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SAEM Responds to Proposed ACGME Common Program Requirements

In response to a request from the Accreditation Council for Graduate Medical Education (ACGME) for review and comments regarding its proposed Phase 2 Common Program Requirements, the Society for Academic Emergency Medicine (SAEM), along with the Association of Academic Chairs of Emergency Medicine, and SAEM's Clerkship Directors in Emergency Medicine academy, Graduate Medical Education Committee, Research Directors Interest Group, and Evidence Based Emergency Medicine Interest Group, have provided the following feedback:

The Society for Academic Emergency Medicine (SAEM) is the largest organization of researchers, educators and learners in the specialty of Emergency Medicine. On behalf of our membership we are writing to share concerns with several of the proposed changes to the ACGME Common Program Requirements. We believe the proposed changes to current practice may result in a meaningful decline in the quantity and quality of scholarly work by attending, fellow, and resident physicians in our field.

Among our greatest concerns is the potential for future RRC requirements to remove the mandate that institutions and programs BOTH bear responsibility for ensuring a minimum effort support for core faculty endeavors. Without this mandate, department chairs will be less armed to justify and to allocate funding for faculty members critical to the academic mission of the residency but without external funding for their work. This will necessarily hinder the ability of department chairs to recruit, hire and develop researchers and educators to contribute to the medical body of knowledge beyond bedside supervision of residents. We foresee a steep drop in academic productivity, and the stalling of the development of future researchers. This may jeopardize the recent gains we have made in developing research-oriented fellowship programs and other mentorship activities.

Specific details of the document that have drawn our attention follow:

1) Section IV.D.1.b) Removes sponsoring organizations from having duty to allocate adequate resources to facilitate resident and faculty involvement in scholarly activities. This duty would now solely fall to the residency program. Again, we feel this will significantly weaken the ability of residency leadership to obtain critical support from their institutions to support faculty participation as core faculty, and in residency non-clinical endeavors overall. We find no rationale for this wording change given the ACGME values include: “Engagement of Stakeholders”

2) Lack of any ability for RRCs to designate that core faculty are to be supported with a minimum amount of effort to support non-clinical work. It appears the only persons who the ACGME would mandate receive protected effort in support of the academic mission are the program director at 20% and program coordinator at 50%. In Emergency Medicine in particular, absence of any RRC expected effort support for non-clinical academic duties will over time result in decreased core faculty participation – in particular for junior and mid-career faculty who have not yet matured to the point of securing external funding. It would also most likely asymmetrically impact programs that are not within large academic centers. These programs will find it difficult to procure support from their institution, to attract dedicated faculty, and to keep them engaged in the myriad amount of work needed to work toward the ACGME vision of “Motivated physician role models leading all GME programs…..Clinical learning environments characterized by excellence in clinical care, safety, and professionalism.”

3) Replacement of lines 548-563 with section IV D.2. re-define what scholarly work would meet ACGME expectations with respect to faculty productivity. Also, it is noted that no longer are individual core faculty each required to produce scholarly work, rather it is the program in aggregate which is expected to meet some productivity standards in 3 of 7 domains (only two of which would be considered research). Could this allow a program to have only one or two faculty members producing education innovations, serving on a professional committee, creating a local didactic program and meeting ACGME expectations? Perhaps individual RRCs would not allow this and would identify this problem on a case by case basis, but there is no guidance in the ACGME approach that would prevent the emergence of significant heterogeneity in how RRCs and programs address this problem.

4) It is acknowledged that the landscape of what can and should constitute scholarly work has changed from the past, and work in quality care improvement and patient safety has, and will continue to impact the way we educate learners and innovate in the academic medical space. However, the potential dilution of expectations that could occur as a result of RRCs expecting less from programs, and programs finding ways of meeting minimum scholarly standards is concerning. We fear that section IV.D.2b).(1) and (2) may allow emergence not just in our field but many specialties of medicine, residency programs with an aggregate faculty scholarly output that is non-peer reviewed, non-published and of minimal impact.

5) We interpret the language on line 1143 "The review committee may further specify" to allow the EM-RRC latitude in defining what constitutes acceptable academic output in the emergency medicine ACGME setting. While we appreciate that this reflects an ACGME desire to allow specialties more autonomy in this decision, we still fear that future RRC laxity will emerge in determining what meets this criterion of scholarly productivity which will threaten the future quantity and quality of academic output in EM and academic medicine in general.

6) A related concern is the proposed change that the residency program director would be required to receive only 20% salary support (or 8 hours per week) to oversee the program (lines 232-234). This is likely inadequate for most programs, especially given the amount of administrative program requirements required by ACGME, and since the program director is also required to pursue scholarship and engage in clinical care activities. While the EM-RRC may further specify the minimum support for the program director (line 236), this language may inadvertently place the program at odds with the program director who will be limited in their ability to effectively supervise and manage the program.

We share these concerns as a group of emergency medicine clinicians, educators and researchers, all dedicated to the pursuit of academic excellence, the advancement of skills to care for acutely ill and injured patients, and our growth as we teach current and future generations of physicians how to do this safely, accurately, and compassionately.

As these proceedings will significantly impact our professional landscape and our trainees’ futures, the Society for Academic Emergency Medicine Board of Directors, as well as the undersigned SAEM entities, have respectfully asked ACGME’s careful consideration of our aforementioned concerns. We will continue to follow these proceedings while we await their response.

 

D. Mark Courtney, MD, MSCI, President
Society for Academic Emergency Medicine

And

Marna Rayl Greenberg, DO, MPH, Chair
SAEM Research Director’s Interest Group

Bryan G. Kane, MD, Chair
SAEM Evidence Based Emergency Medicine Interest Group

David Barnes, MD, Chair
SAEM Graduate Medical Education Committee

Rahul Patwari, MD, President
SAEM Clerkship Directors in Emergency Medicine Academy

Theodore Delbridge, MD, President
Association of Academic Chairs of Emergency Medicine