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JAOA/AACOM Medical Education  |   April 2019
Single Accreditation System for Graduate Medical Education: Transition Update
Author Notes
  • From the Department of Education at the American Osteopathic Association (AOA). Dr Buser is a past president of the AOA and is a clinical professor at the University of New England College of Osteopathic Medicine in Biddeford, Maine. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to the AOA Department of Education, 142 E Ontario, Chicago, IL 60611-2864. Email: singleGME@osteopathic.org
     
Article Information
Medical Education / Graduate Medical Education
JAOA/AACOM Medical Education   |   April 2019
Single Accreditation System for Graduate Medical Education: Transition Update
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 257-262. doi:https://doi.org/10.7556/jaoa.2019.043
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 257-262. doi:https://doi.org/10.7556/jaoa.2019.043
Web of Science® Times Cited: 6
Abstract

In 2014, the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and the Accreditation Council for Graduate Medical Education agreed to establish a new, single accreditation system for graduate medical education in the United States. This article focuses on recent policy enhancements and modifications to facilitate the transition to the single accreditation system and concludes with a discussion of the current transition planning after the end of the transition period on June 30, 2020.

Slated to be completed on June 30, 2020, the 5-year transition to a single accreditation system (SAS) for graduate medical education (GME) recently passed its 3.5-year mark. The Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) established the SAS under the ACGME for several reasons, including to implement a consistent approach to the evaluation of programs and trainees, provide greater opportunities for all physicians in training, align with policy makers’ expectations, create a unified voice in GME funding and advocacy, and preserve the unique dimensions of osteopathic medicine through osteopathic recognition and osteopathic neuromusculoskeletal medicine (NMM) program accreditation.1 While previous reports highlighted structural and governance changes made to establish the SAS,1,2 this report focuses on recent policy enhancements and modifications to facilitate the SAS transition and concludes with a discussion of the current post–June 30, 2020, transition planning. 
Policy Advances
There have been several key policy actions this past year to advance the SAS. In June 2018, the ACGME Board of Directors approved a comprehensive revision of the Common Program Requirements,3 which apply to all ACGME training programs. The new common program requirements, which go into effect on July 1, 2019, explicitly acknowledge AOA specialty board certification as an acceptable credential for program directors. The new requirements also formally accept AOA training as an acceptable pathway to advanced ACGME training and eliminate the exceptional pathway to advanced ACGME training. Reference to the United States Medical Licensing Examination (USMLE) in the specialty program requirements has been removed. Other notable changes include: 
  • ■ the requirement that program directors provide applicants with information on relevant specialty board certifications for that specialty field
  • ■ the establishment of a definition of scholarly work for residents and faculty
  • ■ the recommendation that program directors encourage all eligible graduates to take the certifying examination offered by the American Board of Medical Specialties or AOA certifying boards.
The osteopathic community participated actively in the review of the common program requirements. 
In March 2018, the AOA Board of Trustees approved additional limits on training programs to minimize the number of trainees who may be in AOA training programs that are unable to achieve ACGME accreditation. As the approval body for AOA training programs, the AOA Program and Trainee Review Council (PTRC) held a special meeting in July 2018 to review requests from programs still in the process of achieving ACGME accreditation for permission to accept trainees who might train beyond June 2020. The PTRC reviewed each program's ACGME Letter of Notification and a letter from the program describing the actions taken by the program to correct their ACGME citations and be in substantial compliance with the ACGME requirements. In addition, AOA policies required programs 1 and 2 years in length that wished to continue to accept trainees in 2019 to apply for ACGME accreditation by January 1, 2019. Because trainees in 1-year programs would likely complete training by June 30, 2020, the PTRC approved waivers for internships, 1-year fellowships, and NMM+1 programs to accept trainees in 2019 without applying for ACGME accreditation by January 1, 2019. 
Just as the AOA House of Delegates is the official policy-making body of the AOA, the American Medical Association (AMA) House of Delegates is the principal policy-making body of the AMA. In November 2018, the AMA approved a policy to promote equal acceptance of scores on the USMLE and Comprehensive Medical Licensing Examination-USA (COMLEX-USA) at all US residency programs. Furthermore, the AMA directed its staff to work with appropriate stakeholders to educate residency program directors on interpreting and using COMLEX-USA scores, as well as work with program directors to promote increased COMLEX-USA use with residency program matches in light of the new SAS.4 
This important recognition indicates that osteopathic medical graduates should not be compelled to take the USMLE series as a condition to apply for a residency program. 
Program Status
The transition to the SAS formally began on July 1, 2015, with a total of 1244 AOA residency, internship, and fellowship training programs approved at that time. Throughout 2018, AOA program directors and their teams continued to push forward toward ACGME accreditation. During 2018, the number of AOA programs that had either achieved ACGME accreditation or submitted applications increased from 845 to 918; 278 AOA training programs received initial ACGME accreditation; and 53 programs closed. 
A program may be in one of the following phases of the application process: pre-accreditation, continuing accreditation, or accreditation. 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, AACOM, and the ACGME. Continuing pre-accreditation means that the program's application was reviewed and not found to be in substantial compliance with the accreditation standards; the program is eligible to revise and resubmit its application without being subject to additional application fees. Accreditation status is given to those programs that have attained ACGME accreditation. The application status of the 1244 AOA training programs is illustrated in Figure 1. As of March 1, 2019, 66% of AOA programs had ACGME accreditation, 6% had continuing pre-accreditation, 3% had pre-accreditation status, and 4% were working on their application. Nearly 75% of all AOA programs have submitted an application for accreditation. 
Figure 1.
Application status (No.) of American Osteopathic Association training programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=1244).
Figure 1.
Application status (No.) of American Osteopathic Association training programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=1244).
Not all specialties have advanced through ACGME accreditation at the same pace. The specialties in which more than 80% of the AOA programs have achieved ACGME accreditation include family medicine, internal medicine, osteopathic NMM, pediatrics, anesthesiology, emergency medicine, neurology, physical medicine and rehabilitation, urological surgery, dermatology, and psychiatry. Specialties with fewer than half of their AOA programs having achieved ACGME accreditation are neurological surgery and ophthalmology. 
When looking at training positions, as of March 1, 2019, 81% of the AOA's 2015 filled training positions are now under ACGME accreditation. 
When it debated SAS, the AOA House of Delegates raised concerns about the ability of rural training programs to achieve ACGME accreditation. As a result, the AOA has been monitoring the progress of its teaching health centers (THCs) and rural training programs. Teaching health centers are designed to train residents in primary care specialties at federally qualified health centers with the goal of having the residents choose to eventually practice in medically underserved areas. The funding for THC training programs comes from Health Resources and Services Administration grants. 
The 40 AOA residency programs housed in THCs are doing well in the transition, with 85% of the programs having achieved ACGME accreditation (Figure 2). One program is in continued pre-accreditation and 1 is working on its application. Five THC programs are closing or have closed (13% of the THC programs). 
Figure 2.
Application status (No.) of American Osteopathic Association teaching health centers in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=40).
Figure 2.
Application status (No.) of American Osteopathic Association teaching health centers in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=40).
Training programs in rural areas (rural-urban community area codes 4 or higher, ie, communities with fewer than 50,000 people) are also doing well. Of the 132 AOA training programs in rural locations, more than two-thirds have achieved ACGME accreditation (Figure 3). About 8% are in continuing pre-accreditation or pre-accreditation, 13% have closed, and 8% are planning to close. These data are encouraging in light of the financial challenges confronting rural hospitals. For example, a December 2018 Becker's Hospital CFO Report reported that 93 rural hospitals had closed since 2010.5 
Figure 3.
Application status (No.) of rural American Osteopathic Association programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=132).
Figure 3.
Application status (No.) of rural American Osteopathic Association programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=132).
As mentioned earlier, osteopathic recognition is an integral element of the SAS. The number of programs that achieved osteopathic recognition grew this past year, increasing from 130 on March 1, 2018, to 195 on March 1, 2019. While most osteopathic recognition programs were affiliated with osteopathic medicine through AOA accreditation, 15% of the programs had no previous relationship with the AOA (Figure 4). 
Figure 4.
Distribution of programs with osteopathic recognition as of March 1, 2019. Dual programs are programs that were previously accredited by both the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA).
Figure 4.
Distribution of programs with osteopathic recognition as of March 1, 2019. Dual programs are programs that were previously accredited by both the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA).
The distribution of osteopathic recognition programs by specialty reveals that most are in family medicine (65%), with internal medicine second (14%). Other specialties with at least 1 osteopathic recognition program are allergy and immunology, anesthesiology, cardiovascular disease, dermatology, emergency medicine, hospice and palliative care medicine, obstetrics and gynecology, osteopathic NMM, pediatric sports medicine, pediatrics, physical medicine and rehabilitation, psychiatry, radiology, sports medicine, surgery, and transitional medicine. 
Programs with osteopathic recognition are given a choice regarding the number of residents in designated osteopathic positions (formerly known as osteopathic-focused tracks). The only requirement is that programs must have at least 1 designated osteopathic resident per year, averaged over 3 years. In the 2018-2019 academic year, the ACGME reports that there are 1881 active residents in designated osteopathic positions, 65 of whom are not DOs (written communication, Rebecca Miller, November 30, 2018). Approximately half of the 65 residents were graduates of US medical schools accredited by the Liaison Committee on Medical Education, and the other half were international medical graduates. 
While some mistakenly believe that there is no growth in GME, the overall growth in residency training positions is substantial. Even removing the contributions of osteopathic medicine to the ACGME pool, the number of ACGME programs is increasing. The number of ACGME-accredited programs has increased by 2480 programs, from 8734 in the 2008-2009 academic year to 11,214 in the 2017-2018 academic year. Similarly, the number of filled positions increased by 25,844, from 109,482 in the 2008-2009 academic year to 135,326 in the 2017-2018 academic year.6 
Osteopathic Graduate Placement
Osteopathic graduates have done well in seeking postdoctoral training positions. In 2018, 98.75% of US DO graduates seeking GME placement were successful, compared with 99.34% in 2017.7 These match rates occurred despite the decline in the AOA Match and the growth in the graduating classes. This finding suggests that osteopathic graduates are well prepared to compete in the National Resident Matching Program and other matches. 
Next Steps
Protecting residents is a major goal of the AOA, AACOM, and the ACGME. While the AOA will relinquish its authority to accredit residency training programs on July 1, 2020, it will, nonetheless, retain restricted accreditation authority over AOA training programs with active residents but no ACGME accreditation. The PTRC and the AOA Council on Postdoctoral Training are actively discussing structures to oversee the quality of the training in those programs. 
Programs accredited by the AOA will have 2 pathways to train residents after June 30, 2020; one is to teach out the trainees and close the program and the other is to transfer the residents to an ACGME training program. Pertinent to this issue is AOA Postdoctoral Training Standard X, 10.6(d),8 which requires the following:

AOA programs that do not have ACGME initial or continued accreditation as of July 1, 2019 must work with their OPTI [Osteopathic Postdoctoral Training Institution] and sponsoring institution to develop and submit a plan by September 1, 2019 for the potential transfer of all trainees to an ACGME accredited program or to teach out the remaining trainees under the AOA's restricted accreditation authority. The plan will be reviewed by the Specialty College Evaluating Committee (SPEC) and PTRC for approval at its November 2019 PTRC meeting. This does not negate continued application for ACGME initial accreditation.

 
These training programs will not be allowed to accept new trainees after the transition period ends. 
The AOA training programs that do not achieve ACGME accreditation by June 30, 2020, have access to an appeals mechanism to contest accreditation decisions by an ACGME review committee. Applications with a pre-accreditation status will be reviewed within 6 months of June 30, 2020. The review committee will either grant initial accreditation or accreditation withheld. If accreditation is withheld, the program has 30 days to appeal an adverse decision. The status of programs with “continued pre-accreditation” will automatically be changed to accreditation withheld on July 1, 2020. Those programs will have 30 days to request an appeal of that status. The conditions and requirements for appeal and the appeal process are codified in Sections 18 and 19 of the ACGME's Policies and Procedures.9 
The AOA will continue to monitor the progress of AOA training programs and offer application assistance to AOA programs until the transition concludes. 
References
Buser BR, Swartwout J, Gross C, Biszewski M. The single graduate medical education accreditation system. J Am Osteopath Assoc. 2015;115(4):251-255. doi: 10.7556/jaoa.2015.049 [CrossRef] [PubMed]
Buser BR, Swartwout J, Lischka T, Biszewski M, DeVine K. Single accreditation system update: gaining momentum. J Am Osteopath Assoc. 2017;117(4):211-215. doi: 10.7556/jaoa.2017.038 [CrossRef] [PubMed]
ACGME Common Program Requirements (Residency). Chicago, IL: Accreditation Council for Graduate Medical Education; 2018. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. Accessed March 12, 2019.
Murphy B. DO and MD licensing exams should be viewed equally, says AMA. American Medical Association website. https://www.ama-assn.org/residents-students/match/do-and-md-licensing-exams-should-be-viewed-equally-says-ama. Posted November 14, 2018. Accessed February 19, 2019.
Ellison A. State-by-state breakdown of 93 rural hospital closures. Beckers Hospital Review. December 18, 2018. https://www.beckershospitalreview.com/finance/state-by-state-breakdown-of-93-rural-hospital-closures.html. Accessed February 19, 2019.
Data Resource Book: Academic Year 2017-2018. Chicago, IL: Accreditation Council for Graduate Medical Education; 2018. https://www.acgme.org/Portals/0/PFAssets/PublicationsBooks/2017-2018_ACGME_DATABOOK_DOCUMENT.pdf. Accessed February 19, 2019.
Report on Osteopathic Medicine Placements in 2018 Matches. American Association of Colleges of Osteopathic Medicine website. https://www.aacom.org/docs/default-source/data-and-trends/osteopathicmed-grad-placements-in-2018.pdf?sfvrsn=d82d2597_10. Accessed February 19, 2019.
Section X. AOA program accreditation during transition to single accreditation system. Chicago, IL: American Osteopathic Association website. https://osteopathic.org/wp-content/uploads/2018/02/Basic-Doc-Section-X.pdf. Accessed February 19, 2019.
Policies and Procedures. Chicago, IL: Accreditation Council for Graduate Medical Education; 2018. https://www.acgme.org/Portals/0/PDFs/ab_ACGMEPoliciesProcedures.pdf?ver=2018-10-09-170414-333. Accessed February 19, 2019.
Figure 1.
Application status (No.) of American Osteopathic Association training programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=1244).
Figure 1.
Application status (No.) of American Osteopathic Association training programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=1244).
Figure 2.
Application status (No.) of American Osteopathic Association teaching health centers in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=40).
Figure 2.
Application status (No.) of American Osteopathic Association teaching health centers in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=40).
Figure 3.
Application status (No.) of rural American Osteopathic Association programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=132).
Figure 3.
Application status (No.) of rural American Osteopathic Association programs in the transition to the single accreditation system through the Accreditation Council for Graduate Medical Education (ACGME) as of March 1, 2019 (N=132).
Figure 4.
Distribution of programs with osteopathic recognition as of March 1, 2019. Dual programs are programs that were previously accredited by both the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA).
Figure 4.
Distribution of programs with osteopathic recognition as of March 1, 2019. Dual programs are programs that were previously accredited by both the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA).