Residencies Roll Out New Training System

Abstract

MEDICAL RESIDENCY PROGRAMS are about to undergo substantial changes in the ways the physicians of tomorrow are trained. Beginning in July, the Accreditation Council for Graduate Medical Education (ACGME) will implement the Next Accreditation System to oversee training residents in 7 specialties: emergency medicine, internal medicine, neurological surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urological surgery. In July 2014, the Next Accreditation System will be implemented by all remaining specialties and ultimately cover more than 9000 medical residency programs throughout the country. The aims of the new system are to “enhance the ability of the peerreview system to prepare physicians for practice in the 21st century, to accelerate the ACGME’s movement toward accreditation on the basis of educational outcomes, and to reduce the burden associated with the current structure and process-based approach” (Nasca TJ et al. N Eng J Med. doi:10 .1056/NEJMsr1200117 [published online March 15, 2012]). The ACGME was founded in 1981 when the graduate medical education environment faced 2 major stresses: variability in the quality of resident education and the emerging formalization of subspecialty education. The ACGME emphasized program structure and increased the amount and quality of teaching. But while the group believed it was successful, new stresses emerged, such as an increasingly prescriptive nature of program requirements that reduced opportunities for innovation. Acknowledging the new stresses, the ACGME pushed for the Next Accreditation System. Under this approach, each medical residency program accredited by the ACGME will have to demonstrate that its residents have the core competencies and clinical skills to provide quality patient care and the ability to respond to ongoing developments in health care delivery. Competency will be assessed in 6 core areas: patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication. To measure such competencies, each specialty is developing educational milestones with collaboration among American Board of Medical Specialties certifying boards, review committees, medical-specialty organizations, program-director associations, and residents. Milestones may be measured by levels of competence. For example, for practice-based learning and improvement, a resident with level 1 competency would be able to describe basic concepts in clinical practice, epidemiology, biostatistics, and clinical reasoning. The resident would also be able to categorize the study design of a research study. To achieve level 3 competency, the resident would need to be able to apply a set of critical appraisal criteria to different types of research, including synopses of original research findings, systematic reviews and meta-analyses, and clinical-practice guidelines, and to critically evaluate information from others, such as colleagues, experts, pharmaceutical representatives, and patients. Level 5 competency would find the resident independently teaching and assessing evidence-based medicine and information-mastery techniques and citing evidence supporting several common practices. Changes in resident training mean changes in the teaching of medical students as well. Carol Aschenbrener, MD, chief medical officer at the Association of American Medical Colleges, said her member institutions are working with the ACGME, but they are also adopting their own competency-based medical education systems. “Basically, the difference between competency-based education and the way we have always done it is that competency means that what the public needs, good health outcomes, is what a physician should actually be able to do, and each specialty has to decide how to achieve this,” said Aschenbrener, who has also held dean’s office positions at the University of Iowa College of Medicine in Iowa City and who served as chancellor of the University of Nebraska Medical Center in Omaha. “And we need faculty members who can help students learn how to ask questions or read a research article. It’s not about giving them a lecture but teaching them how to think.”