Uniqueness in Unity

MDs, DOs Pursue Accreditation Merger

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Medical Education Feature – January 2013

By Amy Lynn Sorrel
Associate Editor

Tex Med. 2013;109(1):43-48.

For decades, allopathic and osteopathic residency programs followed two separate paths to accreditation. Now those two paths may merge as the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) discuss a single, unified accreditation system for graduate medical education (GME) beginning in July 2015.

On the road there, the nation's 10,000 GME programs – 9,000 allopathic and 1,000 osteopathic – will consolidate under one roof. That roof will be the ACGME, but the entity traditionally responsible for accrediting allopathic residency programs will expand to include leadership from the osteopathic community, namely the AOA and the American Association of Colleges of Osteopathic Medicine (AACOM).

The move will modify ACGME's governance as the organizations create a common system. Because current ACGME standards largely will be the framework for the new model, the changes will mostly affect osteopathic programs and certain organizational elements of the ACGME, GME leaders say. Allopathic programs would open their doors wider to osteopathic graduates with the creation of a common pool of residency slots.

For the six Texas training programs dually accredited by ACGME and AOA, the impact likely will be minimal, and if anything, beneficial in reducing duplications and some costs.

But for stand-alone, community-based osteopathic residency programs like the one Steven L. Gates, DO, runs as director of medical education at Bay Area Corpus Christi Medical Center, the announcement invites questions about the fate of such programs in Texas and elsewhere – and their residency slots – if they fall short of the new accreditation standards.

"We are always looking at ways to improve the quality of the health care we provide. I would embrace any new format that does that, as long as it also preserves the uniqueness and distinctness of the osteopathic philosophy," Dr. Gates said. "Many [osteopathic] programs are community based, and this uniqueness will need to be addressed. Fortunately, our programs have been growing, and our hospital has been supportive of our growth." He added that some rural programs "may have issues" meeting the new standards, however, if they do not have access to certain resources.

Medical education leaders say the collaboration is an opportunity to improve the quality and efficiency of GME programs during heightened scrutiny on a number of fronts, including Congress, the Centers for Medicare & Medicaid Services, and the recently-established Institute of Medicine Committee on the Governance and Financing of GME.

The emerging accreditation system will enhance the medical profession's accountability to the public, regardless of which tradition of medicine they come from, through a set of common competency expectations and uniform standards for GME programs nationwide, said ACGME Chief Executive Officer Thomas Nasca, MD.

"This will give us the ability to say with a single voice that all programs that are graduating residents are meeting high standards and achieving the new outcomes the public has asked for: use of electronic health records, literacy, the ability to function in multidisciplinary teams," he said.

As the country faces a severe physician workforce shortage, due in part to a federal cap on Medicare-funded GME residency positions, "we'll be able to provide accountability for the use of those dollars, and the public could then wisely invest in expanding those numbers to meet the public need," Dr. Nasca added.

The merger also would help prepare physicians to practice in an ever-changing health care environment, as evidenced by the federal health system reform law, said Boyd R. Buser, DO, an AOA Board of Trustees member and chair of the organization's Bureau of Osteopathic Graduate Medical Education Development. Those changes show up at all levels of medicine, from medical schools, to board certification, to licensure maintenance.

At the same time, both ACGME and AOA were reevaluating their accreditation systems to adapt to more outcomes-based performance, with some ACGME changes threatening to limit osteopathic graduates' access to allopathic residency programs.

"All of these things came together, and it made sense for us to be talking about possible ways to work together to improve the system," said Dr. Buser, dean of the University of Pikeville-Kentucky College of Osteopathic Medicine. "It's an opportunity to share best practices in training physicians, including performance standards that emphasize positive results. That ultimately should translate into better, more affordable care for patients."

Although the agreement represents a historic change, one thing will remain the same, Dr. Buser affirmed. The AOA is "very clear about maintaining those things that are distinct about our [osteopathic] education and practice."

Dr. Nasca says the ACGME structure will require some changes to reflect the differing osteopathic principles, and the council will add a special review committee on neuromusculoskeletal medicine to oversee the osteopathic component of training programs.

And in the coming months, "it's almost certain that working groups will have to be put together specialty by specialty to do the heavy lifting of comparing the standards and seeing what makes sense and coming to agreements on them," Dr. Buser said.

Best of Both Worlds

But the two disciplines have more in common than not when it comes to training expectations, says Don Peska, DO, dean of the Texas College of Osteopathic Medicine (TCOM) at the University of North Texas Health Science Center in Fort Worth.

For DOs, the agreement represents "a very important breakthrough in the recognition that our [osteopathic and allopathic] programs are virtually identical," said Dr. Peska, who also sits on the AACOM board.

With the exception of an osteopathic principles component, the two residency training tracks share the same six core clinical competencies: patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills. Duty hours and duration of training requirements also are similar.

To be sure, there are differences, "but there are things that both sides find appealing in the others' programs," Dr. Peska said. "When we see the uniform standards emerge in July 2015, we expect to see standards that borrow from the best of both worlds."

For instance, osteopathic programs traditionally use smaller, more community-based hospitals or ambulatory facilities. That could be a way to expand the number of residencies across the country, particularly in primary care, often a focus of osteopathic programs, Dr. Peska says.

Only about 40 percent of allopathic programs are based in bigger academic or institutional medical settings, but about 60 to 70 percent of trainees enroll there because they are larger programs, Dr. Nasca says. "There is no desire on our part to do anything other than reinforce the importance of community-based training."

Allopathic programs function within their accredited sponsoring institutions, and oversee specialty training via so-called residency review committees (RRC), composed of members nominated by the American Medical Association, the medical specialty's board, and the designated national medical specialty society. AOA requires osteopathic programs to belong to an intermediary organization called an osteopathic postdoctoral training institution (OPTI). The regional consortium, comprised of at least one college of osteopathic medicine and one hospital, oversees quality and provides on-site educational resources to support community-based training. All of the 21 Texas osteopathic training programs are affiliated with TCOM's OPTI.

The ACGME is "very interested in that [consortium] style and how it might be adapted into their system," Dr. Peska said. On the other hand, ACGME standards use what he described as a more "prescriptive" approach to which AOA programs may have to adapt.

For example, AOA requires "ample" call space and study facilities for its programs, but ACGME specifies how big that space must be. Osteopathic programs primarily use volunteer faculty, whereas ACGME requires minimum payments. And the two organizations have different minimum requirements for the number of residents that programs need to remain accredited.

Some uniformity will have to be established, but most of the forthcoming modifications will require what Dr. Peska characterized as subtle changes for osteopathic programs. "One of my host CEOs said it's 'nothing big, but a lot of little things that will cost me money.'"

Meanwhile, the merger could be a boon to residency programs dually accredited in both osteopathic and allopathic training. Because many of these programs are in family medicine, primary care training also could get a boost. About half of the AOA-accredited family medicine programs and a majority of pediatric residencies are in dually accredited institutions.

Those Texas osteopathic programs that are dually accredited have the support of both a local university and an OPTI, says Lisa R. Nash, DO, associate dean for educational programs at TCOM. In addition, "70 to 80 percent of our graduates go into ACGME programs and have for a number of years, so I don't see this [merger] as a game changer" for Texas institutions.

Instead, the collaboration could reduce headaches for dually accredited programs that would no longer have to deal with two sets of inspections, paperwork, and fees to comply with accreditation requirements.

Nor would these programs have to hire two residency program directors, says Ron Cook, DO, chair of the Department of Family and Community Medicine at Texas Tech University Health Sciences Center and former director of the family medicine residency program. Fortunately for the school, whose family medicine residency program was dually accredited until last June, Dr. Cook is board certified in both allopathic and osteopathic family medicine.

Such savings could go towards program improvements that directors might have delayed for lack of resources, and because many dually accredited residency programs focus on family medicine, a streamlined system could provide an additional boost to primary care training, as well.

For Texas DO graduates in particular, the move also would help open up the pool of residency slots to those who might otherwise leave the state because there were too few osteopathic positions to go around, particularly in specialties, Dr. Cook says.

"Once residents leave Texas to get training, they are gone. Maybe 50 percent return, but most stay within a 50- to 75-mile radius of where they train," he said. "The goal of any GME program in Texas, regardless of whether it is AOA or ACGME-accredited, is for the money we put into medical education to be used to take care of patients in Texas. This [merger] is good for Texas because it means any graduate of a GME program in Texas can more easily stay in Texas."

A unified system also could help eliminate the administrative hassles that often keep DOs who train in allopathic programs from returning to osteopathic medicine, he says.

At the same time, because some other states exclusively designate certain residency positions to osteopathic training, some of those slots remain vacant – often those in primary care – due to factors like geographic distribution, a complicated and competitive match system, and specialty preferences.

"One of our goals is that with all of these programs meeting the same standards, they would be optimally filled, which would give us some more capacity," Dr. Nasca said. "One potential scenario is that primary care educational capacity is slightly expanded." 

Winners and Losers?

Still, Dr. Gates anticipates at least some future costs with the change.

His South Texas program has strong ties to TCOM and its OPTI, and an affiliation with a hospital system, HCA Healthcare, whereas not all osteopathic programs are as fortunate.

If they lack a strong academic sponsor, for example, "some rural programs may have issues with the research requirement. And our hospital has already allowed us to have some paid faculty positions, both full- and part-time," Dr. Gates said. "At this time, I do not see our program's viability being threatened. I would anticipate there will be needed changes, but our administrative team has always been willing to support any new requirement."

If a training program were to close, however, that would put those residency slots in jeopardy at a time when the number of medical school graduates is on track to exceed the number of GME training positions, medical education leaders say. The problem is even more acute in Texas, where strong population growth has made it difficult to grow the physician supply.

Twice in recent years, CMS used a mechanism to redistribute unused, federally funded residency slots based on factors related to geography and specialty mix. The positions within the region were placed in a federal pool for the government to redistribute out of state.

"All of that is subject to federal budget constraints," Dr. Nash said.

Texas suffered under the last federal distribution of unused Medicare-funded GME positions in August 2011, losing rather than gaining positions, despite the population growth. The state lost direct funding for 50 GME positions and indirect funding for 40 slots from 21 hospitals, according to Texas Medical Association data. The Patient Protection and Affordable Care act required CMS to reduce unused residency slots by 65 percent and redistribute them according to certain criteria. Texas did not qualify to receive any redistributed slots.

Nobody wants to see programs close, the ACGME's Dr. Nasca and the AOA's Dr. Buser both says. Both organizations believe the vast majority of osteopathic programs AOA now accredits can meet the new standards.

Dr. Buser added that one of the non-negotiables in the process is that community-based programs would not be disadvantaged wholesale. But the organizations will not compromise on quality.

"This is not a question of protecting slots for the sake of protecting slots. It's about working with any program, whether ACGME or AOA, to help them meet the standards and minimize the risk" of losing any of them, he said.

To that end, ACGME will work with AOA and AACOM to design communication and educational programs to highlight standards and expectations and give residency programs time to adjust.

 Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.  

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