What Every Resident
Should Know About the ACGME, RRC and Your Program
Corey E. Collins, M.D.
Residency Review Committee for Anesthesiology
n the course of our training as anesthesiology residents
and fellows, we are subject to many rules, standards,
objectives, limitations and expectations. Yet how
many of us are fluent with these parameters and where
they came from?
Four years of constant participation in the American
Medical Association, ASA, my state medical societies,
hospital graduate medical education (GME) committees
and most recently the Residency Review Committee (RRC)
for Anesthesiology of the Accreditation Council for
Graduate Medical Education (ACGME) have brought me
to a number of basic truths about our training. It
is with some commitment to the spirit of collegiality,
some frustration at how difficult it is to communicate
among training anesthesiologists and a sense of responsibility
to the roles I have played in representing many unspoken
voices that I write this column.
First, I must clearly disclose that these are my personal
opinions and observations and do not speak to the
policy of any of the above organizations. Further,
I have a fiduciary obligation to all of these organizations
that will limit the scope of my comments.
Starting locally I recommend that every resident should
read our specialty’s ACGME program requirements.
The Common Program Requirements for all residencies
are available at <www.acgme.org/Req/commonReqs.asp>.
Anesthesiology-specific requirements can be found
at <www.acgme.org/RRC/An_Req.asp>.
These are the requirements for accreditation and form
the curricular basis for our training. On the RRC,
we review every program for compliance with these
requirements. As every program director knows, we
create “citations” in our report with
reference to these documents. What we residents may
not know is that ACGME reports are available to us.
A resident can request to review the latest program
review at the time of interviews or during training.
Knowledge of the specific citations of areas of noncompliance
may be of interest to applicants, but the residents
in the program certainly should be aware of areas
of weakness that must be addressed prior to the next
review.
How are programs reviewed? With an interval of one
to five years reflecting the previous reviews’
citations, ACGME sends site surveyors to spend one
or two days in our departments. These are often nonclinician,
doctorate-level education specialists, but sometimes
academic anesthesiologists are asked to survey programs
when that option seems best. Interviews are scheduled
with staff, administration and peer-selected residents/fellows.
This last point is important as those interviewed
should speak for the trainees and not be selected
by the program director or the administration. These
interviews are often our best avenue for advocacy.
All trainee comments get considerable attention and,
in my experience, often trigger thorough investigation
into areas of noncompliance, improper training conditions
or significant areas of concern to the residents.
To effect change on our programs, honest answers to
a site surveyor are the most powerful tool we have
available to us. Should you have the opportunity to
participate in a review, I suggest that you offer
sober and objective responses to all questions as
they will shape your program for the next three to
five years.
Next up the ladder is the institutional review process.
All of our institutions have a designated institutional
official (DIO) who is responsible for coordinating
all GME at the institution. There are separate institutional
requirements that must be followed <www.acgme.org/IRC/IRCpr703.asp>.
Significant citations can lead to a “nonfavorable”
institutional designation that must be reported to
all trainees. The DIO is then responsible for implementation
of a program of changes to remedy the areas of noncompliance.
“A Sponsoring Institution’s failure to
comply substantially with the Institutional Requirements
may jeopardize the accreditation of all of its sponsored
ACGME-accredited programs.” (Institutional Requirements
[I.R.] I.C.2.)
It is likely that the potential loss of all residency
programs and the commensurate federal dollars of GME
support (approximately $80,000/resident per the Council
on Graduate Medical Education’s “Financing
Graduate Medical Education in a Changing Health Care
Environment,” December 2000) has driven the
rapid implementation of duty hours regulations. Residents
and fellows must be involved in every institution’s
GME committee (I.R. IV.A.I). While chief residents
are appointed often to the GME committee, my experience
is that an interested resident can often achieve appointment
simply by asking the DIO or his/her program director.
The next level of regulation is the ACGME’s
RRC for Anesthesiology. Our RRC accredits programs,
recommends the interval between program site surveys,
initiates the process whereby programs with a significant
history of noncompliance with the program requirements
or catastrophic events might lose accreditation, evaluates
requests for new programs, changes the number of residents
and establishes the training requirements for all
accredited residency programs. Current membership
of the committee is listed at <www.acgme.org/RRC/An_Com.asp>.
RRC reviewers are compelled to remain objective and
not consider any “street knowledge” that
we may know about a program. As the only trainee at
a table with 10 distinguished leaders of our profession,
I often give voice to the thousands of residents and
fellows in the United States. Although I am not the
proper avenue to address individual program concerns
or complaints (contact your program director, DIO
or ACGME Complaint Officer Marsha Miller <mmiller@acgme.org>
or <www.acgme.org/ResInfo/complaint.asp>),
I welcome the opportunity to receive inquiries and
offer appropriate suggestions. The opportunity for
anonymous reporting of program violations may seem
obscured in bureaucracy; and in truth, identifying
information is documented when reports are
made to the ACGME (ACGME Procedures Addressing Complaints
Against Residency Programs, B.1-3.), but specific
confidentiality measures are maintained.
While compliance with requirements is a notable goal
for all programs, the RRC strives to foster and recognize
innovation and leadership as the profession continues
evolving. A challenge is the limited influence that
trainees and future ASA leaders have in participating
in this process of evolution. A recent survey of proposed
changes to the program requirements in anesthesiology
was distributed to program directors and members of
the Society of Academic Anesthesiology Chairs/
Association of Anesthesiology Program Directors. To
my knowledge, no specific input from residents was
solicited, and except for my voice on your behalf,
residents and fellows have been silent on the issue.
While the previous ASA-RRC resident member, Maneesh
Sharma, M.D., published a sketch of the then-current
curricular changes in the April
2003 ASA NEWSLETTER,
no responses to the letter by residents were subsequently
published (ASA site search as of October 10, 2004).
Does this mean that none of us felt very strongly
about proposed changes, were not prepared to contribute
to the debate, were too busy to respond or were just
happy that the changes will not apply to us?
Active participation in our profession takes time
and motivation. It is confusing, and the bureaucracy,
as it is, can seem beyond the influence of individual
residents and programs. I submit that the barriers
to our influence on all levels of the profession are
nominal. The ASA Resident Component is an excellent
avenue for introduction to ASA. ASA officers take
an active interest in our ideas and solicit input
on many issues facing the Society. Residents and fellows
sit on many committees and task forces. The American
Medical Association (AMA) is another open avenue for
training and education.
In closing, each of us has an opportunity to shape
the course of the profession. From local advocacy
to duty hour concerns, service on the GME committee
or sharing openly with site surveyors, each program
can benefit from our participation. Nationally our
understanding of the accreditation process and how
we all can interact with the RRC and ACGME makes each
of us a powerful tool for improving our training.
Many of us may be happy with the status quo, but if
you share a commitment to becoming an active leader
in the profession, your RRC, AMA and ASA Resident
Component welcome your energy!
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Corey
E. Collins, M.D., is a clinical anesthesiology
fellow at Children’s Hospital and Harvard
Medical School, Boston, Massachusetts. |
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