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 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. 

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. 

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). 

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 

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). 

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 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. 

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: 

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.