerequisite education in osteopathic principles and practice to enter into osteopathically recognized positions. Before matriculation, allopathic residents must have sufficient background and/or instruction in osteopathic philosophy and techniques in manipulative medicine sufficient to prepare them to engage in the curriculum of the program, including the following
7:
As of February 27, 2017, 69 programs had achieved osteopathic recognition (
Table 2). Of these, 44 were dually accredited programs, 13 were ACGME programs with no previous affiliation to osteopathic postdoctoral training, and 12 were AOA programs that had achieved ACGME accreditation. The Osteopathic Principles Committee has 18 additional applications it is reviewing: 9 AOA programs, 8 dual programs, and 1 ACGME-only program. Thus, as more AOA programs enter into the new system, more are choosing to apply for osteopathic recognition.
In May 2016, the AOA established an Application Assistance Program to provide free peer-to-peer consulting to programs. Some programs have used this service to seek advice on answering a particular question. Others ask this service for an independent review of their application before submitting it to the ACGME. Consulting is available for both accreditation and osteopathic recognition applications. A few have asked for assistance in arranging a mock inspection. Overall, the assistance program has provided 45 consultants and fielded hundreds of questions. Programs are encouraged to e-mail
singleGME@osteopathic.org or call the AOA Application Assistance Program at (312) 202-8272.
Having completed 20 months of the 5-year transition, the osteopathic medical community has made substantial advances in the new single GME accreditation system. Most programs are engaged in working on their applications. The ACGME has been a supportive partner in helping to successfully eliminate barriers to AOA program transition. Osteopathic physicians have integrated seamlessly into the governance and administration of ACGME. Educational programming about the single accreditation system is ongoing through the AOA, the ACGME, AACOM, osteopathic specialty societies, and the Association of Osteopathic Directors and Medical Educators. Overall, the transition is gaining momentum and moving forward as anticipated.